Every finding on record at Groesbeck LTC Nursing and Rehabilitation

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen in the facility. The facility did not ensure that unopened packages of meat that were taken out of the original box had a date on it. The facility did not ensure that the floors in the walk-in refrigerator and the walk-in freezer were free of debris. These failures could place all residents who eat prepared food in the kitchen at risk of foodborne illnesses.Findings included: Observation on 07/28/2026 at 9:32 AM of the freezer revealed the following:There were food particles and a sticky substance on the floor underneath the bottom shelf of the freezer. There were food particles and a sticky substance on the floor under the bottom shelf of the refrigerator. There was an opened package of frozen breadsticks in an opened undated box in the freezer. There were four 10 pounds sticks of ground beef packages without a date on them on the bottom shelf of the freezer that were not in a box. During an interview on 07/29/26 at 10:22 AM with the DM, she said she had been at the facility for less than two months and she did not know that there were undated packages of ground beef out of the original box in the freezer. She also said she did not know there was an undated opened box with an undated opened package of breadsticks in the freezer. She stated the facility had a policy on food storage and dating. She said that all boxes in the freezer should be dated. She said once a box was opened and items were taken out, the date on the box should also be written on the unopened food packages. She said all opened packages in the freezer should have an open date and a discard date on them. She said the discard date was normally the manufacturer's best if used by date. She said the importance of making sure the food was dated correctly was to prevent foodborne illnesses, and contamination of other food, which could make residents sick. DM also said she did not know that the cooler or the freezer floor was sticky and had food particles underneath the bottom shelves of each. She said she did not go in either often and that it was the responsibility of the cooks to ensure both floors were swept and cleaned. She stated she was aware of the existing cleaning form on the wall in the kitchen, but she said she posted a new cleaning list when she first arrived. She said that she did not require the staff to sign it but may consider it. She stated that she did not list a responsible person for each task but expected all staff to chip in and assist. She said that the cooks were responsible for cleaning the floors in the cooler and refrigerator since they go in there more than anyone else. She stated the importance of keeping the freezer floor clean was to prevent foodborne, illnesses or contamination of other food in the freezer. During an interview on 07/28/2026 at 10:42 AM with CK E, she said she did not know that there were undated packages of ground beef out of the original box in the freezer. She also said she did not know that there was an undated opened box with an undated opened package of garlic bread in the freezer. CK-E said the facility had a policy on food storage and dating. She said all boxes in the freezer should be dated. She said once a box was opened and items were taken out, the date on the box should also be written on the unopened food packages. She said all opened food packages should have an opened date and a discard date. She said the discard date was the manufacturer's use by date. CK E said labeling and dating food correctly will help keep track of inventory and keep residents from eating old food. CK E said there was an older cleaning list posted on the wall in the kitchen that was posted by the previous DM and there was another cleaning schedule posted on the wall by the current DM. She said the new checklist did not indicate who was responsible for what. She said that she did not sign either list and no one told her to sign them. She said she did not know she was responsible for ensuring the freezer floor was clean and said she thought the DM was responsible for that task. She said the importance of keeping the floors clean in the cooler and the walk-in freezer was to prevent foodborne illnesses, which could make residents sick. During an interview on 07/28/26 at 2:26 PM with CK F, he said he was not aware that there were not any dates on the unopened packages of ground beef in the freezer. He said that he normally took meat out of the package, but always ensured a date was on the package if it were not in the box. CK F said he did not know that there was an undated opened box with an undated opened package of breadsticks in the freezer. CK-F said the facility had a policy on food storage and dating. He said all boxes in the freezer should be dated. He said once a box was opened and items were taken out, the date on the box should also be written on the unopened food packages. He said all opened food packages should have an open date and a discard date. He said the discard date for food in the freezer was the manufacturer's use by date. He said dating and labelling food correctly would prevent residents from eating expired food. He stated that he knew about the old and the new checklist in the kitchen. He said that he cleaned the kitchen floor before he left each night because the old checklist indicated that cooks were to clean and sweep the floor in the freezer and the cooler every day. He said he did not sign any form and did not know that there was an area at the bottom of the checklist cleaning form for him to sign. He stated that the old checklist was posted on the bulletin board in the kitchen for at least over a year and the new DM posted another checklist not too long ago. He said that the new form did not list who did what in the kitchen. He said it was important to keep the floor clean and keep food off the floor in the cooler and the freezer to prevent foodborne illnesses. During an interview on 07/30/26 at 3:22 PM with the ADM, she stated that she expected the kitchen staff to ensure that all food was dated and labeled properly and that the floors in the walk-in refrigerator and walk-in freezer were clean and free from debris and did not know this had happened. She said a clean-up checklist was posted in the kitchen for a few years now with tasks that should be done by the kitchen staff. She said she was not sure if staff were required to sign the list or not and did not know if staff were assigned to certain tasks. She said the DM started working there about 2 months ago and did not know if she posted a new checklist or updated the existing list. However, she said she expected everything on the check list to be completed every day. She said that if an unopened package of food was taken out of the original box in the freezer, it should have the same on it as the box had. She stated that all unopened food packages in the freezer should have an open date on them. She stated these failures could cause the food to become contaminated, which could eventually make the residents sick. ADM said she was unaware that the floors were sticky and that there were food particles underneath the shelves in the kitchen. She stated the DM was responsible for making sure all food in the kitchen was dated correctly and to make sure the floors in the walk-in refrigerator and freezer were cleaned every day. Record review on 07/30/26 of the food preparation and storage policy (revised 2022) revealed the following: Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:4.Food services, or designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times.Refrigerated / Frozen Storage:All food stored in the refrigerated or freezer are covered, labeled, and dated (used by date). Record review on 07/30/26of the closing checklist for shift cooks (undated) revealed the following: Cooler:All food is covered securely, label has identification and date is on the label.No spills on the floorNo items on the floor Freezer:All food is covered securely, label has identification and date is on the label.No spills on the floorNo items on the floor. TO BE COMPLETED BY EACH SHIFT COOKRecord review also revealed that there was a place for a signature and a date. Record review on 07/30/2026 of the new cleaning schedule created by the DM revealed the following:Daily Cleaning Schedule (undated): Initial and Date ach day completed.ItemWhenPosition responsibleMonTuesWedThurs Refrigerator, freezer, and cooler (wipe out and sweep)Once a day Record review revealed the form included Friday, Saturday, and Sunday and there was not a place for a signature and a date on the form. Record review revealed there was not a name listed in the position responsible field.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 5 of 7 residents (Resident # 22, Resident #37, Resident #23, Resident #2, and Resident #27) reviewed for medication errors.The facility failed to ensure MA D followed ordered BP parameters for administration of Atenolol Oral Tablet 50 MG (treating high blood pressure) ordered by physician for Resident #22. MA D failed to notify charge nurse to recheck BP for Resident #22 and hold administration of medication on 07/23/2026, 7/24/2026, and 7/28/2026. The facility failed to ensure MA D followed BP parameters ordered for administration of Lisinopril Oral Tablet 20 MG (treating high blood pressure) ordered by physician for Resident #37. MA D failed to notify charge nurse to recheck BP for Resident #37 and hold administration of medication 0n 07/23/2026, 07/24/2026, 07/28/2026, and 07/30/2026. The facility failed to ensure MA D followed BP parameters for administration of Metoprolol Succinate 25 MG (treating atrial fibrillation - heart condition where the upper chambers of the heart beat fast and out of sync) ordered by physician for Resident #23. MA D failed to notify charge nurses to recheck BP for Resident #23 and hold administration of medication on 07/01/2026. 07/10/2026, 07/20/2026, 07/23/2026, 07/24/2026, and 07/28/2026. The facility failed to ensure MA D followed ordered BP parameters for administration of Carvedilol Oral Tablet 12.5 MG hydralazine HCl 50MG (treating high blood pressure) ordered by physician for Resident #2. MA D failed to notify charge nurse to recheck BP for Resident #2 and hold administration of medication on 07/10/2026. The facility failed to ensure MA D followed ordered BP parameters for administration of Carvedilol Oral Tablet 12.5 MG (treating high blood pressure) ordered by physician for Resident #27. MA D failed to notify charge nurses to recheck BP for Resident #27 and hold administration of medication 07/09/2026, 07/10/2026, and 07/20/2026. These failures could place residents at risk of low blood pressure, falls, injuries and not receiving the therapeutic benefits of the prescribed medication. Findings included: 1. Record review of Resident #22 's face sheet, dated 07/29/2026, indicated a [AGE] year-old female admitted on [DATE] with diagnoses which included acute on chronic systolic (congestive) heart failure (long-term, stable heart pumping weakness experiences a sudden, severe worsening of symptoms), essential (primary) hypertension (high blood pressure without a single clear cause), and heart failure. Record review of Resident #22's quarterly MDS assessment, dated 07/02/2026, indicated Resident #22's BIMS score of 14, indicating intact cognition. Record review of Resident #22's comprehensive care plan revised 04/15/2026, indicated a focus: Congestive heart failure and is at risk for shortness of breath, chest pain and increased edema and elevated BP with interventions: of her cardiac medications as ordered. Resident #22's focus: altered cardiovascular status related to atrial fibrillation with interventions: Give Amiodarone as ordered.,Record review of Resident #22's order summary report dated 07/30/2026, indicated she had an order for Atenolol Oral Tablet 50 MG (Atenolol) Give 1 tablet by mouth one time a day related to essential primary hypertension, hold if systolic BP <110 AND diastolic BP <60, HR <60 with start date of 02/10/2026 at 9:00 a.m Record review of Resident #22's MAR for July 2026, indicated: On 7/23/26 Atenolol Oral Tablet 50 MG was given by MA D, the blood pressure and heart rate was checked prior to administration and documented. The blood pressure was 109/55 and the pulse was 70. Record review ofvitals summary for Resident #22 on 7/23/2026 at 11:10 a.m. revealed BP reading: 109/55. On 7/24/26 Atenolol Oral Tablet 50 MG was check marked given by MA D, prior to administration the blood pressure and heart rate were checked and documented. The blood pressure was 119/57 and the pulse was 71. Record review of vitals summary of Resident #22's BP indicated on 07/24/2026 and 11:00 a.m.: 119/57 and on 07/24/2026 at 2:06 p.m.: 120/60. On 7/28/26 Atenolol Oral Tablet 50 MG was check marked given by MA D, prior to administration the blood pressure and heart rate was checked and documented. The blood pressure was120/59 and the pulse was 74. Record review of vitals summary of Resident #22's BP indicated on 07/28/2026 and 10:49 a.m.: 120/59. On 7/29/26 at 8:11 a.m. Atenolol Oral Tablet 50 MG was check marked given by MA D, prior to administration the blood pressure and heart rate was checked and documented at BP 113/55 and the pulse was 70, this medication was observed during survey observation and was witnessed by surveyor that this medication was not given, it was held due to systolic BP was less than 60. Record review of vitals summary of Resident #22's BP indicated on 07/29/2026 and 8:11 a.m.: 113/55. No BP recheck was identified in the nursing notes. Record review of Resident #22's eMAR progress notes did not have any nurse entries referencing medication was held on any of these days. Observation of Resident #22 on 07/29/2026 at 8:15 a.m. did not reveal Resident #22 in distress or exhibiting signs of low blood pressure: dizziness, weakness or shortness of breath. During an observation and interview with Resident #22 on 07/30/2026 at 1:17 p.m., Resident #22 stated MA D or other medication aides checked her BP before administering BP medications and if it showed low BP, they rechecked it with a nurse and did not give her BP medication. She stated she did not feel dizzy, shortness of breath or lightheaded like she had low BP. 2.Record review of Resident #37 's face sheet, dated 07/29/2026, indicated an [AGE] year-old female admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and makes it hard to breathe), essential (primary) hypertension (high blood pressure without a single clear cause), chronic diastolic (congestive) heart failure (occurs when the heart muscle becomes stiff and cannot relax normally between beats, leading to poor blood filling and fluid backup). Record review of Resident #37's quarterly MDS assessment, dated 07/05/2026, indicated Resident #37's BIMS score of 12, indicating moderate cognitive impairment. Record review of Resident #37's comprehensive care plan revised 11/11/2025, indicated a focus: Resident #37 has hypertension with interventions: Give Lisinopril as ordered. B/P as ordered. Record review of Resident #37's physician's orders revealed she has an order, with start date 09/25/2025, for Lisinopril Oral Tablet 20 MG (Lisinopril) Give 1 tablet by mouth one time a day related to essential (primary) hypertension. Hold if systolic blood pressure <100 diastolic BP<60 HR<60. Record review of Resident #37's MAR for July 2026 revealed the following: 7/23/26 at 9:00 a.m. - Lisinopril mg was given by MA D, blood pressure was 136/77 and the pulse was 58, 7/24/26 at 9:00 a.m. - Lisinopril 20 mg was marked given by MA D blood pressure was 118/52 and the pulse 57, 7/28/26 at 9:00 a.m. - Lisinopril 20 mg was marked given by MA D blood pressure was 132/53 and the pulse was 55. 7/29/26 at 9:00 a.m. - Lisinopril 20 mg was marked 4 indicating it was held and not given by MA Dblood pressure was 131/53 and the pulse was 63. BP was rechecked but not documented and no follow up notes were observed in Resident #37's electronic medical records. 7/30/26 at 9:00 a.m. - Lisinopril 20 mg was marked given by MA D, blood pressure was 134/53 and the pulse was 61. Record review of Resident #37's eMAR progress notes on 07/23/2026, 07/24/2026, 07/28/2026, 07/29/2026 and 07/30/2026 did not reveal any nursing entries referencing Lisinopril 20 mg was held on any of these days and her BP was rechecked. Observation of Resident #37 on 07/29/2026 at 8:37 a.m. and 07/30/2026 at 2:09 p.m., did not reveal Resident #37 being in distress or exhibiting signs of low blood pressure: dizziness, weakness or shortness of breath. During an interview with Resident #37 on 07/30/2026 at 2:09 p.m., Resident #37 stated MA D checked her BP before administering BP medications and nurse rechecked if needed, but she did not remember details of it happening. She stated she did not feel dizzy, shortness of breath or lightheaded like she had low BP or heat issues. 3.Record review of Resident #23 's face sheet, dated 07/29/2026, indicated an [AGE] year-old female admitted on [DATE] with diagnoses which included unspecified atrial fibrillation (a fast and irregular heart rhythm diagnosis given when medical records do not state whether the condition is paroxysmal, persistent, or permanent), presence of cardiac pacemaker (a small electronic device placed in the chest or heart to help manage slow or irregular heart rhythms), and anxiety disorder (a mental health condition involving excessive, ongoing fear and worry that interfere with daily life). Record review of Resident #23's quarterly MDS assessment, dated 07/01/2026, indicated Resident #23's BIMS score of 4, indicating severe cognitive impairment. Record review of Resident #23's comprehensive care plan revised 02/16/2024, indicated a focus: Resident #23 has hypertension with interventions: Give anti-hypertensive medications, Metoprolol as ordered. B/P as ordered. Monitor for side effects. Record review of Resident #23's physician's orders on 07/30/2026, she has an order for Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth one time a day related to presence of pacemaker. Hold if SBP <100 or DBP <60 OR HR is <60. Do not crash. Record review for Resident #23's MAR for July 2026 indicated Metoprolol was given on the following dates: 7/1/26 at 9:00 a.m.