Every finding on record at Shiner Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and residents with pressure ulcers receive necessary treatment and services, consistent with professional stands of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents (Resident #2, Resident #3, and Resident #5) reviewed for pressure ulcers. 1. The facility failed to ensure Resident #2, who had a pressure wound, was wearing heel protector boots or had his heels floated while in bed on 08/14/2026 and 08/15/2026.2. The facility failed to ensure Resident #3, who has a chronic ulcer, was wearing heel protector boots on 08/14/2026.3. The facility failed to complete weekly ulcer assessments for Resident #3. 4. The facility failed to ensure Resident #5 was wearing heel protector boots or had his heels floated while in bed on 08/14/2026. These failures could hinder the healing of the residents existing pressure ulcers or lead to the development of additional skin injuries. The findings include: 1. Record review of Resident #2's face sheet, dated 08/14/2026 revealed a [AGE] year-old male with an admission on [DATE] and a readmission on [DATE] with diagnoses that include type 2 diabetes mellitus without complications (blood sugar is elevated due to insulin resistance), muscle wasting and trophy, not elsewhere classified, multiple sites (significant loss of muscle mass and strength across multiple muscle groups in the body). Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed in section M. Skin Conditions under M.0150 Risk of Pressure Ulcers/Injuries it was documented Resident #2 was at risk of developing pressure ulcers/injuries. Further review of the MDS in section M. Skin Conditions under M.0210 Unhealed Pressure Ulcers/Injuries documented that Resident #2 had one or more unhealed pressure ulcers/injuries as well as under section D.4 Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling the facility marked that Resident #2 had 1 stage 4 pressure ulcer. Record review of Resident #2's care plan last revised 04/26/2026 revealed: Resident has a potential for pressure ulcer development last revised 11/07/2025 with interventions that included ensure heels are floated with the use of pillows initiated on 09/26/2025 Record review of Resident #2's order summary dated 08/14/2026 revealed the following order: Float heels while in bed or apply heel protectors, every shift for DTI with a start date of 04/26/2026 with no end date. Record review of Resident #2's wound care note dated 08/10/2026 revealed a stage 4 pressure wound of the right heel, full thickness with recommendations including offload wounds and float heels in bed. 2. Record review of Resident #3's face sheet, dated 08/14/2026 revealed an [AGE] year-old female with an admission on [DATE] and a readmission on [DATE] with diagnoses that include pressure ulcer of right heel, stage 4 (severe, full thickness wound), and non-pressure chronic ulcer of right calf with fat layer exposed (persistent wound). Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderate cognitive impairment. Further review of the MDS revealed in section M. Skin Conditions under M.0150 Risk of Pressure Ulcers/Injuries it was documented Resident #3 was at risk of developing pressure ulcers/injuries. Further review of the MDS in section M. Skin Conditions under M.0210 Unhealed Pressure Ulcers/Injuries documented that Resident #3 did not have any unhealed pressure ulcers/injuries as well as under M.1030 Number of Venous and Arterial Ulcers as having 2 presently. Record review of Resident #3's care plan last revised 07/27/2026 revealed: The resident has a pressure ulcer or potential for pressure ulcer development: right heel, [right] calf wound, sacral wound last revised 05/20/2026 with interventions that include administer treatments as ordered. last revised on 06/15/2026. Record review of Resident #3's order summary dated 08/14/2026 revealed the following order: Podus boot to be worn while in bed or in chair, may remove for transferring, every shift for stage 3 pressure ulcer with a start date 05/27/2026 with no end date. Record review of Resident #3's wound care note dated 07/28/2026 revealed Resident #3 had a non-pressure chronic ulcer of the right posterior (rear) leg with fat layer exposed, a non-pressure chronic ulcer of right heel with fat layer exposed, and cellulitis (bacterial skin infection) of right lower limb. Further review of the wound care note revealed under the non-pressure chronic ulcer of right heel with fat layer exposed section periwound skin treatment: The ulcer is to be offloaded using offloading heel boot. 3. Record review of Resident #3's weekly ulcer assessment forms revealed the last weekly ulcer assessment was completed on 07/28/2026 which documented Resident #3's right ulcer. 4. Record review of Resident #5's face sheet, dated 08/14/2026 revealed a [AGE] year-old male with an admission on [DATE] and a readmission on [DATE] with diagnoses that include type 2 diabetes mellitus without complications (blood sugar is elevated due to insulin resistance). Record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating the resident's cognition was intact. Further review of the MDS revealed in section M. Skin Conditions under M.0150 Risk of Pressure Ulcers/Injuries it was documented Resident #5 was at risk of developing pressure ulcers/injuries. Further review of the MDS in section M. Skin Conditions under M.0210 Unhealed Pressure Ulcers/Injuries documented that Resident #5 did not have any unhealed pressure ulcers/injuries Record review of Resident #5's care plan last revised on 3/16/2026 revealed: The resident has a pressure ulcer or potential for pressure ulcer development: related to but not limited to limited mobility, extensive assist for all mobility and bed mobility, use of w/c. incontinence, and pain last revised 03/15/2024 with interventions that include ensure heels are floated with the use of pillows initiated on 08/28/2023 and heel protectors as ordered revised on 03/16/2026. Record review of Resident #5's order summary dated 08/14/2026 revealed the following order: Heel protectors to bilateral feet when in bed dx: atrophy of posterior heel with paint/preulcer, fat pad syndrome per podiatrist . with an order date 04/24/2026 and no end date. In an observation on 8/14/2026 at 1:43 PM, revealed Resident #5 was observed resting in bed, positioned on his back with his eyes closed. Resident #5 was not wearing heel protector boots, nor were his heels floated off the surface of the bed with pillows or another device. In an observation on 8/14/2026 at 1:45 PM, revealed Resident #2 was observed resting in bed on his left side. Resident #2's heels were not floated off the surface of the bed with pillows or another device. In an observation on 8/14/2026 at 2:45 PM, revealed Resident #3 was observed resting in bed, positioned on her back with the head of the bed elevated. Resident #3 was not wearing heel protector boots. In an observation on 08/15/2026 at 10:51 a.m., revealed Resident #2 was observed resting in bed, positioned on his back with his eyes closed. Resident #2 did not have his heels floated off the surface of the bed with pillows or another devices. During an interview on 08/16/2026 at 9:42 a.m., CNA C stated they were familiar with Resident #3. CNA C stated they knew Resident #3 was required to wear a boot on her foot because she had a boot in her room. CNA C stated they were unsure as to why Resident #3 was not wearing her boot in bed. CNA C stated they put boots on residents that required them. CNA C stated they had previously put on Resident #3's boot in the past. CNA C stated the risk of not putting the boots on residents could lead to new wounds. During an interview on 08/16/2026 at 10:12 a.m., CNA A stated they were familiar with Resident #5. CNA A stated they were aware Resident #5 had an order to float his heels and use heel protectors. CNA A stated they were unsure as to why Resident #5 did not have his heels floated nor had heel protectors on, but that Resident #5 should have had those interventions in place. CNA A stated in the past they floated Resident #5's heels and used heel protectors. CNA A stated the risk to the resident if they were not using heel protectors or floating their heels could be the wounds could get worse. During an interview on 08/16/2026 at 10:25 a.m. CNA D stated they were familiar with Resident #2. CNA D stated when they put Resident #2 to bed, they put heel protectors on Resident #2. CNA D stated they were aware Resident #2 needed to have his heels floated while in bed or wear heel protectors. CNA D stated they were unaware that Resident #2 did not have their heels floated in bed. CNA D stated the risk to not floating residents' heels or using heel protectors could be more break down. During an interview on 08/16/2026 at 11:21 a.m., LVN E stated they were providing care for Resident #2 and Resident #3. LVN E stated they were aware that Resident #2 had wounds on his right heel and was aware he needed his heels floated in bed or using heel protectors. LVN E stated they were aware that Resident #3 needed to have her heels floated in bed, but was unaware Resident #3 needed a boot. LVN E stated they could find what residents needed in the resident's care plan or orders. LVN E stated they were unsure as to why Resident #2 and Resident #3 did not have their heels floated but stated residents did move a lot in bed. LVN E stated the risk to not providing interventions to prevent ulcers could be new wounds. LVN E stated weekly ulcer assessments were to be completed weekly and accurately in order to know the status of resident's wounds. LVN E confirmed Resident #3's last weekly ulcer was done on 07/28/2026 and was unsure why they were not up to date or accurate. LVN E confirmed Resident #3 did have chronic ulcers and no pressure wounds. During an interview on 08/16/2026 at 12:06 p.m., LVN B stated they were providing care for Resident #5. LVN B stated they were aware that Resident #5 needed to wear heel protectors and have his heels floated in bed as well. LVN B stated Resident #5 could sometimes be non-compliant with having his heels floated but stated that they did not document that. LVN B stated the risk of not floating residents' heels or residents not wearing heel protectors could be further breakdown on their feet or heels. During an interview on 08/16/2026 at 2:55 p.m., the RCN stated they expected staff to follow the orders of the residents' doctors. The RCN stated if residents had orders for boots, heel protectors or their heels to be floated in bed then residents should be receiving that care. The RCN stated the risk of not providing pressure relieving interventions could lead to residents' feet being injured or their pressure may not be relieved. The RCN stated weekly ulcer assessments should be completed on a weekly basis and accurately. The RCN stated that the risk to not completing weekly ulcer assessments could be the inability to monitor worsening or improving wounds. The RCN stated the nursing staff were responsible for following the residents' plans of care. Record review of the facilities policy, Pressure Injury: Prevention, Assessment and Treatment last revised on 05/05/2025, revealed: Procedure: 3. Upon assessment and identification of pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will:1. notify the physician of pressure sore and obtain and follow any orders directed by physician. 7. Nursing Care Plan. 2.Under nursing intervention physician ordered treatments Assessments: 2. If a resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 4 of 5 residents (Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accuracy of records: 1. The facility failed to document wound care on 08/12/2026, failed to document floating heels in bed on 08/07/2026 and 08/12/2026, failed to document medication administration on 08/08/2026 and failed to document a diagnosis for Resident #2. 2. The facility failed to document wound care on 07/11/2026, 07/25/2026, and 08/13/2026 for Resident #3. 3. The facility failed to update Resident #4's care plan to reflect she no longer required adaptive devices during meals. 4. The facility failed to update Resident #5's meal ticket and physician's order to reflect he no longer required adaptive devices during meals The failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings include: 1. Record review of Resident #2's face sheet, dated 08/14/2026 revealed a [AGE] year-old male with an admission on [DATE] and a readmission on [DATE] with diagnoses that include type 2 diabetes mellitus without complications (blood sugar is elevated due to insulin resistance), muscle wasting and trophy, not elsewhere classified, multiple sites (significant loss of muscle mass and strength across multiple muscle groups in the body). Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS in section M. Skin Conditions under M.0210 Unhealed Pressure Ulcers/Injuries documented that Resident #2 had one or more unhealed pressure ulcers/injuries as well as under section D.4 Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling the facility marked that Resident #2 had 1 stage 4 pressure ulcer. Record review of Resident #2's diagnosis page dated received on 08/16/2026 had no diagnosis for stage 4 pressure ulcer to the right heel. Record review of Resident #2's care plan last revised 04/26/2026 revealed: The resident has a potential/actual impairment to skin integrity to. Stage IV to [right] heel last revised 08/14/2026 with interventions that included follow MD orders for treatment revised on 11/18/2025 The resident has edema initiated on 09/26/2025 with interventions that included administer medications as ordered initiated on 09/26/2025. Record review of Resident #2's order summary dated 08/14/2026 the following order: Levothyroxine Sodium Oral Tablet 50 MCG (Levothyroxine Sodium), give 1 tablet by mouth one time a day related to hypothyroidism with a start date of 04/26/2026 with no end date. [Right] heel pressure ulcer: cleanse with wound cleanse, pat dry, apply calcium alginate silver to wound area only and cover with bordered gauze dressing, every day shift for stage 4 pressure wound with an end date of 08/13/2026. Float heels while in bed or apply heel protectors, every shift for DTI with a start date of 04/26/2026. Record review of Resident #2's WAR and MAR dated 08/15/2026 revealed a blank on the following dates for the orders: Levothyroxine Sodium Oral Tablet 50 MCG (Levothyroxine Sodium), give 1 tablet by mouth one time a day related to hypothyroidism with a start date of 04/26/2026 with no end date. -08/08/2026 [Right] heel pressure ulcer: cleanse with wound cleanse, pat dry, apply calcium alginate silver to wound area only and cover with bordered gauze dressing, every day shift for stage 4 pressure wound with an end date of 08/13/2026. -08/12/2026 Float heels while in bed or apply heel protectors, every shift for DTI with a start date of 04/26/2026. -Night: 08/07/2026 -Day: 08/12/2026 2. Record review of Resident #3's face sheet, dated 08/14/2026 revealed an [AGE] year-old female with an admission on [DATE] and a readmission on [DATE] with diagnoses that include pressure ulcer of right heel, stage 4 (severe, full thickness wound), and non-pressure chronic ulcer of right calf with fat layer exposed (persistent wound). Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderate cognitive impairment. Further review of the MDS in section M. Skin Conditions under M.0210 Unhealed Pressure Ulcers/Injuries documented that Resident #3 did not have any unhealed pressure ulcers/injuries as well as under M.1030 Number of Venous and Arterial Ulcers as having 2 presently. Record review of Resident #3's care plan last revised 07/27/2026 revealed: The resident has a pressure ulcer or potential for pressure ulcer development: right heel, [right] calf wound, sacral wound last revised 05/20/2026 with interventions that include administer treatments as ordered. last revised on 06/15/2026. Right lower leg: the resident has a venous/stasis ulcer [referring to] PVD last revised on 11/18/2025. Record review of Resident #3's order summary dated 08/15/2026 revealed the following orders: Right heel wound: cleanse with vashe or Dakins cleanser, pat dry, apply biostep Ag to wound bed, cover with allevyn life dressing, and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound with an end date of 07/17/2026. Right calf wound: cleanse area with Vashe, or Dakins cleanser, pat dry, apply xeroform and cover with ABD pad, wrap with kerlix, every day shift every Tuesday, Thursday, Saturday with an end date of 07/28/2026. Right calf Achillies wound: cleanse with [NAME]/Dakins, pat dry, apply xeroform, cover with ABD pad and wrap with Kerlix, every day shift every Tuesday, Thursday and Saturday with an end date of 07/28/2026. Left Calf Wound: cleanse with wound cleanse pat dry apply activated hydrafera blue to open area not to touch outer skin, cover with 4 by 4 gauze and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound care with an end date of 08/03/2026. Right Calf Achillies wound: cleanse with vashe/dakins, pat dry, apply triad/zinc to peri wound then apply xeroform to wound, cover with ABD pad and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound care with a start date of 8/6/2026. Left Calf Wound: cleanse with wound cleanse pat dry apply activated hydrafera blue to open area not to touch outer skin, cover with 4 by 4 gauze and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound care with a start date of 08/04/2026. Record review of Resident #3's WAR dated 08/15/2026 revealed a blank on the following dates for the orders: Right heel wound: cleanse with vashe or Dakins cleanser, pat dry, apply biostep Ag to wound bed, cover with allevyn life dressing, and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound with an end date of 07/17/2026. -07/11/2026 Right calf wound: cleanse area with Vashe, or Dakins cleanser, pat dry, apply xeroform and cover with ABD pad, wrap with kerlix, every day shift every Tuesday, Thursday, Saturday with an end date of 07/28/2026. -07/25/2026 Right calf Achillies wound: cleanse with [NAME]/Dakins, pat dry, apply xeroform, cover with ABD pad and wrap with Kerlix, every day shift every Tuesday, Thursday and Saturday with an end date of 07/28/2026. -07/25/2026 Left Calf Wound: cleanse with wound cleanse pat dry apply activated hydrafera blue to open area not to touch outer skin, cover with 4 by 4 gauze and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound care with an end date of 08/03/2026. -07/25/2026 Right Calf Achillies wound: cleanse with vashe/dakins, pat dry, apply triad/zinc to peri wound then apply xeroform to wound, cover with ABD pad and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound care with a start date of 8/6/2026. -08/13/2026 Left Calf Wound: cleanse with wound cleanse pat dry apply activated hydrafera blue to open area not to touch outer skin, cover with 4 by 4 gauze and wrap with kerlix, every day shift every Tuesday, Thursday, Saturday for wound care with a start date of 08/04/2026. -08/13/2026 3. Record review of Resident #4's face sheet, dated 08/14/2026 revealed a [AGE] year-old female with an admission on [DATE] and a readmission on [DATE] with diagnoses that include Parkinson's disease with dyskinesia, without mention of fluctuations (involuntary, erratic movements). Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed in section K- Swallowing/Nutritional Status under the following sections K0300. Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in the last 6 months Resident #4 was marked as 0. No or unknown and in section K.0310. Weight gain. Gain of 5% or more in the last month or gain of 10% or more in the last 6 months Residet #4 was marked as 0. No or unknown. Record review of Resident #4's care plan last revised on 04/14/2026 revealed: Resident has a diet order other than regular and is at risk for unplanned weight loss or gain. Elongated spoon with meals last revised on 01/22/2026 with interventions that include place a red glass on the resident's tray to identify the resident to staff as soon as possibly needing assistance initiated on 04/01/2025. Record Review of Resident #4's order summary dated 08/14/2026 revealed: May have elongated spoon for meals with an order date of 12/04/2024 with no end date. 4. Record review of Resident #5's face sheet, dated 08/14/2026 revealed a [AGE] year-old male with an admission on [DATE] and a readmission on [DATE] with diagnoses that include moderate protein-calorie malnutrition (significant but not severe weight loss). Record review of Resident #5's comprehensive MDS dated [DATE] revealed a BIMS score 12 out 15 indicating the resident's cognition was intact. Further review of the MDS revealed in section K- Swallowing/Nutritional Status under the following sections K0300. Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in the last 6 months Resident #5 was marked as 0. No or unknown and in section K.0310. Weight gain. Gain of 5% or more in the last month or gain of 10% or more in the last 6 months Residet #5 was marked as 0. No or unknown. Record review of Resident #5's care plan last revised on 03/16/2026 revealed: Resident has a diet order other than regular and is at risk for unplanned weight loss or gain. cup w/handles and straw last revised on 03/09/2026. In an observation and record review on 8/14/2026 at 11:41 AM, revealed Resident #4 was observed eating lunch in the dining room. Record review of the printed ticket presented with Resident #4's tray reflected Resident #4 was to receive an elongated spoon with her tray. The spoon on the tray was the same size and shape as the silverware being used by the other residents at the table. Resident #4 did not have a beverage served in a red glass, and Resident #4 was being fed by CNA A. In an interview with CNA A on 8/14/2026 at 11:48 AM, she said she was unsure what an elongated spoon was, but she thought it might be the spoon with the heavy handle that was provided from the kitchen. She said the trays were checked by the nurse for adaptive devices before they were served, but she had never seen Resident #4's tray served with an elongated spoon. She said Resident #4 was sometimes able to feed herself independently. In an observation and record review on 8/14/2026 at 11:41 AM, revealed Resident #5 was observed eating lunch in the dining room. Record review of the printed ticket presented with Resident #5's tray reflected Resident #5 was to receive a cup with two handles with his tray. Resident #5 had three beverage cups at his place setting, all of which were served in cups with single handles. The three cups did not have straws. Resident #5 was observed drinking one of the beverages without spilling any of the liquid or obvious difficulty with grasping the cup. In an interview with Resident #5 on 8/14/2026 at 11:41 AM, he said the single handled cups without straws were fine and not difficult to use. In an interview on 8/14/2026 at 11:55 AM, LVN B said she had checked the residents' trays in the dining room before the residents were served. She said she checked the tickets for meal types as well as adaptive