- blood pressure was 113/52 and the pulse was 83. 7/10/26 at 9:00 a.m.- blood pressure was 107/55 and the pulse was 83. 7/20/26 at 9:00 a.m.- blood pressure was 106/60 and the pulse was 80. 7/23/26 at 9:00 a.m. - blood pressure was 107/54 and the pulse was 85. 7/24/26 at 9:00 a.m. - blood pressure was 110/53 and the pulse was 85. 7/28/26 at 9:00 a.m.- blood pressure was 105/62 and the pulse was 83. Review of vital signs in PCC from May -July 2026 did not show vital signs recheck. Review of eMAR nurses' notes do not show an entry by a nurse or med aide recording med was held, or any further notification. Observation of Resident #23 on 07/30/2026 at 1:43 p.m., did not reveal Resident #23 being in distress or exhibiting signs of low blood pressure: dizziness, weakness or shortness of breath. During an interview with Resident #23 on 07/30/2026 at 1:43 p.m., was unable to comprehensively recall the administration of BP medications stating: they do what they needed to do. 4.Record review of Resident #2's face sheet, dated 07/29/2026, indicated a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included heart failure (a serious condition where the heart cannot pump blood well, leading to key signs like shortness of breath, extreme fatigue, and swelling in the legs), unspecified atrial fibrillation (irregular, fast heart rhythm originating in the upper heart chambers), and essential (primary) hypertension (high blood pressure without a single clear cause). Record review of Resident #2's quarterly MDS assessment, dated 05/27/2026, indicated Resident #2's BIMS score of 99, indicated resident was not able to complete the interview. Record review of Resident #2's comprehensive care plan revised 03/02/2026, indicated a focus: Resident #2 has hypertension with interventions: Blood pressure as ordered. Give Carvedilol, Hydralazine.as ordered. Record review of Resident #2's physician orders, he has an order with start date 05/26/2026 for Carvedilol Oral Tablet 12.5 MG (Carvedilol). Give 1 tablet by mouth two times a day related to essential (primary) hypertension. Hold if SBP<110 OR DBP<60 OR HR<60 Give with meals or snack and order with start date 02/20/2026 for hydralazine HCl Oral Tablet 50MG. Give 1 tablet by mouth three times a day related to essential (primary) hypertension. Hold for SBP below 110 or DBP below 60. Record review of Resident #2's MAR revealed on 7/10/2026 Carvedilol and Hydralazine both scheduled for 5 p.m. was documented as administered by MA D, blood pressure was 100/57 and the pulse was 75. Record review of Resident #2'seMAR did not show a vital signs' recheck for Resident #2. Record review of Resident #2's eMAR nurses notes on 07/30/2026 at 12:13 p.m., did not show an entry by a nurse or med aide recording med was held, or any further notification. Observation of Resident #2 on 07/30/2026 at 2:37 p.m., did not reveal Resident #2 being in distress or exhibiting signs of low blood pressure: dizziness, weakness or shortness of breath. During an interview with Resident #2 on 07/30/2026 at 2:37 p.m., Resident #2 was unable to comprehensively verbalize his response to questions. 5.Record review of Resident #27's face sheet, dated 07/29/2026, indicated an [AGE] year-old male admitted on [DATE] with diagnoses which included acute on chronic combined systolic (congestive) heart failure (long-term, ongoing heart failure (where the heart does not squeeze well and body fluid backs up) suddenly gets much worse), chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and makes it hard to breathe), and type 2 diabetes (a chronic condition where blood sugar levels are too high because the body does not use insulin properly or make enough of it). Record review of Resident #27's quarterly MDS assessment, dated 06/30/2026, indicated Resident #27's BIMS score of 14, indicating intact cognition. Record review of Resident #27's comprehensive care plan revised 11/11/2025, indicated a focus: Resident #27 has hypertension with interventions: Blood pressure as ordered. Give Carvedilol.as ordered Record review on 07/30/2026 of Resident #27's physician's orders revealed he had an order with start date 03/25/2026 for Carvedilol Oral Tablet 12.5 MG (Carvedilol). Give 1 tablet by mouth two times a day related to essential (primary) hypertension. Hold if SBP<110 OR DBP<60 OR HR <60. On 07/09/2026 at 9:00 a.m. Carvedilol was check marked given by MA D, prior to administration the blood pressure and heart rate was checked and documented. The heart rate was 55.On 07/10/2026 at 9:00 a.m.Carvedilol was check marked given by MA D, prior to administration the blood pressure and heart rate was checked and documented. The heart rate was 52.07/20/2026 at 9:00 a.m. Carvedilol was check marked given by MA D, prior to administration the blood pressure and heart rate was checked and documented. The heart rate was 52. Record review of vital signs in Resident #27's electronic medical records did not show vital signs recheck. Record review of Resident #27's eMAR nurses notes did not show an entry by a nurse or med aide recording med was held, or any further notification. During an interview with MA D on 07/30/2026 12:31 p.m., she stated she worked as medication aide and certified nursing assistant at this facility for 6 years. She stated that she had a training on medication administration 2 weeks ago. She stated that she was trained on preparing medications for each resident before the administration of medications by checking residents' orders before administration of medications one resident at a time. She stated that if residents had blood pressure medications ordered, she checked their blood pressure first with checking their parameters ordered by the doctor. She stated if BP was below 110/60 and 60, she held the medication and documented BP in resident medication administration record. She stated that everybody had the same BP holding parameters. She stated she did not administer medication if BP outside of ordered parameters. She stated that she would consult with a charge nurse to recheck resident's BP and according to nursing instruction would administer or not. She stated that if administered BP medication with low BP reading, residents could pass out or get hurt. She stated that LVN B was the nurse on Station #1 and she did not remember if she administered those medications for Resident #37, Resident #22, Resident #23, Resident #2, she Resident #27 on those specific dates. She stated if she did not notify a nurse about low BP, residents would not be monitored, and residents could pass out. She stated that nurses were responsible for rechecking BP after she reported to them and she would document a new BP. She stated that she notified today, 07/30/2026, one of the nurses about Resident #37's BP being out of parameters. She reviewed the eMAR for Resident #37 on 7/30/26 when Lisinopril was check marked given by MA D, prior to administration the blood pressure and heart rate was checked and documented. The blood pressure was 134/53 and the pulse was 61. She stated that she did not administer medication and marked it as administered by mistake. During an interview with LVN B on 07/30/2026 at 12:49 p.m., she stated she worked as a charge nurse at station #1 and received the medication administration training as an annual continuing education. She stated that medication aides were supposed to come to her if BP or HR for residents were elevated or low. She stated that she was responsible for rechecking residents' BP and recording BP and HR in their electronical medical chart. She stated that she was responsible for instructing medication aides to hold the BP medication, documenting it in progress notes and contacting the physician and DON if issue did not resolve. She stated that the process for blood pressure out of parameters was to check on the residents first to make sure they did not have any change of condition which could follow the low blood pressure if unresolved. If residents' BP was lower, she documented their BP rechecks in vital signs in resident's chart. She stated that she did not get notifications of low blood pressure for Resident 37, Resident #22, Resident #23, Resident #2, and Resident #27. She stated that MA D did not notify her today, 7/30/26 about low BP for Resident #37: On 7/30/26 Lisinopril was check marked given by MA D, prior to administration the blood pressure and heart rate was checked and documented. The blood pressure was 134/53 and the pulse was 61. Observation of Resident #27 on 07/30/2026 at 1:27 p.m. did not reveal Resident #27 being in distress or exhibiting signs of low blood pressure: dizziness, weakness or shortness of breath. During an interview with Resident #27 on 07/30/2026 at 1:27 p.m., Resident #27 stated MA D or other medication aides checked him BP before administering BP medications and rechecked what he remembered to make sure it was not low. He did not recall any issues with his medication administration and feeling like he had low BP that negatively affected him. During an interview with DON on 07/30/2026 at 3:56 p.m., she stated Medication administration training provided to nursing staff at hire, annually and on as needed basis when somebody needed additional training. She stated that medication aides and nursing staff were supposed to check BP parameters before preparing medications and administering BP medications. She stated that the training was provided to nursing staff and medication aides on BP parameters recently to hold medication below 110/60 and HR below 60. She stated that medication aides were responsible for notifying charge nurses about BP/HR outside the parameters and hold medication until charge nurse rechecks BP/HR and gives them instructions to administer medication or continue to hold BP medication. She stated that charge nurses were responsible for rechecking BP if outside of parameters, documenting it in residents' medical charts and notifying the physician and her regarding low BP. She stated she was not aware regarding Resident #37, Resident #22, Resident #23, Resident #2 and Resident #27's BP medications were administered when BP was low. She stated if BP recheck and holding medication was not documented, it did not happen. She stated if BP medications were administered not according to the physician orders, it could be considered medication error and could hurt residents. She stated that nursing staff were responsible for checking each residents' orders before medication administration to make sure they follow the orders and don't hold medication if it was not necessary. During an interview with ADM on 07/30/2026 at 4:15 p.m., she stated that her expectations from nursing staff to follow proper medication administration policy. She stated that nursing staff: DON, ADON, charge nurses and med aides were responsible for following physician orders for medication administration for each resident. She stated she was not aware of BP parameters for different residents, but she expected that nursing staff should check each resident's physician order for those parameters before medication administration every time. She stated nursing staff should hold medication if it was outside of those parameters, document it and notify charge nurse, DON and physician if necessary. She stated that she was not sure how exactly it could affect residents if BP medication was administered outside of parameters but assumed it could negatively affect their health conditions. Record review of facility's policy Administration Medication, revised 04/2019, revealed Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders,.11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. Record review of facility in-service Blood Pressure, dated 6/10/2026, revealed While checking blood pressure, if you get a reading of less than 110/60 or a heart rate of less than 60, you must notify the nurse prior to giving medications/documenting so the nurse can recheck blood pressure and evaluate resident to determine if the condition needs to be escalated to the physician. MA D and LVN B signatures were verified on the in-service sign-in-sheet.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 housekeeping carts (Housekeeping Cart #1) and for 2 of 8 tables (Table 6 and Table 5) reviewed for hazards. The facility failed to ensure HSK did not leave keys accessible on an unsupervised Housekeeping Cart #1 with cleaning chemicals inside the compartments. The facility failed to ensure that dining room furnishings (Table 6 and Table 5) were structurally sound, stable and safe, having the potential to affect all residents who use the main dining area for meals or activities. This failure could place residents at risk of injuries, illness, and hospitalization. Findings included: 1. Observation on 07/28/2026 at 9:16 am, revealed Housekeeping Cart #1 was located on 100 hall next to therapy gym against housekeeping closet. The key was left unattended on the top of the Housekeeping Cart #1 with locked compartment containing cleaning chemicals. The compartment had glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader. HSK was not standing near the housekeeping cart, and no other staff was near the housekeeping cart. HSK came back in 5 minutes. There were not any residents near the Housekeeping Cart #1. During an interview with HSK on 07/28/2026 at 9:16 a.m., she stated the housekeeping cart was expected to be locked anytime housekeeper walked away from the cart. HSK stated she left the building to go to the parking lot to retrieve her name tag from the car and was gone for a few minutes. She stated that chemicals for cleaning rooms and bathrooms were stored in the housekeeping cart. She stated there was a possibility that if residents sprayed some of the chemicals, they could hurt themselves. She stated that she did not recall having the training on locking hk carts, but she knew she was supposed to take keys with her when stepping away from the hk cart. During an interview with HMGR on 07/28/2026 at 4:00 p.m., she stated HSK carts were expected to be locked and put in HSKclosets any time when not attended. She stated that the one who used HSK cart #1 was responsible for locking it and putting it in the HSK closet on 100 hall. She stated the key from HSK carts should be hung in the HSK closet and locked. She stated that residents could get the key, open the HSK carts and mess with chemicals on HSK cart. She stated that the following chemicals were on HSK carts: disinfectants spray [NAME] and glass cleaner. She stated the HSK staff get annual training and at hire where they trained on never leave housekeeping carts unattended. The HMGR stated that she never had any residents trying to mess with HSK carts before but potentially if a resident sprays or swallows some chemicals, it could hurt them. During an interview on 7/30/2026 at 4:15 a.m., the ADM stated she expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. The ADM stated all housekeeping staff had been in-serviced on locking the housekeeping carts at hire and annually. The ADM stated if a resident could get a key and opened a housekeeping cart, they could get exposed to chemicals on that cart and there was a possibility a resident may become ill. 2. Following an interview on 7/28/2026 at 11:15 AM, when surveyor used the tabletop to rise to a standing position, the tabletop (Table 6) wobbled significantly and tilted when downward pressure was applied. During an observation on 7/28/2026 at 11:26 AM, during the lunch meal, surveyor observed nursing staff member attempt to use the tabletop to rise to a standing position. The tabletop (Table 5) wobbled and tilted when she rested her arms on the table and leaned forward. During an interview on 07/29/2026 4:13 PM with HMGR, she revealed that some of the tables just need to be tightened up. Stated that she believed that it could be a hazard to the residents if they leaned on the tables because anything is possible. Stated she was not aware if a work order had been submitted to repair the tables. During an interview on 07/30/2026 12:30 PM with KS H she is aware of the wobbling tabletops, and they have been that way for a while. Stated she is not aware of any incidents resulting from the unstable tables, but it could be a hazard to the residents. Stated she believes it would be the responsibility of dietary to submit the work order for the tables to be repaired. Stated she does not know if a work order has been submitted. During an interview on 07/30/2026 at 3:50 PM with MTDR, he revealed that he is aware of the tabletops being wobbly, but he does not think they are unstable. Stated he is only aware of a couple of them being wobbly and that he is unable to tighten them. Stated they will have to be replaced. Stated whether or not they are a hazard depends on how far they go down. Stated he has tightened them up in the past, but they are just old and have been in use for over 18 years. Stated he has 2 tables in storage that he can use. Stated he is not aware of any incidents due to the tables being unstable. During an interview on 7/30/2026 at 4:20 PM, ADM revealed she is aware of the dining tables being wobbly. Stated they have a latch on them that allows you to flip the top over, so they have become wobbly over time. Stated the residents eat and play games on the tables, but she supposes that they could tip over. Stated she is not aware of any incidents because of the unstable tabletops.