devices. She said Resident #5 always receives his beverages in single handled cups, and she had never seen a double handled cup with a straw at the facility. She was unsure what an elongated spoon was, and she said she had never seen an elongated spoon for any resident provided from the kitchen. During an interview on 08/16/2026 at 11:21 a.m., LVN E stated nurses were responsible for providing wound care treatments to residents. LVN E stated whenever they provided wound care they documented it in the residents WAR. LVN E stated they were unsure as to why there were blanks in documentation on both Resident #2 and Resident #3's WARs. LVN E stated blanks in residents WARs can look like the treatment was not done or the treatment could have possibly not been done. During an interview on 08/16/2026 at 12:54 p.m., the DOR stated they had assisted with residents' meal tickets. Resident #5 did not need a cup with two handles anymore. The DOR stated Resident #5's meal ticket should have reflected Resident #5's current status. The DOR stated Resident #4 did not need the elongated spoon or the red glass anymore. The DOR stated Resident #4's care plan, orders and meal ticket should accurately reflect Resident #4's current status. The DOR stated along with the corporate dietician they both can edit meal tickets. The DOR stated the risk to for residents to have inaccurate documentation regarding their diets and needed assistive devices could lead to not getting proper nutrition. During an interview on 08/16/2026 at 2:26 p.m., LVN F stated they were responsible for care plans. LVN F stated they were unaware that Resident #4 did not need an elongated spoon anymore. LVN F stated Resident #4 should have an updated care plan without the elongated spoon on it anymore. LVN F stated care plans should be accurate in order to provide the appropriate care to residents. LVN F stated they were unaware that Resident #2's medical diagnosis record did not include Resident #2's wound. LVN F stated Resident #2's medical diagnosis of the wound should have been recorded. LVN F stated the medical diagnosis records should be accurate to provide an accurate picture of what is going on with the resident. During an interview on 08/16/2026 at 2:40 p.m., MA G stated they gave medications to residents. CMA G stated when providing medications to residents they must document in the residents MAR. CMA G stated they were unsure as to why there was a blank in Resident #2's MAR. CMA G stated they always gave medications and always documented. CMA G stated they or whomever was giving medications must have forgotten to sign the MAR but that it could look like the medication wasn't given. During an interview on 08/16/2026 at 2:55 p.m., the RCN stated residents care plans, orders, records and dietary tickets should be accurate to provide the correct care to residents. Record review of the facility's policy titled, Documentation, with no date, revealed: GoalThe facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.The facility will ensure that information is comprehensive and timely and properly signed. - 23

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infection for 1 of 5 residents (Resident #2) reviewed for infection control. The facility failed to ensure appropriate transmission-based precautions (EBP) were implemented for Resident #2 who had pressure sore (wound). This failure could lead to the spread of infection or illness. Findings included: Record review of Resident #2's face sheet dated 8/14/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included need for assistance with personal care and unspecified dementia [decline in cognitive function, affecting memory and decision making]. Resident #2's face sheet did not contain a diagnosis related to wounds or pressure ulcers. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 02, which indicated severely impaired cognition. Section M0300 of the MDS reflected Resident #2 had 1 stage 4 pressure injury (a pressure wound extending through all layers of the skin with exposed bone, tendon, or muscle) that was present on admission to the facility. Record review of Resident #2's Order Summary Report dated 8/14/2026 did not reveal an order for EBP. Record review of Resident #2's Care Plan Report undated/ printed 8/14/2026 reflected the following:Resident is on enhanced barrier precautionsDate initiated: 12/02/2025 In an observation on 8/14/2026 at 1:45 PM, Resident #2's room was observed without signage indicating Resident #2 required EBP, nor was a cart containing PPE observed near the entrance to Resident #2's room. In an interview on 8/16/2026 at 2:55 PM, the RCN said all residents with wounds that required a dressing, such as Resident #2, should have a sign on their door indicating they require EBP as well as documentation in the electronic medical record. She said the risk of not having appropriate precautions in place was the transmission of infection. Record review of the facility policy titled Enhanced Barrier Precautions dated 4/1/2024, reflected the following: .Communication to StaffThe facility will utilize postings outside the room and [electronic medical record] to communicate to staff if a resident requires EBP.

Based on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The Dietary Manager did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services, to include not following policy to substitute foods for 03/17/2026 lunch and not storing a container [whipped topping] appropriately on 03/17/2026. This failure could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.The findings included: Record review of Resident #5's admission record, dated 03/17/2026, reflected [AGE] year-old female initially admitted [DATE] and re-admitted [DATE]. Record review of Resident #5's quarterly MDS assessment, dated 02/27/2026, reflected a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #5's Nutritional Risk Assessment, dated 02/27/2026 and authored by the RD, reflected resident had a significant weight loss of 9.1% (14.2 pounds) in 1 month but may be related to hospitalizations in Feb (2/3-2/7 & 2/20-2/24).[Resident #5] is also at risk for weight fluctuations r/t fluid fluctuations AEB BLE edema. and [Resident #5] on diuretic tx and Nutritional interventions were add house shakes BID and add weekly weights for 4 weeks to monitor. Record review of Resident #5's weight summary prior to 02/03/2026 reflect resident had stable weight from November 2025 to January 2026. Record review of the Dietary Manager's certifications reflected no document that reflected she was a Certified Dietary Manager. During an observation and interview on 03/17/2026 at 10:41 AM, the Dietary Manager revealed she was not a Certified Dietary Manager (CDM) and was going to school to become an CDM. She revealed she started working at this facility in October 2025 and did not start her schooling until January 2026. In an observation, there was a container of [whipped topping] in the reach-in refrigerator in the food preparation area. The container reflected that it was received on 03/03/2026 and the use by date was 07/06/2027 if the food product was frozen. The Dietary Manager revealed she was not aware that the container of [whipped topping] said that the discard date was 07/06/2027 if the food product was frozen, because she did not read it. She revealed it was important to follow the directions on the container to prevent residents from getting sick. During an observation, interview, and record review on 03/17/2026 at 11:52 AM, Resident #5 revealed she did not want potato soup instead of chicken and sausage gumbo because she already had potato soup for the soup of the day. Observation revealed Resident #5's lunch meal consisted of 2 bowls of potato soup. Resident #5's lunch meal tray ticket reflected a preference of no sausage and the meal would include: soup, entree, starch, salad, bread, dessert, condiment, and beverage. It revealed the soup was 1 serving soup of the day and the entree was 1 cup of chicken and sausage gumbo. Record review of the lunch menu substitution for Tuesday 03/17/2026's meat (protein) was ham and cheese sandwich. During an interview on 03/19/2026 at 08:19 AM, the ADM revealed the recipe for the loaded baked potato soup that was served at Tuesday's lunch showed that it should meet the requirement for protein because the recipe called for bacon, cheese, milk, and sour cream. Record review of the Loaded Potato Soup recipe's nutrition facts reflected 1 serving of the soup yielded 9.42 grams of protein. During an interview on 03/20/2026 at 03:36 PM, the RD revealed the Dietary Manager was not certified but was currently in school to be an CDM. She revealed if the Dietary Manager could not get ahold of her, she was allowed to make substitutions for meals if the replacement was similar in nutritive value. She revealed the substitution should be documented on substitution log. She revealed the Dietary Manager should have contacted her about substituting loaded potato soup for chicken and sausage gumbo, because the potato soup would not have as much protein as the chicken and sausage gumbo. She revealed she would have added chicken because 9g of protein from the loaded potato soup was not as much protein as was in the chicken and sausage gumbo. She revealed if the [whipped topping] container read that the discard date was 07/06/2027 if the product was frozen, then it should have been stored in the freezer. The RD further revealed she will review all of this with the Dietary Manager. During an interview on 03/20/2026 at 04:02 PM, the ADM revealed the Dietary Manager was not certified and did not have to be certified if she was in school. Record review of the facility's diet manual, dated 2025, reflected Suggested Meal Patterns Diabetic and Calorie Controlled Diets for 1600 to 1800 calorie diets 2 servings of meat needed to be served at lunch. For 2000 to 2400 calorie diets, 3 servings of Meat needed to be served at Lunch. Further record review of the 2025 diet manual reflected the meat and meat substitute group for 1 serving equated to 7 grams of protein. This would mean 2 servings of meat or meat substitute would be 14 grams of protein and 3 servings would be 21 grams of protein. Record review of the USDA's Dietary Guidelines for Americans, dated 2025-2030, reflected a diet included protein, dairy, healthy fats, vegetables, fruits and whole grains. Record review of the facility's policy MENU APPROVAL AND HONORING SPECIAL REQUESTS, AND FOOD BROUGHT TO THE FACILITY FROM UNAPPROVED SOURCES, dated 2012, REFLECTED . 4. Every attempt will be made to honor resident food preferences. In addition, an appealing option of similar nutritive value is provided for each meal, for those residents who do not like the main menu items being served. Record review of the facility's policy Menu Substitutions Form, dated 2012, reflected .5. Substitutions must be of equal value as the item to be substituted (ie meat for meat, vegetable for vegetable, etc.) Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12. Record review of the facility's job description for the dietary service manager, dated 2014, reflected The following is a non-exhaustive criteria that relates to the job of a Dietary Service Manager, and it is consistent with business needs of the facility. There are legitimate measures of the qualifications for a Dietary Service Manager, and are related to the functions that are essential to the job of a Dietary Service Manager. Base Knowledge: Current certification by state as required. Ability to procure and store all food and supplies.

Based on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food that accommodates residents' food preferences and foods of similar nutritive value for 2 of 8 residents (Resident #5 and Resident #16) reviewed for food preferences and nutritive value.The facility failed to ensure Resident #5 received an entree that was of equal nutritive value as what was originally served for Tuesday 03/17/2026's lunch meal (chicken and sausage gumbo) instead of loaded potato soup.The facility failed to ensure that Resident #5 was not served fried food Friday 03/20/2026 meal as was noted on her dislikes.The facility failed to update Resident #16's meal tray ticket to reflect she could have a regular diet instead of a mechanical soft diet as was reflected in her Negotiated Risk Agreement, dated 06/24/2025.This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. The findings include:Record review of Resident #5's admission record, dated 03/17/2026, reflected [AGE] year-old female initially admitted [DATE] and re-admitted [DATE]. Record review of Resident #5's quarterly MDS assessment, dated 02/27/2026, reflected a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #5's Nutritional Risk Assessment, dated 02/27/2026 and authored by the RD, reflected resident had a significant weight loss of 9.1% (14.2 pounds) in 1 month but may be related to hospitalizations in Feb (2/3-2/7 & 2/20-2/24).[Resident #5] is also at risk for weight fluctuations r/t fluid fluctuations AEB BLE edema. and [Resident #5] on diuretic tx and Nutritional interventions were add house shakes BID and add weekly weights for 4 weeks to monitor. Record review of Resident #5's weight summary prior to 02/03/2026 reflect resident had stable weight from November 2025 to January 2026. Record review of Tuesday 03/17/2026's lunch menu reflected: chicken and sausage gumbo, steamed rice, tossed salad, cornbread, bread pudding, margarine, and iced tea. During an observation, interview, and record review on 03/17/2026 at 11:52 AM, Resident #5 revealed she did not want potato soup instead of chicken and sausage gumbo because she already had potato soup for the soup of the day. Observation revealed Resident #5's lunch meal consisted of 2 bowls of potato soup. Resident #5's lunch meal tray ticket reflected a preference of no sausage and the meal would include: soup, entree, starch, salad, bread, dessert, condiment, and beverage. It revealed the soup was 1 serving soup of the day and the entree was 1 cup of chicken and sausage gumbo. Record review of the lunch menu substitution for Tuesday 03/17/2026's meat (protein) was ham and cheese sandwich. During an interview on 03/19/2026 at 08:19 AM, the ADM revealed the recipe for the loaded baked potato soup that was served at Tuesday's lunch showed that it should meet the requirement for protein because the recipe called for bacon, cheese, milk, and sour cream. Record review of the Loaded Potato Soup recipe's nutrition facts reflected 1 serving of the soup yielded 9.42 grams of protein. During an interview on 03/20/2026 at 03:36 PM, the RD revealed the Dietary Manager should have contacted her about substituting loaded potato soup for chicken and sausage gumbo, because she would not have agreed that this was an adequate substitution. She revealed the potato soup would not have as much protein as the chicken and sausage gumbo. She revealed she would have added chicken because 9g of protein from the loaded potato soup was not as much protein as was in the chicken and sausage gumbo. Record review of the facility's diet manual, dated 2025, reflected Suggested Meal Patterns Diabetic and Calorie Controlled Diets for 1600 to 1800 calorie diets 2 servings of meat needed to be served at lunch. For 2000 to 2400 calorie diets, 3 servings of Meat needed to be served at Lunch. Further record review of the 2025 diet manual reflected the meat and meat substitute group for 1 serving equated to 7 grams of protein. This would mean 2 servings of meat or meat substitute would be 14 grams of protein and 3 servings would be 21 grams of protein. Record review of the USDA's Dietary Guidelines for Americans, dated 2025-2030, reflected a diet included protein, dairy, healthy fats, vegetables, fruits and whole grains. Record review of the facility's policy Menu Substitutions Form, dated 2012, reflected .5. Substitutions must be of equal value as the item to be substituted (ie meat for meat, vegetable for vegetable, etc.) 2. Record review of Friday 03/20/2026's lunch menu reflected: fish sandwich, fried okra, creamy diced coleslaw, hush puppies, double chocolate pie, tartar sauce, and iced tea. Record review, interview, and observation on 03/20/2026 at 11:55 AM, Resident #5's lunch meal tray ticket reflected she disliked fried-breaded foods. Her lunch meal tray included fried okra, fried fish, and hushpuppies. Resident #5's meal tray ticket revealed her meal had too much fried food for her to handle. She revealed after she had her gallbladder removed, she could not eat fried food because it affected her digestion. During an interview and observation on 03/20/2026 at 12:09 PM, LVN I revealed she was checking the meal tray tickets for accuracy before they were given to the residents. She revealed Resident #5 was not supposed to have fried foods and she was given fried food. LVN I could not give a reason why she left fried foods on Resident #5's tray but walked back to the kitchen door and asked if Resident #5 could have any food substitutions instead of the fried foods for lunch today. The Dietary Manager revealed she did not realize that Resident #5 was being served fried food on her tray today and confirmed that Resident #5 should not have fried foods on her tray ticket because it was her preference after her gallbladder removal. She revealed recently Resident #5 told her that the resident felt like she could start including fried foods because it was not upsetting her stomach as much. During an interview on 03/20/26 at 12:26 PM, Resident #5 revealed she did not finish the fried food on her plate but mentioned she did not really feel like she was still hungry and her family was going to visit her and bring her food soon. During an interview on 03/20/2026 at 03:36 PM, the RD revealed the expectation was to follow the preferences for Resident #5 and not serve her fried foods. She was surprised because they typically served baked food and not fried foods. Record review of the facility's policy MENU APPROVAL AND HONORING SPECIAL REQUESTS, AND FOOD BROUGHT TO THE FACILITY FROM UNAPPROVED SOURCES, dated 2012, REFLECTED . 4. Every attempt will be made to honor resident food preferences. In addition, an appealing option of similar nutritive value is provided for each meal, for those residents who do not like the main menu items being served. 3. Record review of Resident #16's admission record, dated 03/20/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dysphagia (difficulty or discomfort in swallowing) Record review of Resident #16's admission MDS assessment, dated 02/10/2026, reflected Resident #16 had a BIMS score of 15 out of 15, indicating intact cognition. It reflected that she had no weight loss or weight gain in the last month or in the last 6 months. It further reflected that she had a mechanically altered diet (require change in texture of food or liquids). Record review of Resident #16's care plan, accessed on 03/20/2026 at 12:06 PM, reflected no mention of Resident #16's Negotiated Risk Agreement (NRA) that was dated 06/24/2025 and no mention of Resident #16 allowed to eat a regular diet instead of mechanical soft diet. It reflected [Resident #16] has a diet order other than Regular and is at risk for unplanned weight loss or gain., revised 03/09/2026, with intervention Served diet and snack as ordered., initiated 02/03/2026. Record review of Resident #16's order summary report, dated 03/20/2026, reflected her diet was mechanical soft texture and not regular texture. Record review of Resident #16's Negotiated Risk Agreement, dated 06/24/2025, that Resident #16 preferred to eat regular foods even though she was at risk for aspiration. Interview, observation and record review on 03/20/2026 at 12:08 PM revealed Resident #16 received a lunch meal tray that was mechanically soft, as was reflected on her meal tray ticket. Resident #16 requested a meal that was regular diet. Nursing staff (name unknown) went back to the kitchen to get her a regular textured meal because the kitchen said it was okay to give Resident #16 a regular diet lunch tray and the nursing staff was not aware and said Resident #16's tray ticket shows she should be served a mechanical soft meal. Resident #16 revealed she was allowed to be served a regular diet. The Dietary Manager said Resident #16 was allowed a regular diet because Resident #16 had the right to request this and signed that she was aware she was prescribed a mechanical soft diet and not a regular diet. During an interview on 03/20/2026 at 12:18 PM, the ADM revealed Resident #16 had an NRA because she wanted to eat a regular diet instead of a mechanical soft diet (per her doctor's orders) when she chose to eat a regular diet because it was not all the time. She revealed she was not sure if a doctor's order needed to be in place to show that Resident #16 could have a regular diet instead of the mechanical soft diet at times. She revealed they had not updated the tray ticket to reflect it was okay for Resident #16 to have a regular diet. Record review of the facility's policy Diet Orders/Diet Manual, dated 2012, reflected The physician will prescribe diets in accordance with the approved Diet Manual. A written order must appear on the medical record before the resident may be served.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety.1.The facility failed to keep the kitchen's ice machine free of black circular spots on the inside of the ice machine.2.The facility failed to ensure containers of [whipped topping] were stored properly in the reach-in refrigerator in the food preparation area on 03/17/2026.3.The facility failed to ensure raw protein food products were not stored right next to fully cooked food products.4. The facility failed to ensure a food product had the name of it on its label.5. The facility failed to label 3 buckets of food products in the food preparation area. These failures could place residents at risk for food borne illness.The findings included:During an observation and interview on 03/17/2026 at 10:41 AM it was revealed that the ice machine had black circular spots on the inside of the ice machine above the ice. The DM confirmed there were black circular spots present but that it did not look like mold. She was able to wipe these spots off and showed an unnamed substance on a paper towel. She further revealed that she cleaned the inside of the ice machine once a week by putting plastic bag on top of the ice and cleaned the inside. She revealed it was important to ensure the inside of the ice machine was cleaned because the residents could drink whatever contaminants were in the ice machine. Observation in the reach in refrigerator in the food preparation area revealed there were containers of [whipped topping] (amount unknown), dated 03/03/2026 and use by date 07/06/2027. Further reading of the container of [whipped topping] reflected when frozen-used by 06 July 2027. The DM revealed she was not aware that this food product needed to be frozen for the discard date to be 07/06/2027. During an observation and interview on 03/17/2026 at 10:51 AM revealed in the reach-in freezer, there were raw protein foods stored next to fully cooked food products. [NAME] J and the DM revealed the raw protein foods should not be stored near the fully cooked foods in the reach-in freezer because the blood leaking from the raw protein packages could get into the fully cooked food products and contaminate these fully cooked food products. There was an observation of a food product that did not have its name on it. The DM revealed the food products needed to have the name of the food product to know what the food was. The DM revealed with these labels sometimes they fell off easily. The DM revealed she typically ensured frozen raw proteins were stored in a separate freezer from the fully cooked food products to prevent cross contamination. The DM revealed when she was off from work, she noticed that everything got unorganized with food storage. There was an observation of 3 unlabeled buckets of food products in the food preparation area. [NAME] J revealed these buckets were: cornmeal, flour, and sugar and that they were currently not labeled. The DM and [NAME] J revealed they should be labeled so people knew what was in these buckets. The DM revealed she oversaw the kitchen to ensure everything was in order. During an interview on 03/20/2026 at 03:36 PM, the RD revealed the ice machine should not have black circular spots inside of it. She revealed the kitchen regularly cleaned the ice machine and were responsible for keeping it clean in between scheduled ice machine cleanings. She revealed it was important to keep the ice machine cleaned to prevent any contaminants and any foodborne illnesses from the ice. She revealed it was expected to read the food products to ensure proper food storage and to prevent food spoilage, so if the containers of [whipped topping] had a discard date for when it was frozen then these products should have been frozen. She revealed that raw protein foods should not be stored near fully cooked food products: She revealed she would instruct the kitchen staff to store raw protein food products separate from fully cooked food products to decrease the risk of cross contamination. The RD revealed she had come into the facility to do inspections of the kitchen and had not found any of these deficiencies during her visits, but she will educate the kitchen staff and the DM, as she was overseeing the DM while the DM went to school to become an CDM. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the FDA Food Code 2022 reflected, 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from:. (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food. Record review of the facility's policy Cleaning of the Ice Machine, dated 2012, reflected . 4. If any type of soil/food stains are present, wash with all purpose cleaner and rinse well. Record review of the facility's policy Storage Refrigerators, dated 2012, reflected . 5. Food must be covered when stored, with a date label identifying what is in the container. 6. Frozen food that has been thawed will be used within three days of thawing. Record review of the facility's policy Dry Storage and Supplies, dated 2012, reflected .3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled.