Based on observations, interviews, and record reviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen equipment reviewed for essential equipment.The facility failed to repair the internal door latch which prevents the walk-in cooler door from being opened from the inside.This failure placed all dietary employees who use the cooler at risk for entrapment, hypothermia or other adverse health effects, which would affect facility operations and emergency preparedness for residents. Findings included:During an observation on 7/28/2026 at 9:24 AM, revealed the kitchen's walk-in cooler door was left propped open with a sign posted on the door that read Remember .this door does not open from the inside! Make sure to prop the door open.During an observation on 7/28/2026 at 9:28 AM, revealed the kitchen's walk-in cooler header jamb was observed to have a black substance consistent with mold, a reddish brown substance indicative of rust, and visible moisture.During an observation on 7/28/2026 at 2:16 PM, revealed the kitchen's walk-in cooler door was propped open.During an observation on 7/28/2026 at 2:18 PM, the kitchen's walk-in cooler thermostat revealed a temperature of approximately 53 degrees Fahrenheit. Surveyor 1 thermostat revealed a temperature of 51 degrees Fahrenheit. Surveyor 2's thermostat revealed a temperature of 58.4 degrees Fahrenheit.A record review on 7/28/2026 at 2:21 PM of the facility Refrigerator/Freezer Temperature Log revealed the temperature in the refrigerator was checked daily at 5am and at 2pm from 7/1/2026 - 7/27/2026. The temperature logged each day and time was 30 degrees Fahrenheit. The log revealed that the temperature was checked on 7/28/2026 at 5am and was recorded to be 30 degrees Fahrenheit. The 2pm check on 7/28/2026 appeared to be covered with white out.A record review on 7/29/2026 at 11:35 AM of the facility Refrigerator/Freezer Temperature Log revealed the temperature in the refrigerator was checked on 7/28/2026 at 2:30 PM and the temperature logged was 30 degrees Fahrenheit. No temperature was logged for the AM check on 7/29/2026.During an observation on 7/29/2026 at 11:41 AM, the kitchen's walk-in cooler thermostat revealed a temperature of approximately 53 degrees Fahrenheit.During an interview on 7/29/2026 at 11:43 AM, the DM revealed that the walk-in cooler door has been unable to be opened from the inside since she has worked at the facility for the last 2 months. She stated she was not aware if a work order to repair the door had been submitted prior to her taking the position, but she has not requested for the door to be repaired. When DM was asked for the current temperature reading of the cooler, she replied that it was about 44 degrees. The DM stated that the safe temperature should be below 40 degrees and that she was not aware of the fluctuating temperature. The DM stated that the cook is required to check the temperature of the cooler at shift change and that is her expectation. During an interview on 7/30/2026 at 10:32 AM, KS H revealed that the cooler door had been broken since she started working at the facility over a year ago. She stated she is aware that it cannot be opened from the inside. She stated the temperature in the cooler had been in the 45's and that it is not a good temperature. She stated the safe temperature is 40 degrees Fahrenheit or below. She stated serving food that had not been kept as a safe temperature can cause foodborne illnesses. She stated whenever she is aware of an issue, she reported it to administration but is not sure if the issue with the walk-in cooler door had been reported. During an interview on 7/30/2026 at 10:47 AM, KS I revealed that he is aware that the walk-in cooler door does not open from the inside. She stated that it had been that way since he started 7 months ago. She stated the current temperature in the cooler is around 40 degrees Fahrenheit. Stated to keep food safe, the temperature should be 40 degrees Fahrenheit and that 50 degrees Fahrenheit will be a danger zone. She stated he had seen the temperature close to 50 degrees Fahrenheit, and he notified KS H. She stated if residents are served food that had not been kept at a safe temperature, they could get sick from foodborne illness.During an interview on 7/30/2026 at 11:47 AM, the ADM revealed that they do not have maintenance logs. Stated the MTDR does not keep a record of requests and repairs.A record review of the facility Maintenance Policy revealed no policy for maintenance request, submitting work orders, or maintaining a maintenance log for submitted and/or completed maintenance requests.During an interview on 7/30/2026 at 2:03 PM, CK F revealed that she is aware of the walk-in cooler door issues. Stated she knows that it cannot be opened from the inside, so she just leaves it open because she does not want to get stuck in the cooler. Stated she is aware of fluctuating cooler temperatures, but that it is sometimes right at 40 degrees Fahrenheit. Stated if the food is not kept at a safe temperature, it will go bad and the food could make residents sick.During an interview on 7/30/2026 at 3:50 PM, the MTDR, he revealed that maintenance requests are introduced during their morning meetings. Stated he transfers the requests from the shift reports to his pad and goes to take care of it. Stated there is no maintenance log. Stated during the stand-down meeting in the afternoon, they go over the repairs that were made. Stated he uses TELS for regular maintenance duties, but not for work order requests. Stated he determines how repairs are prioritized and anything electrical, running water, refrigeration or temperature take priority. He stated alone is responsible for documenting and tracking repairs for compliance. Stated he does not know how it was discovered that the walk-in cooler door did not open from the inside, but it has been broken for about a month. Stated he has not performed a full inspection on the cooler in a while and he doesn't have anyone that comes out to check the cooler. Stated he just checks the temperature of the cooler. Stated the door has not been serviced or replaced in the past. Stated the door being left open will jump the temperature up and can create moisture and mold. Stated an outside technician will have to complete the repair of the door.During an interview on 7/30/2026 at 4:20 PM, the ADM revealed that during the morning meeting with department heads, any repair that is on the shift report is discussed. The MTDR writes the repairs in his book and addresses the request. Stated that at the stand-down meeting they go over the status of the requests to see what has been completed. Stated they have TELS, but they do not have the component that allows you to submit work orders on the app. When asked how repairs are handled in the absence of the MTDR, she stated the MTDR never misses work but if she has to, she will call their sister property or an outside vendor for emergency repairs. Stated about a year ago, they realized that the latch on the cooler door won't push but no one was locked inside. Stated the DM and MTDR notified her of the issue. Stated she was made aware during the survey that that temperature in the walk-in cooler was sometimes over 50 degrees Fahrenheit. Stated a safe temperature for food is under 40. Stated serving residents food that has not been kept at a safe temperature can cause them to become ill.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #22, Resident #37, and Resident #61) reviewed for infection control. Facility failed to ensure MA D washed hands and sanitized BP cuff between residents during medication pass for Resident #22 and Resident #37.Facility failed to ensure CNA E and LVN C change gloves during care for Resident #61. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization. Findings included: 1. Record review of Resident #22 's face sheet, dated 07/29/2026, indicated a [AGE] year-old female admitted on [DATE] with diagnoses which included acute on chronic systolic (congestive) heart failure (long-term, stable heart pumping weakness experiences a sudden, severe worsening of symptoms), essential (primary) hypertension (high blood pressure without a single clear cause), and heart failure. Observation of medication administration on 07/29/2026 at 7:50 a.m., MA D did not sanitize or wash her hands before going into Resident #22's room, before orafter administering medication, before coming out of her room, and unlocking the cart to prepare medications for next resident. She did not sanitize the blood pressure cuff before checking BP for Resident #22 and after completing the task. Record review of Resident #37 's face sheet, dated 07/29/2026, indicated an [AGE] year-old female admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and makes it hard to breathe), essential (primary) hypertension (high blood pressure without a single clear cause), chronic diastolic (congestive) heart failure (occurs when the heart muscle becomes stiff and cannot relax normally between beats, leading to poor blood filling and fluid backup). Observation of medication administration on 07/29/2026 at 8:21 a.m., MA D did not sanitize or wash her hands before going into Resident #37's room, administering medication, before coming out of her room and unlocking the card to prepare medications for the next resident. She did not sanities the blood pressure cuff before checking BP for Resident #37 and after completing the task. During an interview with MA D on 07/30/2026 12:31 p.m., she stated she completed hand hygiene training annually and at least every month. She stated if not washing or sanitizing hands between residents during medication pass, she could pass germs between residents. She could not tell why she did not sanitize her hands and blood pressure cuff between residents according to the policy. 2.Record review of Resident #61's face sheet, dated 07/30/2026, indicated an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included heart failure (a serious condition where the heart cannot pump blood well, leading to key signs like shortness of breath, extreme fatigue, and swelling in the legs), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot clean the blood or manage body fluids well over time) and major depression (common and serious mood disorder defined by persistent sadness, loss of interest in activities, and changes in daily functioning lasting two weeks or longer). Record review of Resident #61's annual MDS assessment, dated 07/10/2026, indicated Resident #61's BIMS score of 13, indicating moderate cognitive impairment. Record review of Resident #61's comprehensive care plan revised 03/23/2026, indicated a focus: Resident #61 is incontinent of bowels and bladder potential for skin breakdown with interventions: incontinent: check her every 2 hours. Observation of Resident #61's bed change on 07/30/2026 at 9:17 a.m., revealed LVN C and CNA E did not change gloves during changing Resident #61's urine-contaminated linens and touched Resident #61's clothes, body, bed remote adjusting her bed, bed side table and other personal items in her environment while repositioning her. LVN C and CNA E removed contaminated gloves but did not wash their hands before leaving Resident #61's room. During an interview on 07/30/2026 at 9:23 a.m., CNA E stated she had the training on infection control weekly and she was supposed to remove contaminated gloves after she finished handling the urine contaminated linens. She stated she was supposed to wash her hands and put on clean gloves before handling clean linens and before touching Resident #61 and her bedside table, bed remote, bed and other items in Resident #61's environment. She stated if not followed proper infection control and hand hygiene practice, she could cause the cross contamination of infection to residents. During an interview on 7/30/2026 at 9:34 PM, LVN C stated she had an in-service on infection control and hand hygiene a month ago. She stated she was supposed to change gloves after completing the dirty task - handling Resident # 61's urine contaminated linens and before moving to a clean task: handling clean linens and touching items in her environment in the room. She stated that not following proper hand hygiene and infection control policy could cause spreading infection between residents. During an interview with the DON on 07/30/2026 at 3:56 p.m., she stated that her expectation for staff to follow proper hand hygiene and infection control protocol: sanitizing hands between residents, sanitizing equipment between checking blood pressure for each resident during medication pass and during incontinent residents' care/changing contaminated bedding. She stated if staff did not sanitize their hands according to facility's policy, they could spread infection to residents which could hurt residents. She stated that infection preventionist ADON and herself were responsible for training staff on infection control and hand hygiene to protect residents from cross contamination. During an interview with the ADON on 07/30/2026 at 8:05 a.m., she stated she was an infection preventionist in this facility for last two years. She stated she had expectations for staff to sanitize hands/sanitize hands and blood pressure cuff between medication pass for each resident. She stated that if not sanitizing hands and equipment, it could put them at risk for spread of infection. She stated that she was responsible for providing in-services and training for staff at the facility on hire and if something happened in between like increase in infection rate. She stated that she logs and monitors infections spikes in the building and provides additional in-services when she tracks the spike of infection or saw someone not following proper infection control techniques. During an interview with the ADM on 07/30/2026 at 4:20 p.m., she stated that her expectations for all staff to follow proper hand hygiene facility policy. She stated that all staff received hand hygiene and infection control training at hire, annually, and as needed throughout the year and across different departments. She stated that ADON and infection preventionist were responsible for oversight of staff following the proper infection control techniques. She stated that nursing staff were supposed to sanitize hands between residents when passing medications, sanitize equipment like blood pressure cuffs between each resident's use and change gloves after changing contaminated bed linens to prevent spread of infection between residents. Record review of facility's policy Medication Administration, revised 04/2019, reflected staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves.) for the administration of medications, as applicable. Record review of facility's policy Handwashing/Hand Hygiene, revised 11/2023, reflected Facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene: a. immediately before touching a resident. c. after contact with .body fluids, or contaminated surfaces. E. after touching the residents' environment. g. immediately after glove removal. 5. The use of gloves does not replace hand washing/hand hygiene.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #44) reviewed for care plans. The facility failed to include Resident #44 had a code status of DNR on Resident #44's comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services, having important care needs identified and met. Findings include: Record review of Resident #44's face sheet, dated 07/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (a type of stroke caused by a blocked blood vessel that cuts off blood and oxygen to a part of the brain), epilepsy (a brain condition where a person has repeated seizures due to unusual electrical activity in the brain), anxiety (intense, excessive, and persistent worry and fear about everyday situations), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #44's admission MDS assessment, dated 07/01/26, reflected a BIMS score of 99, which indicated Resident #44's was unable to complete the interview. Resident #44 required total assist from staff for transfers, repositioning, eating, required staff to perform incontinent care and used a wheelchair for mobility. Resident #44 had a prognosis that may have resulted in a life expectancy of 6 months or less and received hospice services. Record review of Resident #44's comprehensive care plan, initiated on 7/14/26, reflected Resident #44's DNR code status was not included in the care plan. Record review of Resident #44's hospice orders, dated 07/08/26, reflected Resident #44 had a code status of DNR ordered. Record review of Resident #44's advance directive reflected a DNR that was signed by a physician on 06/30/26. Record review of Resident #44's electronic medical record's documents reflected a DNR was made available in his electronic medical record on 07/13/26. During an interview on 07/30/26 at 1:32 PM, LVN A stated she was the MDS nurse at the facility for 12 years. She stated she was responsible for completing resident care plans. She stated if resident care plans had not included a residents code status, residents' wishes would not have been honored. She stated the DNR status for Resident #44 should have been included in residents care plan. She stated she was not sure why Resident #44's care plan had not included his code status. During an interview on 07/30/26 at 4:14 PM, the DON stated LVN A was responsible for completing resident care plans. She stated LVN A had been trained in completing resident care plans. She stated a resident's code status should have been included on a resident's care plan. She stated a resident's code status should go onto their care plan immediately. She stated she was not aware Resident #44's care plan had not included his DNR code status. She stated if a resident care plan had not reflected their current status or a resident's code status was not included in their care plan, it could have possibly caused harm, but she would not have went to a resident care plan to find a residents code status in an emergency. Record review of the facility's policy, dated 2001 and revised December 2016, titled Care Plans - Comprehensive Person-Centered reflected Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; e. Include the resident's stated goals upon admission and desired outcomes; j. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes.