Based on observation, interview, and record review, the facility failed to 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 disease and infection for 2 of 5 residents (Residents #3 and #7) reviewed for infection control, in that: 1. The facility failed to ensure CNA C sanitized between their fingers while providing incontinent care for Resident #3. 2.The facility failed to ensure LVN D wore a gown while providing wound care for Resident #7 who was on enhanced barrier precaution. LVN D also failed to sanitize her hands between change of gloves after cleaning the wound and before applying the treatment, while providing wound care for Resident #7. These failures could place residents at-risk for infection due to improper care practices.The findings were: Record review of Resident #3's face sheet, dated 03/19/2026, revealed an admission date of 08/18/2023 and, a readmission date of 12/04/2025 with diagnoses that included: Dementia (decline in cognitive abilities), Schizophrenia(mental disorder characterized by abnormal thought processes and an unstable mood) , Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood) , Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Type 2 diabetes mellitus(high level of sugar in the blood) , Hypertension (High blood pressure) , Chronic kidney disease (gradual loss of kidney function). Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact, and was indicated to always be incontinent of bladder and frequently incontinent of bowel. Record review of Resident #3's care plan, dated 08/29/2023, revealed a problem of The resident has bowel incontinence and, and intervention of Provide pericare after each incontinent episode. Observation on 03/19/2026 at 12:35 p.m. revealed while providing incontinent care for Resident #3, CNA C did not sanitize between her fingers when using sanitizer between change of gloves. During an interview on 03/19/2026 at 12:48 p.m. with CNA C, she stated she did not sanitize between her fingers while providing incontinent care for Resident #3. She said she was nervous and forgot. She stated she received infection control training within the year. 2. Record review of Resident #7's face sheet, dated 03/20/2026, revealed an admission date of 11/21/2020 and, a readmission date of 02/14/2024 with diagnoses that included: Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Chronic obstructive pulmonary disease (lung condition caused by damage to the lungs), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Neoplasm of uncertain behavior of skin ( growth whose potential to be benign or malignant cannot be definitively determined without further evaluation). Record review of Resident #7's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact, and was indicated to have two pressure ulcers. Record review of Resident #7's care plan, dated 01/13/2026, revealed a problem of Resident requires ENHANCED BARRIER PRECAUTIONS due to wounds. and, and intervention of Gown and gloves necessary when performing high-contact care activities. Observation on 03/20/2026 at 9:30 a.m., revealed while providing wound care for Resident #7, LVN D did not gown up to enter the room and provide care. A sign and protective equipment could be seen by the door of Resident #7's room. Resident #7 is on enhanced barrier precaution due to her wounds. After cleaning the wound, LVN D changed her gloves but did not sanitize her hands and then applied the clean treatment and dressing to the wound During an interview on 03/20/2026 at 9:55AM with LVN D, she stated she forgot Resident #7 was on enhanced barrier precaution. She stated enhanced barrier precaution were a new thing and she was not used to it. She stated she had dipped her fingers in sanitizer but did not sanitize her whole hands between change of gloves. She stated she changed gloves frequently to make sure to stay clean. LVN D stated she just started working at the facility but received infection control through her orientation. During an interview on 03/20/2026 at 10:30 a.m. with the DON, who was the infection preventionist for the facility, she stated the staff need to wear gown and gloves for resident on enhanced barrier precaution and to sanitize hands between change of gloves for the prevention of infection to the residents but also the staff. She stated when staff used sanitizer, they should sanitize the whole surface of the hands including between the fingers. The DON stated infection control training provided was provided and skills were checked annually. Review of facility's policy, titled Enhanced barrier precautions, dated 04/01/2024, revealed Enhanced barrier precaution are used in conjunction with standard precautions and expand the use of personal protective equipment to donning gown and gloves during high-contact resident care activities. Review of facility's policy, titled Fundamentals of infection control precaution, undated, revealed Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: [ ] after removing gloves. [ .] Recommended techniques for performing hand hygiene with alcohol-based hand rub include applying product to the palm of the hand and rubbing hand together, covering all surfaces of hands and fingers, until the hands are dry.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 16 residents (Residents #8 and unknown resident) observed for nursing care, in that: 1.CNAs A and B did not completely close Resident #8's privacy curtain while providing perineal care for the resident.2. The facility failed on 03/17/2026 to ensure the privacy of unknown residents by not locking the laptop screen on the medication cart (1 of 3), so the residents' information could not be seen and/or accessed by someone walking by. This deficient practice could place residents at risk of embarrassment, lack of self-worth, and feeling disrespected. The findings were: 1.Record review of Resident #8's face sheet, dated 03/20/2026, revealed an admission date of 08/22/2024, and a readmission date of 07/22/2025, with diagnoses that included: End stage renal disease (the kidneys lost their filtering abilities, dangerous levels of fluid, electrolytes and wastes can build up in the body), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) , Anxiety disorder (a group of mental illnesses that cause constant fear and worry), Dependence on renal dialysis (a filtering machine is used to remove waste and extra fluid from the blood, and then return the filtered blood into the body). Record review of Resident #8's quarterly MDS assessment, dated 01/19/2026, revealed the resident had a BIMS score of 5, which indicated severe cognitive impairment, and was indicated to always be incontinent of bladder and frequently incontinent of bowel. Record review of Resident #8's care plan, dated 8/22/2024, revealed a problem of The resident has bowel incontinence with an intervention of Provide pericare after each incontinent episode. Observation on 03/20/2026 at 9:18 a.m. revealed CNAs A and B provided perineal care for Resident #8. During care CNAs A and B tried to pull the curtain to offer privacy to the resident but the curtain was too short in width to go around the resident's bed. Further observation revealed Resident #8 could be seen by his roommate and could have been seen by someone opening the room's door. During an interview with CNAs A and B on 03/20/2026 at 9:25 a.m., CNAs A and B stated the privacy curtain was not closed while they provided care for Resident #8 but should have been. CNAs A and B further stated the resident's privacy curtain was not long enough to close completely around the resident's bed. During an interview with the DON on 03/20/2026 at 10:30 a.m., the DON stated privacy must be provided during nursing care and Resident #8's privacy curtain should have been closed completely. Resident rights training was provided for the staff annually. 2. Observation and interview on 03/17/2026 at 11:46 AM revealed a computer screen on a medication cart (located right outside of the dining room, in the entrance hallway) was unlocked and unsupervised with unknown resident information. There were no residents or visitors present. COTA F walked by and confirmed that the computer screen was unlocked and displayed confidential information. COTA F brought MDS Nurse E to the medication cart. MDS Nurse E confirmed she left the computer screen on the medication cart unlocked accidentally. MDS nurse E revealed it was important for the screen to be locked because of HIPAA reasons. Interview on 03/17/2026 at 4 PM, the ADM revealed the laptop on the medication cart needed to be locked. She said the MDS Nurse E did not typically work on the floor so she may have forgotten. Record review of facility's policy titled, Resident rights, undated, revealed, Privacy and confidentiality -The resident has a right to personal privacy[ .] 1. Personal privacy included accommodations, medical treatment [ .] 3. The resident has a right to secure and confidential personal and medical records .

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Residents #1) reviewed for assessments. The facility failed to ensure Resident #3's quarterly MDS assessment, dated 12/08/2025, reflected his diagnosis of colon cancer. These failures could place residents at risk for inadequate care due to inaccurate assessments.The findings included: Record review of Resident #3's admission record, dated 03/17/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include gastrointestinal hemorrhage (GI bleeding). Colon cancer was not reflected as a diagnosis on his admission record. Record review of Resident #3's hospital documentation with admit date [DATE] reflected Resident #3 had a diagnosis of invasive colonic adenocarcinoma (cancer that originates in the glandular cells of the colon). Record review of Resident #3's quarterly MDS assessment, dated 12/08/2025, reflected Resident #3 had a BIMS score of 15 out of 15, indicating intact cognition. Colon cancer was not reflected as a diagnosis on his MDS assessment. Record review of Resident #3's care plan, undated, reflected no mention of Resident #3's diagnosis of colon cancer. During an interview on 03/17/2026 at 2:16 PM, Resident #3 revealed he went to chemotherapy because he had colon cancer. During an interview on 03/20/26 at 12:39 PM, the MDS Nurse E and the Reimbursement Consultant revealed Resident #3 came back to the facility on [DATE] with the diagnosis of stage 4 colon cancer. They revealed when a resident came to the facility, they reviewed pertinent documents in residents' medical records to see what diagnoses the residents had. Resident #3 went to the hospital on [DATE] for a GI (gastrointestinal) hemorrhage and that was when colon cancer was found. They revealed Resident #3 was currently on chemotherapy for palliative purposes. The Reimbursement Consultant revealed the DON reviewed medications and diagnoses in pertinent documents in residents' medical record and MDS Nurse E reviewed diagnoses to add to the MDS assessments. They revealed it was a team effort to catch any new diagnoses and that diagnoses were added to the MDS assessments and face sheets (admission records). They confirmed the diagnosis of colon cancer was not reflected on his MDS assessment. They revealed it was important to have the diagnosis on Resident #3's MDS assessment because the MDS assessments drove the care plans, which was important because cancer could affect resident care like the resident experiencing pain and staff needed to know about it. During an interview on 03/20/2026 at 04:02 PM, the DON and the ADM revealed they had to verify that colon cancer was not reflected as a diagnosis in Resident #3's MDS assessment, but it had to be there because he had colon cancer and the nurses had to be aware of it. Record review of facility's policy Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy, dated 08/2025, reflected The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are family with his/her physical, mental, and psychosocial well-being. The items in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and outside agencies.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 6 residents (Residents #3 and #16) reviewed for care plans. The facility failed to update Resident #3's care plan to reflect that Resident #3 had colon cancer and was going to chemotherapy after his 12/04/2025 re-admission.The facility failed to update Resident #16's care plan to reflect that Resident #16 had a negotiated risk agreement, dated 06/24/2025, to eat regular texture foods instead of mechanically soft texture diet as was prescribed by her doctor. This failure could place residents at risk of not having their needs met and not receiving appropriate care. The findings included: Record review of Resident #3's admission record, dated 03/17/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dementia (decline in cognitive functions (memory, reasoning, and thinking) which interferes with daily life) and gastrointestinal hemorrhage (GI bleeding). Record review of Resident #3's hospital documentation with admit date [DATE] reflected Resident #3 had a diagnosis of invasive colonic adenocarcinoma (cancer that originates in the glandular cells of the colon). Record review of Resident #3's quarterly MDS assessment, dated 12/08/2025, reflected Resident #3 had a BIMS score of 15 out of 15, indicating intact cognition. Colon cancer was not reflected as a diagnosis on his MDS assessment. Record review of Resident #3's care plan, undated, reflected no mention of Resident #3's diagnosis of colon cancer or going to chemotherapy. During an interview on 03/17/2026 at 2:16 PM, Resident #3 revealed he went to chemotherapy because he had colon cancer. During an interview on 03/20/2026 at 12:39 PM, the MDS Nurse E and the Reimbursement Consultant revealed Resident #3 came back to the facility on [DATE] with the diagnosis stage 4 colon cancer. They revealed it was important to have the diagnosis reflected on his care plans because cancer could affect his care like pain management and staff needed to know about it. They revealed CNAs used the Kardex (platform for CNAs to know how to care for residents) to care for residents and the care plan told nursing staff what interventions were CNA tasks. They revealed they had to manually add the diagnosis to the care plan. They further revealed the IDT and even charge nurses could help make sure the care plan was updated, but the task usually fell on the MDS Nurse. During an interview on 03/20/2026 at 04:02 PM, the DON and the ADM revealed Resident #3's cancer diagnosis should be in his care plan, so nurses were aware that he had cancer and knew any treatment that the nursing staff needed to complete. During an interview on 03/20/2026 at 04:21 PM, CNA A, CNA G, and CNA H revealed Resident #3 had cancer. They revealed Resident #3 went to chemotherapy and they knew when he came back that he was weaker and they had to help him more on those days. They revealed they looked at the Kardex for resident care which could include Resident #3's care when he went to chemotherapy. They were unaware if updated care plans affected the Kardex. 2. Record review of Resident #16's admission record, dated 03/20/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dysphagia (difficulty or discomfort in swallowing) Record review of Resident #16's admission MDS assessment, dated 02/10/2026, reflected Resident #16 had a BIMS score of 15 out of 15, indicating intact cognition. It reflected that she had no weight loss or weight gain in the last month or in the last 6 months. It further reflected that she had a mechanically altered diet (require change in texture of food or liquids). Record review of Resident #16's Negotiated Risk Agreement, dated 06/24/2025, that Resident #16 preferred to eat regular foods even though she was at risk for aspiration (the accidental inhalation of food, liquid, or foreign materials into the airway and lungs). Record review of Resident #16's order summary report, dated 03/20/2026, reflected her diet was mechanical soft texture and not regular texture. Record review of Resident #16's care plan, accessed on 03/20/2026 at 12:06 PM, reflected the care plan did not address Resident #16's Negotiated Risk Agreement (NRA) and there was no mention that Resident #16 was allowed to eat a regular diet instead of mechanical soft diet. It further reflected [Resident #16] has a diet order other than Regular and is at risk for unplanned weight loss or gain., revised 03/09/2026. Interview, observation and record review on 03/20/2026 at 12:08 PM revealed Resident #16 received a lunch meal tray that was mechanically soft, as was reflected on her meal tray ticket. Resident #16 requested a meal that was regular diet. Nursing staff (name unknown) went back to the kitchen to get her a regular textured meal, and the kitchen said it was okay to give Resident #16 a regular diet lunch tray, and the nursing staff was not aware and said Resident #16's tray ticket showed she should be served a mechanical soft meal. Resident #16 revealed she was allowed to be served a regular diet. The Dietary Manager said Resident #16 was allowed a regular diet because Resident #16 had the right to request it and signed that she was aware she was prescribed a mechanical soft diet and not a regular diet. During an interview on 03/20/2026 at 12:18 PM, the ADM revealed Resident #16 had an NRA because she wanted to eat a regular diet instead of a mechanical soft diet (per her doctor's orders) when she chose to eat a regular diet because it was not all the time. She revealed she was not sure if a doctor's order needed to be in place to show that Resident #16 could have a regular diet instead of the mechanical soft diet at times, but she revealed the NRA did not need to be reflected in the doctor's orders. She revealed they had not updated the tray ticket to reflect it was okay for Resident #16 to have a regular diet. Interview on 03/20/26 at 01:03 PM, MDS Nurse E revealed Resident #16 chose not to follow her mechanical soft diet. She revealed Resident #16 had a Negotiated Risk Agreement because she wanted to eat a regular diet instead of a mechanical soft diet. She further revealed that should be in her care plan, so the staff knew it was okay for Resident #16 to have a regular diet because it was her preference and her right. Record review of the facility's policy Negotiated Risk Assessment, undated, reflected . 6. The resident centered care plan will need to be updated with any new or revised interventions as a result of the NRA Record review of the facility's policy Comprehensive Care Planning, undated, reflected The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care planning drives the type of care and services that a resident receives. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and the use of services.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Residents #3) reviewed for incontinent care and catheter care, in that: While providing incontinent care for Resident #3, CNA C did not clean Resident #3's lower abdomen area and the left and right groin areas. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #3's face sheet, dated 03/19/2026, revealed an admission date of 08/18/2023 and, a readmission date of 12/04/2025 with diagnoses that included: Dementia (decline in cognitive abilities), Schizophrenia(mental disorder characterized by abnormal thought processes and an unstable mood) , Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood) , Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Type 2 diabetes mellitus(high level of sugar in the blood) , Hypertension (High blood pressure) , Chronic kidney disease (gradual loss of kidney function). Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact, and was indicated to always be incontinent of bladder and frequently incontinent of bowel. Record review of Resident #3's care plan, dated 08/29/2023, revealed a problem of The resident has bowel incontinence and, and intervention of Provide pericare after each incontinent episode, Observation on 03/19/2026 at 12:35 p.m. revealed while providing incontinent care for Resident #3, CNA C did not clean Resident #3's lower abdomen area and the left and right groin areas. During an interview on 03/19/2026 at 12:48 p.m. with CNA C, she stated she did not clean Resident #3's lower abdomen area and the left and right groin areas. She said she was nervous and forgot. She stated she received incontinent care training within the year. During an interview with the DON on 03/20/2026 at 10:30 a.m., she stated that staff should clean residents' lower abdomen area and the left and right groin areas while providing incontinent care to ensure the residents were cleaned properly and prevent infection. She stated incontinent care training was provided annually and the staff skills we rechecked once a year. Record review of facility's policy titled Perineal care, dated 05/11/2022, revealed, wipe across the pubis area[ .] continue perineal care to the scrotum and inner thigh .