Based on interview and record review the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 6 residents (Resident #22 and Resident #29) reviewed for care plans. 1. The facility failed to revise Resident #22's care plan to reflect a change in code status (the life-sustaining measures a resident wants or does not want) from Full Code (if the heart and breathing stops, the medical team will do everything to try to revive the resident) to DNR (Do Not Resuscitate. If the heart and breathing stops, the medical team will not attempt to revive the resident and will instead allow natural death to occur). 2. The facility failed to ensure Resident #29's care plan was revised to reflect that Resident #29 no longer had an order for ABH Gel. These failures could place residents at risk of getting insufficient care, having personal needs not met, and result in diminishing physical and psychosocial well-being.Findings include: 1. Record review of Resident #22's face sheet, dated 07/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included heart failure (a condition where the heart isn't pumping blood as well as it should), non-rheumatic mitral valve insufficiency (a condition where the mitral valve in the heart is leaking because it doesn't close properly) and atrial fibrillation (an irregular heart rhythm where the heart's upper chambers beat irregularly, too fast and out of sync with the lower chambers). Record Review of Resident #22's admission record, dated 07/29/26, reflected Full Code under the advance directive section. Record review of Resident #22's most recent quarterly MDS, dated [DATE], reflected her BIMS score was 14, which indicated Resident #22 was cognitively intact. Record review of Resident #22's care plan reflected a focus area which stated Resident #22 was a full code. Date initiated: 02/17/26. A goal for the focus area stated Request for CPR to be initiated would be followed. Date initiated: 02/17/26, revised on: 07/17/26. Interventions included End of life wishes will be reviewed routinely and documented in the medical record. Date Initiated: 02/17/26, Initiate BLS CPR if (Resident #22) was without a heartbeat or not breathing. Notify EMS. Initiated: 02/17/26, Revision on: 02/17/26, Notify the charge nurse immediately if (Resident #22) was not breathing or did not have a heartbeat. Date Initiated: 02/17/26. Record review of Resident #22's physician orders, active orders as of 07/29/26, reflected an order for Full Code status with an order date of 02/09/26. Record review of Resident #22's physician orders, active orders as of 07/29/26, reflected an order for Admit to hospice dated 04/01/26. Record review of Resident #22's care plan reflected Resident #22 was on services of hospice Date Initiated: 04/02/26 Revised on: 07/17/26. Record review of Resident #22's hospice IDG comprehensive assessment and plan of care update report reflected start of hospice care, dated 03/31/2026, benefit period dates 06/29/2026 to 09/26/2026, and IDG meeting date 06/30/2026, and reflected Resident #22 had an advance directive of DO NOT RESUSCITATE. Record review of Resident #22's electronic medical record reflected a DNR was uploaded to her electronic medical record on 07/29/26. Record review of Resident #22's electronic medical record reflected a DNR signed by a physician on 04/27/26. 2. Record review of Resident #29's face sheet, dated 07/30/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included chronic kidney disease (long standing disease of the kidneys leading to renal failure), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy). Record review of Resident #29's Quarterly MDS, dated [DATE], Section C - Cognitive Patterns: C0100. Should Brief Interview for Mental Status be Conducted? Code entered was 0 which indicated No (resident was rarely/never understood). Resident #29 required setup or clean-up assistance for eating, substantial/maximal assistance for toileting, and was dependent on staff for showers and personal hygiene. Record review of Resident #29's comprehensive care plan, dated 01/26/25 and revised on 01/31/25, reflected Resident #29 resistive to care r/t Dementia - Note: Has ABH Gel ordered for behaviors PRN. Goal will cooperate with care through next review date. Interventions included Allow Resident #29 to make decisions about treatment regime, to provide sense of control. Record review of Resident #29's physician orders which included discontinued physician order's, dated 07/30/26, reflected Resident #29 had a previous order for ABH gel. Record review of Resident #29's discontinued physician orders, dated 07/30/26, reflected a previous order for ABH gel every 4 hours as needed for agitation related to anxiety disorder for 90 days apply one syringe topically, to inner wrist, side of neck, make sure you are wearing gloves prior to applying to resident was discontinued on 07/23/25. In an interview on 07/30/26 at 1:32 PM, LVN A stated she had been the MDS nurse at the facility for 12 years. She stated she and the SW were in charge of updating the resident care plans. She stated she was supposed to have updated the resident care plans immediately or right away after she received information from IDT morning meetings on weekdays and on Mondays after every weekend. She stated if resident care plan were not updated, residents' wishes would not have been honored. She stated the DNR status for Resident #70 should have been updated in the resident care plan and it was not done. She was not sure why Resident #70's care plan was not updated or entered. She stated Resident #70 was admitted on [DATE] and he had been a resident at the facility before. She stated Resident #29 admitted this time with a DNR status with hospice care and his status was entered as full code which was incorrect. During an interview on 07/30/26 at 2:03 PM, the SW stated she or LVN A was responsible for putting the code status changes in the resident care plans and this should have been done immediately when the change occurred. She stated the residents DNR status should have been confirmed with the resident or family and signed by the MD. She stated she was responsible for reviewing the code status on each resident. She stated if a residents proper code status had not been identified in the care plan, the residents' wishes would not have been respected. She stated when the code status order was available, it should have been updated immediately. She stated Resident #70's DNR order was put in 07/08/26 and she failed to put the code status in his care plan. During an interview on 07/30/26 at 1:57 PM, LVN A stated she was responsible for completing and revising resident care plans. She stated she was trained on completing and revising resident care plans. She stated PRN and routine medications should have been included in the resident care plans and if a medication was discontinued, the care plan should have been revised. She stated she got her information about the residents in their morning meeting and she tried to ensure the care plans were updated right after that. She stated she was unsure about the actual time frame that she was required to update the residents care plan for a discontinued medication, but she thought it was 7 - 14 days. She stated she was not aware Resident #29's ABH gel was discontinued on 07/23/25. She stated she did not feel like the care plan not being updated for the discontinued medication would have affected the resident in any way because the resident's physician orders would have been in place, and that was what the nurses would have followed for providing medications to the residents. During an interview on 07/30/26 at 4:14 PM, the DON stated LVN A was responsible for completing and revising resident care plans. She stated the SW revised some of the resident care plans as well. She stated LVN A and the SW were trained on completing and revising resident care plans. She stated PRN and routine medications should have been included in the resident care plans and if a medication was discontinued, the care plan should have been revised. She stated a resident's code status should have been included in a residents care plan. She stated care plans should have been revised quickly, but she did not have a specific amount of time, and if a medication had been discontinued over a year ago, the care plan should have been revised. She stated a resident's code status should go into their care plan immediately and updated immediately for any changes. She stated she was not aware Resident #29's ABH gel was discontinued on 07/23/25. She stated she was not aware Resident #70's care plan had not included his DNR code status. She stated if a resident's care plan was not revised to reflect their current status, which included medications that were discontinued, it could have potentially caused harm. She stated if a resident's code status was not included in their care plan, it could have possibly caused harm, but she would not have went to a resident's care plan to find a resident's code status in an emergency. Record review of the facility's policy, dated 2001 and revised December 2016, titled Care Plans, Comprehensive Person-Centered reflected: Policy Statement: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT includes: a. The Attending Physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 10%, based on 3 errors out of 30 opportunities, which involved 1 of 7 residents (Resident # 22) and two of six staff (MA D and LVN B) observed during medication administration reviewed for medication errors. The facility failed to ensure MA D followed the ordered BP parameters for administration of Atenolol Oral Tablet 50 MG (treating high blood pressure) ordered by physician for Resident #22 on 07/29/2026 at 8:04 a.m.The facility failed to ensure MA D and LVN B followed the physician order which did not specify any parameters to hold Resident #22's Amiodarone CHl 200 MG (for antiarrhythmic - abnormal heart rhythms) on 07/29/2026 at 8:04 a.m.The facility failed to ensure MA D administered Arginaid Oral Packet (Nutritional Supplements) Give 1 unit by mouth one time a day for aid in wound healing to Resident #22 on 07/29/2026 at 8:04 a.m. These failures could place residents at risk of their medications not being administered according to physician's orders which could lead to low blood pressure, falls, injuries and not receiving the intended therapeutic benefits of their medications. Findings include:Record review of Resident #22 's face sheet, dated 07/29/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included acute on chronic systolic (congestive) heart failure (long-term, stable heart pumping weakness experiences a sudden, severe worsening of symptoms), essential (primary) hypertension (high blood pressure without a single clear cause), and heart failure (a serious medical condition where the heart cannot pump blood well, leading to common signs like shortness of breath, tiredness, and body swelling).Record review of Resident #22's quarterly MDS assessment, dated 07/02/2026, indicated Resident #22's BIMS score was 14, which indicated intact cognition.Record review of Resident #22's comprehensive care plan, revised 04/15/2026, indicated a focus: Congestive heart failure and was at risk for shortness of breath, chest pain and increased edema (swelling caused by fluid trapped in your body's tissues) and elevated BP with interventions: Administer her cardiac medications as ordered. Resident #22's focus: Altered cardiovascular status related to atrial fibrillation (a common irregular and fast heart rhythm where the upper chambers of the heartbeat chaotically out of sync with the lower chambers) with interventions: Give Amiodarone as ordered.Record review of Resident #22's order summary report on 07/29/2026 at 9:28 a.m. revealed: an order with start date of 02/09/2026 for Pacerone Oral Tablet 200 MG (Amiodarone HCl). Give 1 tablet by mouth one time a day related to unspecified atrial fibrillation. No holding parameters were indicated in the order. The order with start date on 05/28/26 for Arginaid Oral Packet (Nutritional Supplements). Give 1 verbal unit by mouth one time a day for aid in wound healing. The medication is initialed by MA D with a check mark that according to the chart codes indicates a medication was administered. An order with start date 02/10/2026 for Atenolol Oral Tablet 50 MG (Atenolol). Give 1 tablet by mouth one time a day related to essential (primary) hypertension hold if systolic BP <110 and dystolic BP <60, HR <60. Notify nurse if medication is held.Record review of Resident #22's medication administration record for July 2026 revealed MA D documented with a check mark that according to the chart codes indicated a medication was administered: Atenolol oral tablet 50 mg, Pacerone (Amiodarone HCl) oral tablet 200mg, and Arginaid Oral packet (nutritional supplements) give 1 unit by mouth on 07/29/2026 at 9:00 a.m. Atenolol oral tablet 50 mg and Pacerone (Amiodarone HCl) oral tablet 200mg were wasted by the MA D & LVN B and excluded from med pass on 7/29/2026 at 8:04 a.m. Arginaid oral packet was not administered during the medication pass on 7/29/2026 at 8:04p.m.Observation of the medication pass on 07/29/2026 at 8:04 a.m. revealed MA D measured Resident #22's blood pressure using an electronic wrist blood pressure cuff with readings: BP 96/51 Pulse 71. MA D asked LVN B to recheck Resident # 22's BP and LVN B rechecked Resident #22's BP with reading: 113/55, pulse 70. MA D prepared Atenolol Oral Tablet 50 MG (Atenolol) Give 1 tablet by mouth one time a day related to essential (primary) hypertension (high blood pressure). MA D picked up a medication cup with Atenolol tablet 50 MG in it and turned to enter Resident #22's room to administer it to Resident #22. After MA D was asked about BP parameters, she realized that BP was out of ordered parameters and was observed not administering Atenolol oral tablet 50 mg and Pacerone (Amiodarone HCl) oral tablet 200mg to Resident #22. She prepared the medications from the beginning and excluded Atenolol and Amiodarone from administration. While observing medication pass Arginaid (medical food powder supplements providing vitamins C and E to support wound healing) was not observed to be prepared or given to Resident #22.During an interview on 07/29/2026 at 8:15 a.m. MA D stated, I think we hold BP medication if BP was below 110/60 and pulse 60. She looked at Resident #22's medication administration record and was unsure how to find the parameters requiring to hold BP medication. She called LVN B for clarification. LVN B came to the medication cart for station #1 on 07/29/2026 at 8:20 a.m. and stated the Amiodarone and Atenolol would be held if systolic BP <110 and diastolic BP <60, HR <60. She stated if the resident was given these medications the blood pressure could get lower.During an interview with Resident #22 on 07/30/2026 at 1:17 p.m., Resident #22 stated MA D or other medication aides checked her BP before administering BP medications and if it showed low BP, they rechecked it with a nurse and did not give her BP medication. She stated she did not feel dizzy, shortness of breath or lightheaded like she had low BP.During an interview with MA D on 07/30/2026 12:31 p.m., she stated she worked as medication aide and certified nursing assistant at this facility for 6 years. She stated she had training on medication administration 2 weeks ago. She stated she was trained on preparing medications for each resident before the administration of medications and checking residents' orders before administration of medications one at a time. She stated if residents had blood pressure medications ordered, she checked blood pressure first and checked their parameters ordered by the doctor. MA D stated if the BP was below 110/60 and 60, she held the medication and documented BP in residents' medication administration record. She stated that she did not realize that Resident #22's BP was outside the ordered parameters when she was going to administer her BP medications. She stated everybody had the same BP holding parameters. She stated she did not administer medication if the BP was outside of ordered parameters. She stated she would consult with a charge nurse to recheck the Resident #22's BP and according to nursing instruction would administer or not. She stated if administered BP medication with low BP reading, residents could pass out or get hurt. MA D stated if medication was not administered to residents according to residents' order, it could cause medication errors and affect the residents' health.During an interview with LVN B on 07/30/2026 at 12:49 p.m., she stated she worked as a charge nurse at station #1 and received the medication administration training as an annual continuing education. She stated medication aides were supposed to come to her if the BP or HR for residents were elevated or low. She stated she was responsible for rechecking residents' BP and records the BP and HR in their electronical medical chart. She stated she was responsible for instructing medication aides to hold the BP medication, documented it in progress notes and contacted the physician and DON if issues did not resolve. She stated the process for blood pressure out of parameters was to check on the residents first to make sure they did not have any change of condition, which could follow the low blood pressure if unresolved. If resident's BP was lower, she put her BP rechecks in vital signs in the resident's chart. She stated residents could have different holding parameters for BP medication and she was responsible for verifying each resident's order before administration of their medication. She stated that Resident #22 had BP medications that had to be held if her BP was outside of parameters.During an interview with the DON on 07/30/2026 at 3:56 p.m., she stated Medication administration training was provided to all nurses and medication aides at hire, annually and on as needed basis when somebody needed additional training. She stated medication aides and nursing staff were supposed to check BP parameters before preparing medications and administering BP medications. She stated the training was provided to nursing staff and medication aides on BP parameters recently to hold medication below 110/60 and HR below 60. She stated medication aides were responsible for notifying charge nurses about BP/HR outside the parameters and hold medication until the charge nurse rechecked BP/HR and gave them instructions to administer medication or continue to hold BP medication. She stated charge nurses were responsible for rechecking BP if outside of parameters, documenting it in the residents' medical charts, and notifying the physician and her regarding low BP. She stated if BP rechecks and holding of BP medication was not documented, it did not happen. She stated if BP medications were administered not according to the physician orders, it could be considered medication error and could hurt residents. She stated nursing staff were responsible for checking each residents' orders before medication administration to make sure they followed the orders and didn't hold medication if it was not necessary.During an interview with the ADM on 07/30/2026 at 4:15 p.m., she stated her expectations for nursing staff was to follow proper medication administration policy. She stated nursing staff: DON, ADON, charge nurses and medication aides were responsible for following physician orders for medication administration for each resident. She stated she was not aware of BP parameters for different residents, but she expected nursing staff should check each resident's physician order for those parameters before medication administration every time. She stated nursing staff should hold medication if it was outside of those parameters, document it and notify the charge nurse, DON and physician if necessary. She stated she was not sure how exactly it could affect residents if BP medication was administered outside of parameters but assumed it could negatively affect their health conditions.Record review of the facility's policy Administration Medication, revised 04/2019, revealed Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders,.11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. Interview with DON Interview with ADM