Based on interview, and record review the facility failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for the resident's immediate care and needs for 2 of 6 residents (Resident #3 and Resident #5) reviewed for physician services. The facility failed to ensure Resident #5's RD recommendations, dated 02/27/2026, were signed by a doctor so that the facility could implement interventions for Resident #5's significant weight loss.The facility failed to ensure another doctor oversaw Resident #3's care when Dr. K did not provide clarification in a timely manner for the resident's pharmacy recommendations that he signed on 03/09/2026. These failures could place residents at risk for not receiving appropriate care per physician orders and required oversight by the physician and could place the residents at risk for harm and overall physical health decline.The findings included:Record review of Resident #5's admission record, dated 03/17/2026, reflected [AGE] year-old female initially admitted [DATE] and re-admitted [DATE]. Record review of Resident #5's quarterly MDS assessment, dated 02/27/2026, reflected a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #5's Nutritional Risk Assessment, dated 02/27/2026 and authored by the RD, reflected the resident had a significant weight loss of 9.1% (14.2 pounds) in 1 month but may be related to hospitalizations in Feb (2/3-2/7 & 2/20-2/24).[Resident #5] is also at risk for weight fluctuations r/t fluid fluctuations AEB BLE edema (swelling caused by excess fluid trapped in the body's tissues). and [Resident #5] on diuretic tx and Nutritional interventions were add house shakes BID and add weekly weights for 4 weeks to monitor. Record review of COMMUNICATION BETWEEN THE DIETITIAN AND THE ATTENDING PHYSICIAN, dated 02/27/2026, reflected Dr. K had not signed diet recommendations for Resident #5. Record review of Resident #5's weight summary prior to 02/03/2026 reflected the resident had stable weight from November 2025 to January 2026. 2. Record review of Resident #3's admission record, dated 03/17/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dementia (decline in cognitive functions (memory, reasoning, and thinking) which interferes with daily life) and Type 2 diabetes. Record review of Resident #3's quarterly MDS assessment, dated 12/08/2025, reflected Resident #3 had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #3's care plan, undated, reflected The resident has Diabetes Mellitus, initiated 08/28/2023, with intervention Diabetes medication as ordered by doctor. Record review of Resident #3's Medication Regimen Review, dated 02/25/2026, reflected Recommendation: Can we increased Januvia to 100mg and attempt to DC sliding scale in order to reduce needle sticks and medication burden for this resident authored by Pharmacist L. The review reflected Dr. K signed the medication regimen review on 03/09/2026 and responded yes if we need to do [unable to decipher words written] a c 6 M Record review of Resident #3's order summary report, dated 03/19/2026, reflected Januvia Oral Tablet (50 MG) Give 1 tablet by mouth one time a day. During an interview on 03/20/2026 at 10:13 AM, the DON and the Compliance Nurse revealed the pharmacy and RD recommendations were emailed to the DON and the DON or MDS Nurse sent them to the doctor to have them signed. The signed doctor's orders were sent back to the DON and the DON would input these orders in the residents' medical record. The Compliance Nurse revealed she had found a lot of doctor's orders that had not been signed yet and they had to resend them to the doctor to have them signed. They confirmed that they had not updated Resident #3's doctor's orders because they called Dr. K on 03/09/2026 for clarification on what his note said. They did not know what a c 6 M meant and they had not heard back from Dr. K. The Compliance Nurse revealed responses should take less than 3 days. The Compliance Nurse further revealed the RD recommendations, dated 02/27/2026, had not been signed yet and should have already been signed at this time. They revealed they had gone to the doctor's office in person to get recommendations signed by the doctors and had not gotten all of the recommendations signed yet. During an interview on 03/20/26 at 01:03 PM, the MDS Nurse E revealed there was a problem with the doctors' response times. She revealed if they sent recommendations for doctors to sign, sometimes the facility did not get the orders back. Corporate had had meetings with the doctors. She revealed these doctors had taken care of these residents for a lot of their lifetime, so the residents were [NAME] to those doctors. During an interview on 03/20/2026 at 03:36 PM, the RD revealed the doctors at the facility had always had a strong opinion whether to follow her recommendations or not and most of the doctors did not want to address her recommendations until they visited the facility. The RD revealed this had not affected the residents with significant weight losses or residents with wounds because the kitchen was able to put residents on a Red Glass and Fortified Food Program where the kitchen immediately provided fortified/enhanced foods to increase their nutrition. During an interview on 03/20/2026 at 04:09 PM, the ADM revealed it was difficult to get responses and support with the group of doctors at the facility. She revealed they had been working on improving the situation. She further revealed a lot of the residents at the facility wanted the current group of doctors so the facility would have to follow residents' rights in their selection of their doctor. During an interview on 03/20/2026 at 04:56 PM, the on-call nurse for the Medical Director of the facility did not have information about Resident #5's RD recommendations or Resident #3's pharmacy reviews. She revealed that the expectation for responding to the requested orders should be as soon as possible. An interview was attempted with Dr. K on 03/20/2026 at 04:59PM. A voicemail was left with no call back. Record review of the facility's policy Drug Regimen Review, dated 03/2025, reflected 4. Facility responsibility: To establish policies and procedures that address response timeframes for monthly DRR and procedures the pharmacist should take if immediate action is required. 7. The Consultant Pharmacist Drug Regimen Review reports are processed as follows: A. Drug Regimen Review recommends to physicians: The report is provided by the Consultant Pharmacist or facility to the Primary Physician and the Director of Nursing within seven working days of review, or according to facility policy. The physician provides a written response of the report to the facility within one month after the report is sent. A copy of the report is kept by the facility until the physicians' signed response is returned. The physician response is provided to the Consultant Pharmacist for review and then filed by the facility . Record review of the facility's policy Nutrition Care recommendations, dated 2012, reflected, .8. The form should be sent to the physician where he/she may use the far right column to accept or reject a recommendation. 9. The physician then signs the form and sends back to the facility. Record review of the facility's policy Physician Services, dated 2015, reflected Medical care of each resident must be supervised by a physician. The physician must visit based on a frequency noted below and must review the resident's total program of care, including medications and treatments, at each visit and write, sign and date progress notes. The paper orders may be sent and returned for Physician/Designee signature by U.S. Mail or hand carried. Also, all paper orders must be signed and dated. All electronic orders will electronically [be] signed by the physician. Physician's orders are completed and signed monthly.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 3 medication carts (medication cart #1) reviewed for medication storage. The facility failed to ensure medication cart #1 that was stationed right outside of the dining room, in the facility's entrance hallway, was locked when not in use. These failures could lead to residents having unintended access to medications and ingestion. The findings were: Observation and interview on 03/17/2026 at 11:46 AM revealed medication cart #1 (located right outside of the dining room, in the facility's entrance hallway) was unlocked (button where key was inserted to open the medication cart was popped out). There were no residents or visitors present. COTA F walked by the medication cart but turned around to get MDS Nurse E. MDS Nurse E confirmed the medication cart was unlocked and the narcotics that were in the medication cart #1 was in another container that was locked inside medication cart #1. She revealed it was important for the medication carts to be locked so no medication could be taken out by someone who did not know what they were doing. Interview on 03/17/2026 at 4 PM, the ADM revealed the medication carts should be locked when left unattended. She said the MDS Nurse E did not typically work on the floor so she may have forgotten.Record review of the facility's policy Medication Storage in the Facility, dated 03/2025, reflected Medications and biologicals are stored safely, securely, and properly.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 1 of 6 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's admission record, care plan, and MDS assessment included his diagnosis of colon cancer since 12/04/2025. These failures could place residents at risk for inaccurate medical records. The findings included:Record review of Resident #3's admission record, dated 03/17/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dementia (decline in cognitive functions (memory, reasoning, and thinking) which interferes with daily life) and gastrointestinal hemorrhage (GI bleeding). Colon cancer was not reflected as a diagnosis on his admission record. Record review of Resident #3's hospital documentation with admit date [DATE] reflected Resident #3 had a diagnosis of invasive colonic adenocarcinoma (cancer that originates in the glandular cells of the colon). Record review of Resident #3's quarterly MDS assessment, dated 12/08/2025, reflected Resident #3 had a BIMS score of 15 out of 15, indicating intact cognition. Colon cancer was not reflected as a diagnosis on his MDS assessment. Record review of Resident #3's care plan, undated, reflected no mention of Resident #3's diagnosis of colon cancer or going to chemotherapy. During an interview on 03/17/2026 at 2:16 PM, Resident #3 revealed he went to chemotherapy because he had colon cancer. During an interview on 03/20/2026 at 12:39 PM, the MDS Nurse E and the Reimbursement Consultant revealed Resident #3 came back to the facility on [DATE] with the diagnosis stage 4 colon cancer. They revealed when a resident came to the facility, they reviewed pertinent documents in residents' medical records to see what diagnosis the residents had. Resident #3 went to the hospital on [DATE] for a GI (gastrointestinal) hemorrhage and that was when colon cancer was found. They revealed the colon cancer diagnosis was not reflected on Resident #3's face sheet (admission record). They revealed It was everybody's responsibility to add this diagnosis to Resident #3's face sheet, so it could pull to the MDS assessment, which drove the care plan. They further revealed the IDT can help make sure the face sheet was updated appropriately. During an interview on 03/20/2026 at 04:02 PM, the DON and the ADM revealed Resident #3's face sheet (admission record) should have the diagnosis of colon cancer because he was going to chemotherapy. During an interview on 03/20/2026 at 04:21 PM, CNA A, CNA G, and CNA H revealed Resident #3 had cancer. They revealed Resident #3 went to chemotherapy and they knew when he came back that he was weaker and they had to help him more on those days. Policy for Accuracy of Records was requested from the ADM on 03/20/2026 at 05:18 PM and not provided.