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to ensure food safety on 05/20/2025 by not temping hot foods before service, consistently monitoring, and discarding expired food, maintaining unsanitary kitchen equipment and storage areas when food items were not labeled and/or dated and Drawers where the serving utensils were stored were dirty. These failures could place residents who received meals from the main kitchen at risk for foodborne illness. Findings included: Observation on 5/20/2025 at 8:45 AM of the walk-in refrigerator reflected the following: - Hot dogs in a sealed bag were dated 4-18 with no discard date. - Cheese in a sealed bag that was not in the original package was dated 5-16 with no discard date. - Lunch meat in a sealed bag that was dated May 16 with no discard date. - Ketchup in a plastic container that was dated 5-19-25 with no discard date. - Mechanical soft breakfast sausage that was dated 5/20 with no discard date. Observation on 5/20/2025 at 8:53 AM of the Pantry reflected the following: - Thickened lemon-flavored water dated 5-14-2025. - Canned Mandarin oranges dated 11-02-2024. - Rice in a sealed bag that was dated 5/2 with no year and no discard date. Observation on 5/20/2025 at 8:53 AM of the freezer reflected the following: - Frozen peas were open and not sealed. - Frozen hot dogs in a sealed bag that was dated 4-19 with no year and discard date. Observation on 5/20/2025 at 9:25 am of the kitchen reflected the following: - Drawer containing serving utensils was dirty with debris of food in the drawer. Observation on 5/20/2025 at 11:50 AM of CK taking food temperatures. - While taking the temperature of the mashed potatoes, rubber gloves were going into the mashed potatoes and other foods on the hot line, - While taking the temperatures of the hot foods. The temperature of the red beans was not taken. - While taking temperatures of the hot food, the thermometer was not sanitized between taking the temperatures of other foods. An interview on 5/22/2025 at 12:20 PM with CK said that the temperature of all the foods on the line should be taken. Before taking the temperature of another food item, the thermometer should be sanitized before it was used again on another food item. The temperature of the food item should be logged in the book. CK said that DM was the one who was responsible for checking the out-of-date products. CK said that if she does have to get something to make a dish, and sees something out of date, she will remove the out-of-date items. CK said that when an item was put in a sealed bag, it should be labeled with the date that it was put in the bag and the expiration date. CK said that if the thermometer was not cleaned between taking the temperature of each food item, there could be cross-contamination. CK said that if a resident was served out-of-date food, a resident could get sick. An interview on 5/22/2025 at 12:38 PM with DM said that when taking the temperature of foods, the thermometer should be cleaned and sanitized with a new wipe before taking temperatures of other foods. DM said that if a new sanitation wipe is not used, there can be cross-contamination. DM said that the stocker is the one who checks for dates. DM said that she also checks for out-of-date products in the kitchen. If she uses something, she checks for dates. Puts out-of-date product on a different shelf. DM stated that someone could get sick if out-of-date food is used. DM stated that when an item is put in the cooler in a sealed bag the date when it was put in the bag and expiration date should be listed on the bag. During an interview on 5/22/2025 at 1:45 PM with ADM said all items in the kitchen should be dated. ADM said that if out-of-date items are used, then residents could get sick. ADM said when taking the temperatures of food, a new sanitation wipe should be used to clean the thermometer between usage. Record review of facility food storage policy updated November 2022, - Critical Control Point means a specific point, procedure, or step in the food preparation and serving process to which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygiene practices. - Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial, or viral organisms capable of causing a disease or toxin formation). - Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 7 residents (Residents #1, #2 and #3) reviewed for resident rights. The facility failed to ensure Resident #1, Resident #2, and Resident's #3 call lights were within reach on 04/29/2025. This failure could place residents at risk of their needs not being met. Findings include: 1.Record review of Resident #1's admission record, dated 04/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: nontraumatic intracerebral hemorrhage in hemisphere cortical (bleeding within the brain tissue, not caused by injury, specifically in the outer layer of one half of the brain.), cachexia (waste disorder characterized by significant weight loss muscle wasting, and fat loss), muscle weakness (reduce ability of the body to contract muscle properly, resulting in a lower strength in one or more muscle), lack of coordination (having difficulty controlling your movements and making them work together smoothly) and need for assistance with personal care (needing help with basic, everyday activities that are necessary for maintaining hygiene, health, and overall well-being). Record review of Resident #1's Admission MDS assessment, dated 04/11/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #1 was dependent in the areas: toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #1 required substantial/maximal assistance in the areas: eating, oral hygiene, and personal hygiene. Record review of Resident #1's care plan, dated 04/29/2025, reflected Resident #1 was care planned for falls and had an intervention be sure his call light is within reach. During an observation on 04/29/2025 at 9:24 am., Resident #1 was observed in his chair while his call light was observed hanging over his nightstand approximately 3 feet away from Resident #1's chair. Attempted to interview Resident #1 on 04/29/2025 at 9:24 am. but it was not successful due to his severe cognitive impairment. 2.Record review of Resident #2's admission record, dated 04/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: paranoid schizophrenia (when someone experiences strong paranoia/they are intensely suspicious and fearful of others), type 2 diabetes mellitus without complications (condition were your body doesn't use insulin properly causing high blood sugar levels), muscle weakness (reduce ability of the body to contract muscle properly, resulting in a lower strength in one or more muscle), and anxiety disorder (mental health condition characterized by excessive and persistent worry and fear). Record review of Resident #2's Annual MDS assessment, dated 02/14/2025, reflected the resident had a BIMS score of 15, which indicated cognitively intact. Resident #2 required supervision or touching assistance in the area of shower/bathe self. Record review of Resident #2's care plan, dated 04/29/2025, reflected Resident #2 was care planned for risk of falls r/t psychotropic med use, and had an intervention for Resident #2's be sure Resident #2 call light is within reach us for assistance as needed. During an observation and interview on 04/29/2025 at 9:24 am., Resident #2's call light was observed hanging between the wall and his bed. Resident #2 stated that he could not reach his call light if he tried to. Resident #2 stated he would have to move his bed to get to his call light. Resident #2 stated he did not know how long his call light was behind his bed. During an observation on 04/29/2025 at 1:40 pm., Resident #2's call light was observed hanging between the wall and his bed. Resident #2 was sleep at the time of this observation. 3.Record review of Resident #3's admission record, dated 04/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: systolic heart failure (happens when the heart's main pumping chamber, the left ventricle, doesn't pump blood effectively), cognitive communication deficit (someone had trouble communicating because they're struggling with thinking and problem-solving skills), lack of coordination (having difficulty controlling your movements and making them work together smoothly), and anxiety disorder (mental health condition characterized by excessive and persistent worry and fear). Record review of Resident #3's Quarterly MDS assessment, dated 03/03/2025, reflected the resident had a BIMS score of 12, which indicated moderate cognitive impairment. Resident #3 required partial/moderate assistance in the area of shower/bathe self, lower body dressing, and putting on/taking footwear. Record review of Resident #3's care plan, dated 04/29/2025, reflected Resident #2 was care planned for risk of falls r/t gait/balance problems, psychoactive drug use, and had an intervention of be sure Resident #3's call light is within reach and encourage her to use it for assistance as needed. During an observation and interview on 04/29/2025 at 10:15 am., Resident #3's call light was observed hanging towards the ground on the left side of her bed. Resident #3 stated that she could not reach her call light if she tried to. Resident #3 was not aware of how long her call light had been out of reach. During an interview with the CNA A on 04/29/2025 at 1:30 pm., CNA A stated she and CNA B both were working the 100 hall where Residents #1, #2, and #3 resided. CNA A stated CNAs made rounds every two hours or as needed. CNA A stated it was everyone's responsibility for ensure residents' call lights were within reach. CNA A stated, when making rounds, CNAs checked to see if residents needed assistance and ensured the residents were safe. CNA A stated the purpose of a call light was a resident to call for assistance. CNA A stated she was not aware Residents #1, #2 or #3's call lights were not within reach. CNA A stated if a resident could not reach the call light, the resident would not be able to call for help if they need something. During an interview with CNA B on 04/29/2025 at 1:50 pm., CNA B stated she and CNA A both worked the 100 hall where Residents #1, #2, and #3 resided. CNA B stated CNAs made rounds at least every two hours unless there was a resident who may require more frequent checks. CNA B stated that it was the CNAs and anyone who entered the resident's room to ensure the call lights was in reach. CNA B stated during rounds, CNAs were taught to ensure the resident call lights were in reach. CNA B stated she was not aware Resident #1, #2, or #3's call light was not within reach. CNA B stated if a resident's call light was not in reach the resident would not be able to call for assistance. During an interview with the DON on 04/29/2025 at 2:55 pm., the DON stated all residents' call lights should be always within reach. The DON confirmed that CNA A and CNA B were working the 100 halls where Residents #1, #2, and #3 resided. The DON stated it was everyone's responsibility to ensure residents' call lights were always within reach. The DON stated if a resident's call light was not within reach the resident would not be able to receive assistance if they needed it. During an interview with the ADM on 04/29/2025 at 3:55pm., the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call light were within reach. The ADM stated if a resident call light was not within reach, then the resident may not be able to call for assistance. The ADM stated her expectation was for all resident's call lights to always be within reach. A record review of the facility's Answering the Call Light policy, undated, reflected The purpose of this procedure is to ensure timely response to the resident's requests and needs. General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's kitchen for one out of one ice machines. The facility failed to ensure the ice machine was free of mold. This failure placed the residents at risk for foodborne illnesses. Findings included: Observation on 3/26/2024 at 09:02 am of the only ice machine had pink and black residue on the outside of the internal plastic covering over the ice drop, the level of ice was up to the bottom edge of covering. Observation on 3/26/2024 at 12:30 pm of ice machine after cleaning faint pink coloring remains, no black residue present on the internal plastic covering over the ice drop. In an interview with the DM on 3/26/2024 at 09:02am, she stated that she was surprised by the pink and black residue on the ice machine as it was cleaned by maintenance on Thursday. She stated she would have it cleaned again. She stated a potential outcome would be the residents would be at risk of getting sick. In an interview with the DA on 03/26/2024 at 09:51 am, she stated she has been at the facility for 3 months and she was not sure what the policy about cleaning the ice machine stated. In an interview with DON on 3/262024 at 4:00 pm, he stated his expectation was that the ice machine be maintained in a sanitary condition and cleaned as scheduled. He stated he was the infection preventionist and monitored the cleaning schedule weekly. He stated maintenance was responsible for the cleaning and sanitation of the ice machine weekly. He stated failure to maintain the cleaning schedule could put the residents at risk for foodborne illnesses. In an interview with the ADM on 3/26/2024, she stated her expectation was that the ice machine was cleaned as scheduled by maintenance. Maintenance did clean the ice machine this morning. She stated that because residents use the ice machine several times a day, at least during meals, they can be at risk for illness . Record review of Kitchen cleaning schedule dated January 2024 on 3/28/2024 at 10:00 am revealed the ice machine was cleaned on 1/2/2024, 1/3/2024, 1/12/2024, 1/17/2024, and 1/24/2024. Record review of Kitchen cleaning schedule dated February 2024 on 3/28/2024 at 10:00 am revealed the ice machine was cleaned on 2/8/2024, 2/14/2024, 2/21/2024, and 2/28/2024. Record review of Kitchen cleaning schedule of cleaning dated March 2024 on 3/28/2024 at 10:00 am revealed that the ice machine was cleaned on 3/6/2024 and 3/14/2024. Record review of Statement made by MD undated on 3/28/2024 at 10:00 am revealed Ice machine received preventative maintenance cleaning/sanitizing on 3/21/2024. Record review of Policy ice machine and ice storage chests revised January of 2012 on 3/28/2024 at 10:00 am revealed 3. Our Facility has established procedures for cleaning and disinfecting ice machines which adhere to the manufacturer's instructions. The infection preventionist (or designee) maintains a copy of these procedures. The facility failed to ensure the ice machine was free of mold. This failure placed the residents at risk for foodborne illnesses. Findings included: Observation on 3/26/2024 at 09:02 am of the only ice machine had pink and black residue on the outside of the internal plastic covering over the ice drop, the level of ice was up to the bottom edge of covering. Observation on 3/26/2024 at 12:30 pm of ice machine after cleaning faint pink coloring remains, no black residue present on the internal plastic covering over the ice drop. In an interview with the DM on 3/26/2024 at 09:02am, she stated that she was surprised by the pink and black residue on the ice machine as it was cleaned by maintenance on Thursday. She stated she would have it cleaned again. She stated a potential outcome would be the residents would be at risk of getting sick. In an interview with the DA on 03/26/2024 at 09:51 am, she stated she has been at the facility for 3 months and she was not sure what the policy about cleaning the ice machine stated. In an interview with DON on 3/262024 at 4:00 pm, he stated his expectation was that the ice machine be maintained in a sanitary condition and cleaned as scheduled. He stated he was the infection preventionist and monitored the cleaning schedule weekly. He stated maintenance was responsible for the cleaning and sanitation of the ice machine weekly. He stated failure to maintain the cleaning schedule could put the residents at risk for foodborne illnesses. In an interview with the ADM on 3/26/2024, she stated her expectation was that the ice machine was cleaned as scheduled by maintenance. Maintenance did clean the ice machine this morning. She stated that because residents use the ice machine several times a day, at least during meals, they can be at risk for illness . Record review of Kitchen cleaning schedule dated January 2024 on 3/28/2024 at 10:00 am revealed the ice machine was cleaned on 1/2/2024, 1/3/2024, 1/12/2024, 1/17/2024, and 1/24/2024. Record review of Kitchen cleaning schedule dated February 2024 on 3/28/2024 at 10:00 am revealed the ice machine was cleaned on 2/8/2024, 2/14/2024, 2/21/2024, and 2/28/2024. Record review of Kitchen cleaning schedule of cleaning dated March 2024 on 3/28/2024 at 10:00 am revealed that the ice machine was cleaned on 3/6/2024 and 3/14/2024. Record review of Statement made by MD undated on 3/28/2024 at 10:00 am revealed Ice machine received preventative maintenance cleaning/sanitizing on 3/21/2024. Record review of Policy ice machine and ice storage chests revised January of 2012 on 3/28/2024 at 10:00 am revealed 3. Our Facility has established procedures for cleaning and disinfecting ice machines which adhere to the manufacturer's instructions. The infection preventionist (or designee) maintains a copy of these procedures.

Based on interviews and record review the facility failed to refer all residents with possible serious mental disorders or a related condition for level II resident review upon a significant change in status assessment for 1 of 5 Residents (Resident #52) whose records were reviewed for mental disorders. The facility failed to refer Resident #52 for a PASRR evaluation based on mental disorder diagnoses including Schizoaffective Disorder, Bipolar type. This deficient practice could affect residents with a mental illness and contribute to a delay in services needed. Findings included: Review of Resident # 52's face sheet dated 3/28/2024 revealed a [AGE] year-old female with admitted [DATE] and a readmitted [DATE] with diagnoses that included Type 2 Diabetes Melllitus without complication (consistent elevated blood sugar), Cardiac Arrhythmia (abnormal heart rate), and Diaphragmatic Hernia without obstruction or gangrene (a hole in the diaphragm a muscle that is used in respiration without tissues damage). Diagnosis added on 3/15/2024 included bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder, bipolar type (a mental illness that affects your mood and thoughts with symptoms of bipolar disorder). Review of Resident # 52's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 which indicated a moderate cognitive impairment. Section I revealed diagnoses that include anxiety disorder, bipolar disorder, and Schizophrenia. Review of Resident # 52's PASRR level 1 screening dated 12/12/2022 revealed no mental illness, intellectual disorder, or developmental disability. Facility was unable to provide PASSR screening for readmitted [DATE] or when new diagnosis was made on 3/15/2024. Review of Resident # 52 's Care Plan revised 5/19/2023 requires antipsychotic medications (Abilify) for diagnosis of behavior management. In an interview with the MDS Coordinator on 3/27/2024 at 1:00 pm, she stated that the Level 1 screening was not sent when the new mental illness was identified, and that it should have been. She continued that she was not sure how it got missed but she would send it in today (3/27/2024). She stated that she was responsible to make sure all PASSR level 1 screenings that were positive were sent to the local authority . She stated the PASSR level 1 screening not being the local authority could cause a delay in the resident receiving needed services. In an interview with DON on 3/27/2024 at 3:30 pm, he stated that his expectations were the MDS coordinator was responsible for making sure the facility meets requirements for PASRR reporting. He stated that a PASRR no submit can put the resident at risk for not receiving recommended services. In an interview with the ADM on 3/28/2024 at 10:30 am, she stated that her expectation was the PASRR level 1 be submitted per facility policy. She stated this was the responsibility of the MDS coordinator. If not done timely the PASSR screening can prevent potential treatment for the resident. Review of Policy titled Policy and Procedure for PASRR Level 1/PASRR compliance 6/27/2014 dated 6/27/2014, 3/28/2024 11:00 am revealed F. If at any time a resident has a significant change or you receive information that might indicate the resident may have a mental illness, intellectual disorder or developmental disability, or condition not contained in the medical record, please submit PASRR level 1 screening for the resident to be evaluated by the local authority.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 2 residents (Resident #50) reviewed for care plans. The facility failed to follow comprehensive care plan interventions for Residents #50. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Review of Resident #50's face sheet dated 06/14/23 revealed Resident #50 was a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysphagia (difficulty in swallowing), hypertension (a condition in which the force of the blood against the artery walls is too high), and hyperkalemia (elevated level of potassium in the blood). Review of the MDS dated [DATE] reflected Resident #50 had a BIMS score of 14 indicating Resident #50 was cognitively intact and Resident #50 was independent for bed mobility, transfers, and eating. Resident #50 required extensive assistance for dressing and required limited assistance for toileting and personal hygiene. MDS reflected Resident #50 used tobacco. Review of Resident #52's clinical record revealed comprehensive care plan initiated 09/18/23 revealed: Resident #50 is a smoker. Goal: Resident #50 will not smoke without supervision through the next review date. Interventions: Instruct him about the facility policy on smoking times and safety concerns, and Monthly smoking assessments. Resident #50 requires supervision with smoking apron. Resident #50's smoking supplies are kept at nurse's station. Review of Resident #50's assessments dated from 07/02/22 to 03/25/24 in electronic medical record revealed there were no initial or monthly smoking assessments completed. In an interview on 03/27/24 at 2:55 PM with Resident #50, he stated he was doing fair, and the staff all treated him pretty good. He stated he had a call button to use to call for help and staff got to him in a timely manner when he called them. He stated he felt safe in the facility. He stated he smoked cigarettes during designated smoke times, and he wore an apron to protect his clothing when he smoked. He stated he had no concerns about anything at the facility. In an interview on 03/27/24 at 2:07 PM with the MDS, she stated Resident #50 did not smoke cigarettes when he had first admitted to the facility. She stated Resident #50 had begun smoking sometime last summer but she was not sure of the date. She stated Resident #50 had begun asking other residents for cigarettes and started out with an electronic cigarette. She stated smoking assessments should be done monthly. She stated all smokers were supervised when smoking but if the care plan interventions were not followed, it could put residents at risk for not wearing their safe smoking aprons or may not allow resident to be kept safe by staff. She stated Resident #50's MDS which was done on admission was correct and did not reflect that Resident #50 was a smoker. The MDS assessment which was done in July did reflect Resident #50 was a smoker, so she did not know the exact date, but it was sometime in between April and July of 2023 when Resident #50 began smoking. In an interview on 03/27/24 at 3:30 PM with the ADM, she stated Resident #50 was currently a smoker, but he did not smoke before when he first admitted to the facility. She stated the admitting nurse was responsible for completing the admission smoking assessment but smoking admitting assessments were only done for residents that were smokers. She stated the monthly smoking assessments should have been completed by the charge nurses. She stated staff should follow care plan interventions. She stated staff have been trained on following care plans and completing smoking assessments. She stated if care plan interventions were not followed, it could cause all kinds of problems for residents such as them receiving the wrong care or wrong diet . In an interview on 03/27/24 at 3:38 PM with the DON, he stated Resident #50 was a smoker at that time, but he had not been a smoker when he first admitted to the facility. He stated he was aware that Resident #50 did not have any smoking assessments at that time but that they had corrected those. He stated smoking assessments were done upon admit and then monthly and only for residents that were smokers. He stated that the charge nurses were responsible for the assessments. He stated staff should always follow care plan interventions and staff had been trained on following care plan interventions and completing smoking assessments. He stated if care plan interventions were not followed, the proper care would not be given to the residents and that no staff should have ever hit the floor to work without being trained on how to read the care plans and follow them or how to access the residents records which indicate the care that should be received . Review of facility policy dated 2001 (revised April 2006) titled Care Plans - Goals and Objectives revealed Policy Statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: a. Are resident oriented, b. Are behaviorally stated, c. Are measurable; and d. Contain timetables to meet the resident's needs in accordance with the comprehensive assessment. 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved, c. When the resident has been readmitted to the facility from a hospital/rehabilitation stay, and d. At least quarterly.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. A. The facility failed to sanitize the oven, walk-in refrigerator and walk-in freezer located in the kitchen. B. The facility failed to properly store and label food in the facility's walk-in refrigerator and walk-in freezer. C. The facility failed to ensure Dietary Aide B wore a beard net when removing clean plates from the dishwasher and Dietary Aide C properly wore a hair net when placing residents' breakfast plates on the meal tray cart. D. The facility failed to dispose of an expired case of prune juice and expired 8 loaves of Texas toast bread in the dry storage room. E. The facility failed to ensure Dietary Cook A properly sanitized hands between tasks. These failures could place the residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: A. Observation of the kitchen equipment on [DATE] at 9:10 AM- 9:45 AM revealed an oven with two doors had yellowish/brownish hard substance inside the glass of both doors. The oven also had dried hard crumbs and a thick hard black substance on the bottom and sides of the oven. In an interview on [DATE] at 9:25 AM the Dietary Cook A stated he was responsible for cleaning the oven. He stated the oven was to be cleaned as needed and once a week. He stated the oven had not been cleaned in approximately two or three weeks. He stated he was busy and forgot to clean the oven. He stated he had been working in this kitchen as a cook for approximately [AGE] years and he was aware of his job duties. He stated if the oven was not clean there could be germs in the oven and possibly spread to the food. He stated he did not know if it could affect a resident. Observation of the walk-in refrigerator on [DATE] at 9:10 AM- 9:45 AM revealed packets of butter on the floor. There were crumbs underneath the shelves and in the middle of the floor. Observation of the walk-in freezer on [DATE] at 9:10 AM - 9:45 AM revealed hard ice on the floor near the door. There were approximately 10 inches of ice on the middle shelf away from the door. Approximately ,d+[DATE] inches of ice particles hanging down from the fan located near the ceiling. Observed crumbs on the floor. B. Observation of the walk- in refrigerator and walk-in freezer in the kitchen on [DATE] at 9:10 AM - 9:45 AM revealed the following: - nectar thickened juice in the refrigerator, not in its original package without a label. -box of turkey breast and one gallon of partially opened [NAME] dressing touching the pipe located near the ceiling of the refrigerator. The pipe had black tape wrapped around it. There were approximately ,d+[DATE] inches of the tape loose and there was grime inside the loose portion of the tape. - there were 4 boxes of food stacked on top of each other with the top box touching the fan located approximately 8 inches below the ceiling of the refrigerator. The label of the boxes was not in view, unable to determine what food was in each box. When moved to view the label, two of the boxes began to fall from the top shelf of the refrigerator. -approximately ,d+[DATE] pounds of pork loin, a plastic bag of chicken in its original package, and boxes of ice cream and french toast stored on the top shelf of the freezer touching the pipe. There were approximately 4 inches of ice on the box of the french toast. The pipe had black tape wrapped around it and the black tape was loose from the pipe. There was grime on the inside of the black tape. - one partially opened pie dough and one sealed pie dough touching the fan on top of the freezer. The pie dough was located where the ice particles were hanging from the fan. - one partially opened left over ,d+[DATE] gallon of ice cream not dated and one partially opened gallon of ice cream not dated. - a bag of ice stored on the floor of the walk-in freezer with a tear on the bottom of the bag. C. Observation on [DATE] at 9:10 AM - 9:45 AM revealed Dietary Aide B was not wearing a beard net. His beard was approximately ,d+[DATE] inches long. He was removing clean plates, pans, and silverware from the dishwasher. In an interview on [DATE] at 9:35 AM Dietary Aide B stated he was required to wear a beard net when in the kitchen. He stated the beard nets were in the same bin as the hair nets. He stated before he entered the kitchen, he placed a hair net on his head but there were not any beard nets available. He stated he looked for beard nets and there was not any in the kitchen. He stated when there were not any beard nets he waited until someone had access to the storage and brought more beard nets to the kitchen. In an interview on [DATE] at 9:40 Am the Dietary Manager stated she forgot to get the beard nets from the storage room. She stated she usually kept extra hair nets and beard nets in the kitchen if there was not any in the bin by the kitchen door. She stated it was her responsibility to ensure the staff had beard nets and hair nets. Observation on [DATE] at 7:55 AM Dietary Aide C's hair net was not completely covering her hair when she placed residents' breakfast plates on the meal tray cart. Approximately ,d+[DATE] inches of her hair was not covered from her forehead to middle of her head. In an interview on [DATE] at 7:58 AM Dietary Aide C stated all her hair was expected to be covered with the hair net. She stated she did not realize most of her hair was not covered with the hair net. She stated she was in serviced on the proper use of wearing hair nets when in the kitchen many times. D. Observation in the dry storage room on [DATE] at 9:10 AM - 9:45 AM revealed: - There was a case of prune juice with a date of [DATE] on the box. The expired date on the cans of the prune juice was [DATE]. - There was a flat tray with eight loaves of Texas toast bread in the original clear bag without a label or date on the bags. On the flat tray was a date [DATE]. In an interview on [DATE] at 9:25 AM the Dietary Manager stated all foods on the flat trays had the dates on labels located on the trays. She stated she did not know if the date was accurate. She also stated the staff was expected to place the label with the expiration date on the tray. She stated if the date was not accurate the staff was expected to change the date on the trays. She stated the date on the Texas toast bread was [DATE] from the label on the tray. E. Observation on [DATE] at 10:15 AM the Dietary Cook A was not wearing gloves. He picked up small pieces of raw chicken from the prep table and opened the top of the garbage can to dispose the raw chicken. He returned to the food prep table and began wiping the table with a wet small towel. He touched the raw chicken stored in a bowl as he was moving the bowl. Dietary Cook A placed oven mitts on his hands to remove the corn bread from the oven. He placed the pan of corn bread on the prep table and removed the oven mitts. When he removed the oven mitts 4 of his fingers on his right hand touched a small portion of the corn bread. After he touched the cornbread, he donned gloves without washing or sanitizing his hands. In an interview on [DATE] at 10:25 AM Dietary Cook A stated he did not wash or sanitize his hands prior to placing the gloves on his hands. He stated he did pick up pieces of raw chicken and opened the garbage can and threw the chicken in the garbage. He stated he did not wash or sanitize his hands or put on gloves when he used the oven mitt to remove the cornbread from the oven. He stated he was required to wash his hands when they were dirty. He stated he would consider his hands dirty when he touched the raw chicken, rag and the garbage can. He stated there was a possibility that germs could transfer to residents' food and a resident could become ill if the cook did not properly sanitize hands when cooking meals for the residents. He stated he had been in serviced on hand washing and wearing gloves. In an interview on [DATE] at 8:35 AM, the Dietary Manager stated the oven was expected to be cleaned immediately when staff observed it was dirty. She stated the oven was dirty on [DATE] and it needed to be cleaned. She stated it was her understanding that it had been approximately 2 weeks since the oven had been cleaned. She stated there was a potential that the food being cooked in the oven could get bacteria on the food from the oven not being sanitary. She also stated with the oven not being clean there was a potential for a fire. She stated the floors in the refrigerator and freezer had not been swept for two or three days. She stated if there was any type of food on the floor in either the refrigerator or freezer the staff was expected to sweep it immediately. She stated with ice on the floor in the freezer there was a potential someone could fall. She stated the ice on the shelf and floor in the freezer was from condensation. She stated she did not check or have maintenance to check the fan or pipes to determine if the ice could be frozen from a possible water leak. She stated boxes of food in the refrigerator and freezer were not to be stacked on top of each other. She stated there needed to be space between boxes for air circulation. She stated stacking boxes on top of each other was a hazard especially if the boxes were on the top shelf. She stated all food including left over food was expected to be labeled and dated. She stated all expired food and juices were to be disposed. She stated any food in the refrigerator or freezer was not to be stored next to the fan or pipe. She stated this was not acceptable. She stated all staff entering the kitchen was expected to wear hair nets and beard nets. She stated the hair net was to cover all the staff's hair and if it did not there was a potential hair could fall into the food, plates, or anything the residents would be using for their meals. She stated it was her responsibility to ensure the staff had adequate amount of beard guards and hair nets. She stated hair could fall from a man's beard into resident food or plates. She stated all staff was to follow the hand sanitizing protocol. She also stated she had not reported anything to Maintenance about the ice on the freezer floor or other areas in the freezer. In an interview on [DATE] at 8:20 AM the Maintenance Director stated he asked if there were any maintenance issues during department head morning meetings. He stated he took a small notebook into the morning meeting and if there were any maintenance issues, he would write it in the notebook and take care of any problems. He stated the Dietary Manager was in these meetings. He stated he was not aware of ice on the floor or shelves in the freezer. He stated if there were icicles on the fan and ice on the shelves there was a possibility it was from condensation or it might be from something else. He stated if there were any maintenance issues that needed to be taken care of after the morning meeting the staff would verbally report it to him or text him. He stated he was not aware of any ice issues in the freezer of the kitchen. In an interview on [DATE] at 11:00 AM the Dietary Manager stated all dietary staff was to wash hands before they placed gloves on hands and between tasks especially when touching raw chicken and the garbage can. She stated this was cross contamination and a resident had the potential of becoming ill with some type of stomach problems and possibly a resident may need hospitalization . She stated if residents had anything that was out of date the resident could become ill with food poisoning. She stated it was her responsibility to monitor the kitchen and the dietary staff. In an interview on [DATE] at 11:35 AM the Administrator stated the oven was required to be cleaned whenever it was dirty. She stated if the oven was not clean there was a potential for residents to become ill from the bacteria in the oven. She stated there was also a possibility of an oven fire. She stated all floors needed to be cleaned whenever there was any type of food or dirt on the floors including refrigerator and freezer. She stated if there was ice on the floor in the freezer this could be a hazard for someone to fall. She stated the ice in the freezer was from condensation. She stated there was a possibility there was a leak, however, she did not believe there was any type of leaks, and the ice was from condensation. She stated if residents ate undated left-over foods there was a possibility for the resident to become ill with food poisoning or any type of stomach issues. She stated all dietary staff was required to wear a hair net and for males with beards a beard net. She stated if hair was not completely covered and if males was not wearing a beard net, hair could fall into residents' food. She stated a resident could become ill. She stated boxes or containers of food were not appropriate to store next to the fan or pipes in the refrigerator or freezer. She stated staff was to wash hands in the kitchen after touching anything that was contaminated. She stated it was the Dietary Manager's responsibility for monitoring the kitchen and the dietary staff. Review of Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices Policy dated [DATE] revealed the following: - Employees must wash their hands: after handling raw meat, poultry, or fish and when switching between working with raw food and working with ready-to-eat food. -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. -Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. -Hair nets or caps and/ or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Review of Food Receiving and Storage Policy dated [DATE] revealed food services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. Partially eaten food may not be kept in the refrigerator. Review of Refrigerators and Freezers Policy dated [DATE] revealed the following - This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. -Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired past perish dates. -Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. -Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of Sanitation Policy dated [DATE] revealed the following: All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/ or chemical sanitizing solution. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: Equipment will be disassembled as necessary to allow access of the detergent/ solution to all parts. Removable components will be scraped to remove food particles accumulation and washed according to manual or dishwashing procedures.

Based on observation, interviews, and record review, the facility failed to ensure the resident's right to be free from any physical restraint imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 4 of 15 residents (Residents #2, #3, #7 and #12) whose care was reviewed for, in that: 1. Residents #2, 3, 7, and 12 had PCA on their beds with no physician orders in place identifying the medical symptom for the use of PCA prior to survey entry. 2. Residents #2, 3, 7, and 12 had PCA on their beds with no documentation of alternative interventions attempted prior to PCA installation. 3. Residents #2, 3, 7, and 12 had PCA on their beds and no indication of monitoring/re-evaluation for the need for use of the bed or chair alarms. 4. Residents #2, 3, 7, and 12 had PCA on their beds and no indication that the resident or their Responsible Party had been provided education informing them of the potential risks and benefits in the use of PCA. This failure could place residents at risk for injury, feelings of imprisonment, feelings of isolation, feelings of depression and diminished quality of life. The findings included: Review of the face sheet dated 9/23/2022, reflected Resident #2 was a [AGE] year-old male, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], reflected Resident #2 had a BIMS of 14 indicating the resident was cognitively intact. Review of the Incident reports for Resident #2 from 7/1/22 - 9/23/22 reflected witnessed falls on 7/24/22, 7/31/22 and 9/20/22; unwitnessed falls on 7/4/22 ,7/16/22, 7/21/22, 7/24/22, 9/1/22 and 9/20/22 Review of the Progress notes for Resident #2, dated 7/21/22 at 2247 (10:47 pm) indicated PCA was in use: Called to room by other resident. Upon arrival found resident laying in bathroom floor with upper part of body laying in adjoining room .resident cleaned up and changed and place(d) in bed with bed alarm in place. Further review of progress notes reflected no resident or RP education was provided informing them of the potential risks and benefits in the use of PCA. Review of Resident #2's physician orders revealed two orders were entered on 7/22/22 as follows: May place bed alarm to resident's bed to alert staff to movement to help prevent falls and May use chair alarm to W/C to alert staff of movement to prevent falls while in W/C. Further review of both orders revealed there were no medical symptoms indicated for the use of the PCAs. Review of Resident #'2's care plan dated as of 9/23/22, with the goal of Resident #2will be free of falls through the next review date with the intervention of bed and chair alarm to alert staff of any movement. Will turn off alarms and remove them from bed/chair initiated on 7/24/22. There was no evidence of other fall interventions or medication reviews attempted prior to applying PCA. Review of the face sheet dated 9/23/2022, reflected Resident #3 was a [AGE] year-old male, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment for Resident #3 dated 7/8/2022, reflected a BIMS of 3 indicating severe cognitive impairment. Review of the incident reports for Resident # 3 from 7/1/22 - 9/23/22 reflected one unwitnessed fall on 8/12/22 and no witnessed falls. Review of the progress notes for Resident #3 as of 9/23/22 reflected no resident or RP education was provided informing them of the potential risks and benefits in the use of PCA. Review of Resident #3's physician orders revealed an order entered on 7/2/22 as follows: May use chair alarm to w/c to alert staff of movement to prevent falls while in W/C. Further review of order revealed there were no medical symptoms indicated for the use of the PCA on his W/C. Review of Resident #3's care plan dated as of 9/23/22, revealed PCA was imitated on 8/12/22: with the problem Resident #3 is at risk for falls r/t gait/balance problems, psychoactive drug use. with the intervention: May use chair alarm to w/c to alert staff of any movement to prevent falls while in w/c. There was no evidence of other fall interventions or medication reviews attempted prior to applying PCA. Review of the face sheet dated 9/23/2022, reflected Resident #7 was a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS for Resident #7 dated 8/5/22, reflected a BIMS of 10 indicating moderately impaired cognition. Review of the incident reports for Resident # 7 from 7/1/22 - 9/23/22 reflected one witnessed fall on 7/14/22 and 0 unwitnessed falls. Review of the progress notes for Resident #7 as of 9/23/22 reflected no resident or RP education was provided informing them of the potential risks and benefits in the use of PCA. Review of Resident #7's physician orders revealed an order entered on 10/8/20 as follows; Chair alarm and bed alarm per request of R(P). Further review of order revealed there were no medical symptoms indicated for the use of the PCA on his W/C or bed. Review of Resident #7's care plan dated as of 9/23/22, revealed the focus: has had an actual fall prior to coming to facility resulting in fx ribs with an intervention of bed and chair alarm to alert staff of any movement q shift, will take chair alarm and scoot it all the way back in the W/C causing it not to sound at times initiated on 10/7/20 and revised on 9/21/22. There was no evidence of other fall interventions or medication reviews attempted prior to applying PCA. Review of the face sheet dated 9/23/2022, reflected Resident #12 was a [AGE] year-old female admitted on [DATE], was her own responsible party, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS for Resident #12 dated 7/27/22, reflected a BIMS of 13 indicating the resident was cognitively intact. Review of the incident reports for Resident #12 from 7/1/22-9/23/22 reflected a witnessed fall on 7/30/22 and an unwitnessed fall on 7/9/22. Review of the progress notes for Resident #12 dated 11/19/2019 reflected: Alarm placed on recliner to alert staff to movement. Resident refused to use call light for assistance. Further review of progress notes revealed no resident or RP education was provided informing them of the potential risks and benefits in the use of PCA. Review of Resident #12's physician orders revealed orders entered on 12/28/2020 as follows May place chair alarm to recliner to alert staff of unsafe rising and may place bed alarm to alert staff to movement to help prevent falls. Further review of orders revealed there was no medical symptom indicated for the use of the PCA for Resident #12 prior to 9/23/22. Review of Resident #12's care plan dated as of 9/23/22, revealed the focus: is at risk for falls r/t gait/balance problems and psychoactive drug use with interventions of alarm placed on recliner to alert staff of movement initiated 11/19/2019 and bed alarm placed on Mrs. Petty's bed to alert staff to movement initiated on 8/28/2019. There was no evidence of other fall interventions or medication reviews attempted prior to applying PCA. During an interview with Resident #3 on 9/23/22 at 10:50 am, he stated they use an alarm on my chair and sometimes it's a pain. It goes off when I move even little. He stated his roommate (Resident #2) has one and it wakes him up at night. He further stated, sometimes he (resident #2) gets mad at it and takes it off. During an observation on 9/23/22 at 10:50 am, a chair alarm was seen on Resident #3's wheelchair. During an interview on 9/23/22 at 11:10 am, CNA#1 stated she had been there about 9 months and several of the residents had PCA. She stated, when they go off, we know we have to go check on that resident because they may have fallen. She further stated that some of the residents know how to turn them off or take them off, so we have to watch them. During an observation on 9/23/22 at 11:19 am a low bed and bed alarm were observed in Resident #7's room., but no fall mat was observed. Investigator sat on Resident #7's bed, and when they got up the alarm went off. The alarm was very loud and shrill, enough to startle the investigator. Approximately 2-3 minutes later a staff came in to check on Resident #7. During an interview on 9/23/22 at 11:19am, Resident #7 stated there's that noise again. it's a pain. Resident stated he knew about the alarm but didn't know why it was there. During an interview on 9/23/22 at 11:50 am, PT #1 stated the facility used different fall interventions after evaluating the reasons for a resident's fall. She further stated they also use low beds, fall mats and if needed the use of bed alarms. She stated they had standing orders for bed alarms. She stated we educated the resident in the use of call bell and make sure it is where they can reach it. During an interview on 9/23/22 at 12:23pm, CNA#2 stated Resident #2 will remove his PCA, yeah, he will remove it and move it out of the way. We put it back in place and tell him not to touch it. Sometimes he has the cognition to not touch it. She further stated she doesn't know if any resident complains about the alarms, but she has seen a couple try and get up from their chairs and when the alarm goes off, they sit back down. During an observation on 9/23/22 at 12:30pm a PCA was noted on Resident #12's bed and recliner. During an interview on 9/23/22 at 12:30pm, Resident #12 stated she did not know what it is or what it's for when asked about the PCA. She stated the alarm in the chair scares her when it goes off if she moves. She stated she does not hear the alarm on her bed at night after taking her hearing aids out. She stated she had no idea how long the alarms have been here. During a joint interview with the DON and AD on 9/23/22 at 1:00pm, the DON stated, we have standing orders for alarms; it is an intervention we use when we have a resident with frequent falls. She stated they don't use if for the first intervention or after the first fall - they meet and discuss the use for a particular resident. The AD stated, we have a corporate policy on the use of alarms and corporate states it is ok. AD further stated, the resident - if able - and family are included in the discussion for the use and we tell the family about it. She stated they do not have a consent form and they don't ask for consent. She stated, the documentation for these conversations would be in the progress notes. During an interview on 9/23/22 at 1:15 pm, the AD stated, the alarms have not prevented falls, but they do help alert staff as to when a resident gets up so they can get in there and help them prior to a fall. During an interview on 9/23/22 at 2:36 pm, the NP stated she was aware of the standing orders for PCA and she gave an order today to d/c all bed alarms because the facility told her they could be restraints. She stated that many of their patients were fall risks and need some type of alarm due to staffing. She stated they don't have enough staff to put patients on 1:1 observation to make sure they don't fall so they need the alarms for patient safety. She stated the facility has protocol and guidelines that establish need. She further stated, we have standing orders for patient safety, so they do not harm themselves falling. She states in some cases the alarm devices do help reduce falls. Facilities are short staffed, and you can't always get to them; the alarm helps alert us to falls and we can go check on the resident. If it wasn't in place and somebody falls it could be 2 hours until they are found if we are doing rounds every 2 hours. She stated she does not believe the alarms have caused any physical or emotional harm to the residents. During an interview on 9/23/22 at 2:59 pm, the ADON stated they try to assess what the reason was for the resident's falls. She stated it could be toileting needs, snack needs, etc and they try to find the why of the fall. She stated some fall interventions they use were low beds, safety mats, moving the resident's room closer to the desk, and more frequent toileting. She stated Resident #2's room was at the end of the hall, away from the nurse's desk. She stated she knew he had recently had some falls and wasn't sure if they had tried to move him closer to the nurse's desk. She further stated all orders for alarms were updated today to put in the medical reason for the alarms and prior to today there was no medical reason in the orders for the alarms. During an interview on 9/23/22 at approximately 3:30pm, the AD stated Resident #2's room was at the end of the hall. He's been here for years and would probably not agree to moving closer to the nurse's desk. She stated she was not sure if anyone had approached him about moving rooms but I'm pretty sure he would not agree to it. During an observation on 9/23/22 at approximately 3:05 pm, the AD went to Resident #2's room (he had just returned from the hospital) and asked him if he would like to move his room closer to the nurse's desk and he said no. During an interview with the MD on 9/27/22 at 9:32 am, he stated he was not aware that PCA could be considered restraints and stated, I never really thought of it that way, but we really don't have choice. He stated they were worried about falls and we work hard to try and prevent falls. He further stated he had been at the nursing facility for over seven years, and they use standing orders for PCA and added there probably wasn't any documentation as to why medically they were needed. He stated that falls can cause serious problems, injuries even death for the residents. He further stated the PCA themselves could cause injuries if a resident were to trip on the cord or get tangled up in the cord, but to his knowledge that had not happened. Record Review of Policy 'Falls and Fall Risk, managing' dated revised April 2006, includes item #7. An attending physician may order non-intervention items to alert staff of falls that include chair alarms and bed alarms. These alerts will be utilized only as an extra alert measure to ensure if resident falls that they receive immediate attention for any injuries. Review of Policy 'Monitoring Subsequent Falls and Fall Risk' dated revised April 2006, includes #1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 8 staff (HSK and DM) reviewed for infection control. 1. HSK failed to wash her hands between tasks or resident's rooms on the 200 Hall. 2. HSK failed to wear her mask properly. 3. DM failed to wear his mask while preparing lunch in the kitchen. These deficient practices placed residents at risk for contracting infections, sickness, and a decreased quality of life. Findings Included: In an observation on 08/29/2022 at 10:15 AM HSK was seen walking down the hallway wearing a pair of gloves. She then went into Resident #1 and Resident #2's room. Both residents were laying in their beds. She came back out of the room took gloves off and put on a new pair of gloves. She did not wash her hands. Her nose was not covered by N95 mask. In an interview on 08/29/2022 at 10:15 AM HSK stated she was in-serviced regularly on COVID-19 and infection control. She stated some of the extra precautions that were done in the facility to help reduce the spread of infection were housekeeping deep cleaned all residents' rooms daily, she cleaned the hand rails every other day, and changed the mop head in between each room. In an observation on 08/29/2022 at 11:08 AM HSK walked down the hallway wearing a pair of gloves. She went into Resident #3 and Resident #4's room and wore the same gloves used to clean the hallway. She cleaned Resident #3 and Resident #4's bathroom. In an observation on 08/29/2022 at 11:09 AM HSK came into the hallway wearing gloves used to clean the Resident #3 and Resident #4's bathroom and reached into the clean mop bucket holding 5 clean mop pads. She wore the same soiled gloves to pick up a clean mop pad and squeezed the excess water back into clean mop bucket. In an observation on 08/29/2022 at 11:10 AM HSK took off the gloves used to clean Resident #3 and Resident #4's bathroom, did not wash hands, put on new gloves, and mopped Resident #3 and Resident #4's room. In an observation on 08/29/2022 at 11:11 AM HSK came out of Resident #3 and Resident #4's room wearing gloves, walked down the hallway to Resident #5 and Resident #6's room, took the gloves off and put on a new pair of gloves without washing her hands. In an interview on 08/29/2022 at 11:12 AM with HSK, she pulled her mask off at this time so she could speak exposing her mouth and nose. She put her mask on properly after surveyor's intervention. She said she had her nose exposed in Resident #1 and Resident #2's room earlier because she was talking to Resident #1. She stated the best way to prevent the spread of COVID is proper hand washing and properly wearing a mask. She said hands should be washed 10-30 seconds to be affective. She said she is supposed to wash hands and change gloves in between each resident's room. She said she did not wash hands before changing gloves because she was distracted by another employee talking to her. In an observation on 08/29/2022 at 11:13 AM DM was seen standing in the kitchen not wearing a mask. She was facing food preparation table #1 where food crumbs were visible. Four feet behind her was food preparation table #2 where DA was standing, wearing a mask, taking rolls off a baking sheet for lunch. In an interview on 08/29/2022 at 11:13 AM DM stated she had been trained on how to properly wear PPE to prevent the spread of COVID. She said staff is to put on a N95/KN95 mask when they come into facility. She said the facility provides all staff with proper PPE including masks. She said she pulled her mask down exposing her mouth and nose when she was away from food because it was hot in the kitchen. She said she had a bad heart that caused her to be short of breath but said the facility did not have that in her personnel records. She said she is aware that wearing a mask and washing hands properly is the best way to prevent the spread of COVID. She said preparation table #1 would be used for the remainder of the day and she would be cleaning the area when she was done with the interview. In an interview on 08/29/2022 at 11:18 AM with Resident #1 she stated the staff does not always wear a mask when in her room. In an observation on 08/29/2022 at 11:30 AM food preparation table #1 where DM was standing unmasked still had food crumbs visible in the same location of table observed previously. In an interview on 08/29/2022 at 2:30 PM DON stated all staff were trained on the proper way to don and doff all PPE including masks. All staff were required to wear a N95 mask while in the facility. She said the only exception to the rule is if they were eating or drinking. She stated there was not currently any employees that have a documented medical reason to not wear a mask while in the facility. She stated all employees had been trained on how to properly wash hands. She stated hands should be washed before and after putting gloves on each time. She said soiled gloves should be changed and hands washed prior to putting hands inside of a clean mop bucket. In an interview on 08/29/2022 at 2:39 PM ADM said in-services on proper PPE were provided to all staff members each time a new resident or staff member tested positive. She said all staff were required to wear N95 mask while in the building. She said there was never a reason for staff to be without mask inside facility. She said she currently had no staff with a medical reason to not wear a mask inside the facility. She stated there was enough PPE in facility for all staff to have a face mask. She said there was no reason anyone should not be wearing a mask correctly. She said the nose and mouth should be completely covered with mask to prevent the spread of COVID to peers and residents. She said the best way to prevent the spread of COVID is to wash hands, wear mask, report symptoms, testing, and follow screening procedure. She said mask were required in the kitchen area. She said mask were required to be worn correctly in resident's rooms. She said staff was trained in handwashing techniques. She said staff are supposed to wash their hands in between resident's rooms and before and after wearing gloves. She said gloves should be changed prior to putting hands inside of clean mop bucket. Record review of the most recent hand washing in-service was dated 07/14/2021. It reveals HSK's signature on in-service sign in log. Record review of an in-service dated 6/8/2022 for COVID PPE, showed pictures and text on how to properly DON and DOFF PPE properly, revealed HSK's signature on in-service sign in log. Record review of an in-service for screening procedure dated 6/8/2022, stated all employees must have their mask on before leaving screening area, revealed HSK's signature on in-service sign in log. Record review of an in-service for COVID positive staff dated 6/8/2022, stated all employees must wear their mask properly at all times! DO NOT REMOVE MASK, especially around our residents! In-service revealed HSK's signature on in-service sign in log. Record review of an in-service dated 8/22/2022 for COVID positive staff, stating all employees must wear their mask properly at all times! DO NOT REMOVE MASK, especially around our residents! In-service revealed HSK's signature on in-service sign in log. Record review of and in-service 6/8/2022 for COVID PPE, showed pictures and text on how to properly DON and DOFF PPE properly, revealed HSK's signature on in-service sign in log. Record review of a Course Completion History for DM show ed Infection Control and Prevention were completed on 02/24/2022 and 07/11/2022. Understanding Bloodborne Pathogens completed 02/23/2022 and 02/25/2022. Record review of the Hand Washing Policy revised August 2019 stated all employees should wash hands after taking gloves off and before putting gloves on.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for professional standards. The facility failed to label, date, and monitor refrigerated food and dispose of food stored in the walk-in-refrigerator after the use-by-date. This deficient practice could affect all residents by placing them at risk for foodborne illnesses. Findings Included: An observation on 10-26-21, at 9:30 a.m. of the facility's walk-in kitchen refrigerator revealed: an opened case of 12 loaves of wheat bread placed directly in the middle of the floor; 6 packages of 1 lb bologna lunch meat not dated or labeled; an opened container of Prune Juice on the shelf with an expiration date of 6-14-21, not discarded ; an opened container of Mustard with an expiration date 10-13-21 located on the shelf ; an opened container of Mayonnaise with an expiration date 10-1-21 placed on the shelf; an opened container of BBQ sauce with an expiration date 9-13-21 located on the shelf; and a opened container of Ranch Dressing with an expiration date of 10-15-21 located on the shelf. Interview on 10-26-21 at 10:00 a.m. with the DT revealed foods are dated and labeled before and after meals. The DT did not know why the kitchen staff were not following the policy for use-by-date procedures. The DT agreed during the interview that all the observed food expiration dates should have been discarded. In an interview on 10-26-21 at 11:00 a.m. with the DM was asked what kind of dating and labeling system was used. The DM confirmed labeling, dating, and monitoring system of refrigerated food should be completed daily by all kitchen staff, and foods should be stored off the floor. The DM also revealed her awareness of the Facility Policy and Kitchen staff in- services regarding safe refrigerated storage. In an interview of 10-27-21 at 1:30 p.m. the ADM stated she was aware of the food items which were observed as past due in the walk-in refrigerator. The ADM revealed the DM is responsible for the kitchen, and she knew the risk to residents of not using safe practices for storing refrigerated food. Review of an in-service dated 7-31-21 revealed the cook and cook aides were all responsible for labeling and dating foods for refrigerated storage. Record review of the facility Food Storage Policy dated 6-1-19 #03.003 titled Food Storage stated: All food will be stored according to the state, federal and US food Codes and guidelines; store all foods on racks or shelves off the floor; date, label and tightly seal all refrigerated food; and discard items that are over 72 hours old.

Based on record review and interviews the facility failed to ensure residents diagnosed as having a mental illness were properly screened for 1 of 3 residents reviewed for PASRR Screening (Resident #41). The facility failed to correctly identify Resident #41 who has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice placed residents at risk for not being properly assessed by the local authority and not receiving services to prevent decline. Findings included: Record Review of Residents #41's Face Sheet reflected a [AGE] year-old male admitted [DATE] and had an original diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no disqualifying diagnosis. Record review of Resident #41s MDS comprehensive assessment dated [DATE] reflected a BIMS score of 15 (Reflecting No Cognitive Impairment), A 1500 was marked yes for Depression and [CONDITION(S)] Disorder. Record Review of Resident #41's Care Plan dated 09/07/2021 reflected he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #41's Level 1 PASSAR screening dated 09/01/2021 reflected there is no evidence or an indicator this is an individual with a mental illness. In an interview on 10/28/2021 at 10:10 AM with MDSN she stated when a resident is PASRR 1 screened by the hospital, she copies that PASRR when conducting her own, but stated she does check their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why Resident #41 admitted with a mental illness but the PASRR LEVEL 1 notation for mental illness she completed indicates no, she could not provide the reason. When asked how she checks to insure the PASRR Level 1 is correct she stated she forwards everything to LA to double check that the Level I PASSR is correct and the LA determine if the resident will qualify for services, so there is no concern they will not be identified as PASRR Level 1 positive since the LA checks MDSNs Level I PASRR. She stated if a person has a mental illness, that does not mean they will be PASRR positive and receive services. In an interview on 10/28/2021 at 11:08 AM with ADM she stated thought if a resident is [CONDITION(S)] and has major depressive disorder the PASRR I would indicate yes under mental illness and need a PASRR II, but she does not understand that well. She stated they send their information to LA who checks over the PASRR 1 to see if the resident needs services. She stated Resident #1 had admitted to the facility from home but because he was in the hospital shortly before admitting the hospital PASRR 1 information was sent over to the facility. In an interview on 10/28/2021 at 11:19 AM with LA she stated the facility sends all the Level 1 PASRR forms to her and she checks them to see if the form is correct and determines if the resident will be eligible for services. She stated she reviewed Resident #41's Level 1 PASRR and did not conduct a Level II PASRR because he would not be eligible for services even though he has a mental illness. She stated Resident #1 was negative for PASRR because he had not gone to a mental hospital, he had gone to a regular hospital, and would not qualify for services so a PASRR II was not done. She informs MDSN if a resident will receive services. She stated residents are reviewed every year. Record Review of Facility Policy and Procedure for PL/PASRR/NFSS/1012/PCSP Revised 1/16/2019 reflected a Level I PASRR form must be submitted for every person entering the facility within 72 hours. The facility is only allowed to complete/submit the form for long-term facility to long-term facility transfers. If the resident is admitting from home, the family must complete the form and the facility can assist. If the Level I PASRR is negative, the facility submits the form, if the is resident positive, the LA submits the form. If the resident is coming from the hospital, the referring entity completes the form and sends it to the facility to submit to the LA. The LA determines whether the individual requires specialized services for mental illness.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for eight (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) of twelve residents reviewed for infection control. The facility failed to ensure all staff wore proper N95 face masks, per the CDC guidelines, in the facility during a COVID-19 outbreak. This failure could place residents at risk of exposure to [CONDITION(S)]-Cov-2 (COVID-19), which could result in illness, hospitalization or death. Findings include: 1. Record review of Resident #1's face sheet, dated 10/07/2021, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record review of Resident #2's face sheet, dated 10/07/2021, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Record review of Resident #3's face sheet, dated 10/07/2021, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Record review of Resident #4's face sheet, dated 10/07/2021, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Record review of Resident #5's face sheet, dated 10/07/2021, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Record review of Resident #6's face sheet, dated 10/07/2021, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Record review of Resident #7's face sheet, dated 10/07/2021, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's immunization records reflected he was not vaccinated for COVID-19. Record review of Resident #7's Social Services Note, on 9/09/2021, revealed the COVID vaccination was discussed and declined by family at this time. 8. Record review of Resident #8's face sheet, dated 10/07/2021, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's immunizations records reflected he was not vaccinated for COVID-19. Record review of Resident #8's Social Services Note, on 10/07/2021, revealed the COVID vaccination was discussed, and family was not interested in their father receiving the vaccine. Observation on 10/07/21 at 1:10 PM revealed DM at the computer in the kitchen office with a medical mask below the nose and mouth. Observation on 10/07/21 at 1:30 PM revealed KA replacing a N95 mask over her nose and mouth while opening the laundry room door. A plate of food was observed on the folding table next to the dryers KA stated she had been eating her lunch. Observation on 10/07/21 between 5:10 PM - 5:30 PM revealed CNA A wore a medical mask while she assisted with passing dinner trays in the warm and hot zone. Warm zone is a quarantine area for residents who have an unknown COVID-19 status, and Hot zone is a sealed off area with an exit door to the outside. Residents that have tested positive for COVID-19 and designated staff are in the Hot zone. CNA A was observed delivering dinner trays into resident rooms in the warm zone and handing them to staff through plastic barrier into the hot zone. CNA A had a release from her physician to wear a medical mask for a medical reason. Wearing an N95 mask assisted in protecting residents and staff members and to help reduce the spread of COVID-19. Observation on 10/11/2021 at 1:55 PM revealed LVN A in the MDS office and did not wear a face mask. The MDS office was located in a trailer behind the facility that also houses a printer, conference room, ADON's office, and a cubby for transportation. Multiple staff members were observed going in and out of the trailer from the facility during the investigation on 10/07/21 and 10/11/21, and they were observed wearing an N95 mask. During an interview on 10/07/2021 at 5:45 PM with the ADM revealed CNA A had a release from her physician to wear a medical mask for a medical reason. The facility had 12 residents that were positive for COVID-19, and there were designated staff members working in the COVID unit providing care for the 12 residents. She stated an N95 mask was required for the COVID-19 positive rooms to help protect residents and staff members and to help reduce the spread of COVID-19. During an interview on 10/11/21 at 5:00 PM with the ADM, she stated her expectations were all staff should wear an N95 mask during an outbreak in the facility and full PPE should be worn in both the COVID-19 unknown rooms and the COVID-19 positive room. She stated full PPE included a gown, gloves, face shield and mask. She stated an N95 mask was required for the COVID-19 positive rooms to help protect residents and staff members and to help reduce the spread of COVID-19. Record review of the facility's COVID-19 Response Plan reflected the following: .6. Comply with all CMS and CDC guidance related to infection control. Record review of the CDC website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 450 reflected HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator).

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 2 of 19 residents reviewed for care plans. (Resident #'s 10 and 57) A. Resident #10's care plan did not reflect an unstageable pressure ulcer on Resident's coccyx and reflected potential for pressure ulcers instead of actual. B. Resident #57's care plan did not reflect the use of a bed alarm to help alert staff to falls. These facility failures could place all residents at risk for not receiving care and services to meet their needs. Findings include: A Review of Resident #10's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly MDS dated [DATE] reflected Resident #10's cognitive skills for daily decision making was severely impaired, with a BIMS of 7. Review of Physician order [REDACTED]. Review of Weekly Ulcer Assessment for Resident #10, dated 8/5/19 reflected an unstageable pressure ulcer to the coccyx identified on 7/22/19 with measurements of 2.5 (length) x 1.5 (width) cm with unidentifiable depth, wound bed color of black and yellow, and approximately 75% necrosis (tissue death) signed by Wound Care Nurse. Review of Resident #10's Care Plan dated 8/7/19 reflected that Resident #10 had a potential for pressure ulcers but did not identify any actual pressure ulcers. The Care Plan did not reflect any interventions or goals to address an actual pressure ulcer. Observation of Wound Care for Resident #10 with the Wound Care Nurse and CNA 1 assisting on 8/6/19 at 11:22 AM. Resident 10 had a foul odor present when old dressing was removed from the coccyx (buttocks) area, dead tissue that was black and yellow around the wound appeared. Odor was still present after the Wound Care Nurse had cleaned wound with normal saline and applied Santyl. Surveyor was not able to observe beneath the wound due to dark black and yellow crust over the wound. Interview with Wound Care Nurse on 8/6/19 at 1:45 PM revealed that Resident #10's pressure ulcer was identified on 7/22/19. Interview with ADON and MDS Coordinator on 8/7/19 at 10:30 AM revealed that pressure ulcers should be care planned and Shift Report is given every morning to help identify issues both acute and chronic for Residents in the facility. Interview with DON on 8/7/19 at 11:02 AM revealed that it was her expectation that pressure ulcers would be care planned pretty quickly. She stated that Resident #10's pressure ulcer not being care planned did not meet her expectation. B. Review of Resident #57's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #57's Physician order [REDACTED].#57. Review of Resident #57's Quarterly MDS dated [DATE] reflected Resident #10's BIMS score of 8, indicating cognitive skills for daily decision making was moderately impaired. Review of Resident #57's Current Care Plan reflected Resident #57 was a risk for falls with actual falls on 4/28/18, 12/12/18, 1/30/19 and 3/13/19. The Care Plan did not reflect an intervention that included a bed alarm. Observation of Resident #57 on 8/5/19 at 9:50 AM asleep in recliner, bed alarm observed on bed. Interview with CNA 1 on 8/7/19 at 10:07 AM revealed Resident #57 had a bed alarm but did not have a chair alarm. Interview with DON on 8/7/19 at 11:02 AM revealed that it was her expectations all bed and chair alarms would be on the care plan. Review of Facility Policy titled Policy and Procedure Comprehensive Care Planning (undated) reflected the following elements: Purpose: Ensure every resident has comprehensive, complete, accurate and all inclusive specific care plan written timely to meet all requirements of the RAI and Regulatory process to include input from all the IDT members. Procedure: 7. Every resident will have all active medical [DIAGNOSES REDACTED]. 16. Care Plans will be revised an needed weekly with S[NAME] meeting and/or when applicable between routine reviews.