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. The ice machine in the kitchen was leaking. 2. The double door standing refrigerator was leaking water from the mechanism at the top, with containers of food in standing water at the bottom of the unit. 3. The silver refrigerator had an accumulation of ice inside the walls. The lid, base, and inside seal were visibly soiled with a black substance. 4. The white deep freezer had an accumulation of ice inside the walls. The lid, base, and inside seal were visibly soiled with a black substance. 5. The kitchen floors were stained and soiled with food particles, two electrical outlets were visibly soiled, the kitchen drying racks were rusty, and the large return filter was covered with dust. 6. The vent hood over the stove was inoperable. These deficient practices could place residents at risk for cross-contamination and foodborne illnesses. The findings were: 1. Observation on 05/16/2025 at 11:11 a.m. revealed the ice maker located within the facility kitchen was surrounded by multiple wet towels and water on the floor around the machine. 2. Observation on 05/16/2025 at 11:15 a.m. revealed the double door standing refrigerator had towels and standing water in the bottom of the unit. Further observation revealed gallon jars of picante sauce, pickles, mustard, relish, and vinaigrette dressing, and a quart jar of chili sauce were all sitting in the water on the bottom of the unit. Observation of the unit temperature revealed it was within range. 3. Observation on 05/16/2025 at 11:17 a.m. revealed the silver refrigerator had an accumulation of ice inside the walls. The lid, base, and inside seal was visibly soiled with a black substance. Observation of the unit temperature revealed it was within range. 4. Observation on 05/16/2025 at 11:20 a.m. revealed the white deep freezer had an accumulation of ice inside the walls. The lid, base, and inside seal was visibly soiled with a black substance. Observation of the unit temperature revealed it was within range. 5. Observation on 05/16/2025 at 11:25 a.m. revealed the kitchen floors were stained and soiled with food particles, two electrical outlets were visibly soiled, the kitchen drying racks were rusty, and the large return filter was covered with dust. 6. Observation on 05/16/2025 at 11:12 a.m. revealed the switch for the vent hood over the stove was covered with blue tape and marked Do Not Touch, underneath the tape was a metal plate with two openings. During an interview with Dietary [NAME] A on 05/16/2025 at 11:12 a.m., Dietary [NAME] A stated the ice machine has a water leak behind it and water is always on the floor. Dietary [NAME] A stated the vent hood over the stove was inoperable. During an interview with Dietary [NAME] A on 05/16/2025 at 12:20 p.m., Dietary [NAME] A stated the drain behind the ice machine was often clogged which resulted in water from the ice machine leaking onto the floor. She stated the issue had been reported to the Maintenance Director and that the Maintenance Director had unclogged the drain several times in the past. Dietary [NAME] A stated the standing water in the double door refrigerator was a result of water dripping from the top of the unit, confirmed the issue had been reported to the Maintenance Director and to the Dietary Manager, and stated the issue had been like that for a long time. Dietary [NAME] A stated she had noted the accumulated ice in the silver refrigerator but not in the white freezer. During an interview with Dietary [NAME] B on 05/16/2025 at 3:00 p.m., Dietary [NAME] B stated the ice machine had been in disrepair for a few months and the double door refrigerator had been in disrepair since last year. During an interview with the Maintenance Director on 05/16/2025 at 2:20 p.m., the Maintenance Director stated the switch for the vent hood over the stove needed to be replaced, that she was actively looking for the correct part to repair the hood, and that the vent hood had been inoperable for approximately one month. The Maintenance Director stated the water under the ice machine was caused by a clog in the drain line and confirmed the clog was a reoccurring issue. She stated it had currently been clogged for approximately three days. The Maintenance Director stated the door gasket for the double door refrigerator had been broken for approximately six months which resulted in condensation leaking from the top of the unit and puddling at the bottom. She stated she had replaced the gasket, but the repair thought she may have utilized an incorrect part since the issue was still ongoing. The Maintenance Director stated the silver refrigerator appeared to need a new seal and stated she believed this was the cause of the accumulated ice and the black substance on the seal. During an interview with the DON on 05/17/2025 at 3:18 p.m., the DON confirmed the double door standing refrigerator had towels and standing water in the bottom of the unit, the silver refrigerator had an accumulation of ice inside the walls and the lid, base, and inside seal was visibly soiled with a black substance, the white deep freezer had an accumulation of ice inside the walls and the lid, base, and inside seal was visibly soiled with a black substance, and the kitchen floors were stained and soiled with food particles, two electrical outlets were visibly soiled, the kitchen drying racks were rusty, and the large return filter was covered with dust. The DON stated she was new to the facility and was unaware of these issues in the facility kitchen. The DON stated it was important to the health of vulnerable residents to serve them meals prepared in a kitchen which was sanitary with equipment in good repair. The DON stated the facility Administrator's last day had been Friday 05/16/2025 and that an interim Administrator would be in the post beginning Monday 05/19/2025. The DON stated she would report the sanitation and equipment issues to the interim Administrator so they may be resolved. Record review of the facility's policy titled, Food Storage, revised June 1, 2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 1 of 1 dining room reviewed, in that: The dining room air conditioning vents were visibly soiled. This deficient practice could result in residents living, staff working, and families visiting in an unclean and unpleasant environment. The findings were: Observation on 05/16/2025 at 12:00 p.m. revealed the facility dining room had eight air conditioning vents in the ceiling. Further observation revealed each vent was soiled with a black substance and with rust. Further observation revealed the return vent was covered with dust. During an interview with the Maintenance Director on 05/16/2025 at 2:20 p.m., the Maintenance Director confirmed that the eight air conditioning vents in facility dining room were rusty and soiled, and confirmed the return vent in the dining room was covered with dust. The Maintenance Director stated the Housekeeping Department was responsible for cleaning the return vent and that she was responsible for cleaning the ceiling air conditioning vents. She stated she occasionally wiped the vents and sprayed bleach on the black substance but that it was ineffective in removing the substance, adding that she needed to paint the vents. She stated there was no set schedule for cleaning the vents and the last time it had been completed was in October or November of 2024. The Maintenance Director stated she planned to replace the vents because they were rusty and stated it was important for the vents to be clean because residents and staff breathe air that originates with the air conditioning vents. She stated she has cleaned the return vent with a damp cloth to remove the dust and confirmed that the task was currently overdue to be completed. During an interview with the DON on 05/17/2025 at 3:15 p.m., the DON confirmed the eight air conditioning vents in the dining room ceiling were soiled and rusty, confirmed the return vent was dusty, and stated it was important for these fixtures to be clean so that vulnerable residents had access to air from unsoiled vents. Record review of the facility's policy, Physical environment Safe/functional/sanitary/comfortable environment, dated 11/28/2017, revealed, Preventive maintenance will be completed routinely and according to protocol by the [Maintenance Supervisor] or qualified staff. The facility shall provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 42 days (5/11/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/8/24, 6/10/24/, 6/12/24, 6/13/24, 6/14/24, 6/17/24, 6/18/24, 6/21/24. 6/22/24. 6/25/24, 6/27/24, 6/28/24, 6/29/24,7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23,24, 7/24/24, 7/27/24, 7/28/24, 8/1/24, 8/2/24 and 8/12/24) of 184 days reviewed for nursing services. The facility had no RN coverage for 5/11/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/8/24, 6/10/24/, 6/12/24, 6/13/24, 6/14/24, 6/17/24, 6/18/24, 6/21/24. 6/22/24. 6/25/24, 6/27/24, 6/28/24, 6/29/24,7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23,24, 7/24/24, 7/27/24, 7/28/24, 8/1/24, 8/2/24 and 8/12/24 for a total of 42 days from May 11, 2024 through August 12, 2024. This failure could result in residents not receiving the required services to meet their needs. The findings were: Record review of the CMS PBJ staffing data report run date 11/27/24 for quarter 3 (April 1 - June 20) revealed the facility triggered for no RN hours on 5/11/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/8/24, 6/10/24/, 6/12/24, 6/13/24, 6/14/24, 6/17/24, 6/18/24, 6/21/24. 6/22/24. 6/25/24, 6/27/24, 6/28/24, 6/29/24. Record review of the facility timesheets revealed no RN coverage for 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23,24, 7/24/24, 7/27/24, 7/28/24, 8/1/24, 8/2/24 and 8/12/24. During an interview on 12/12/24 at 10:01 a.m. the DON stated she worked at a minimum of 40 hours a week Monday through Friday but often worked outside her normally scheduled hours but is salaried and does not clock in or out so her hours were not recorded on a time sheet. The DON stated she just started working at the facility on 07/17/24 as the full time DON. During an interview on 12/13/24 at 3:00 pm with the previous Administrator B (who now works at a sister facility), she stated they did not have a DON during June and July but were trying to fill shifts. She stated we had an interim and our regional nurse who is an RN was coming in to help and also did things remotely. She also stated they put in an interim DON in August and she stayed until the current DON was hired. The Administrator stated they were actively trying to find a DON or get an RN to fill in to meet RN requirements but it was difficult to find an RN due to the competition for nursing staffing.

Based on observation, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive and determine the choice to recieve or not recieve CPR (cardiopulmonary resuscitation) for 3 (Resident #5, Resident #25, Resident #40) of 8 residents reviewed for accuracy and completeness of clinical records. 1 The facility failed ensure Resident #5's OOH DNR was not missing the physicians printed name. 2 The facility failed to ensure Resident #25's OOH DNR was signed a 2nd time by the resident representative. 3. The facility failed to ensure Resident #40's OOH DNR was signed a 2nd time by the resident. This failure could affect any residents who have medical records and could result in misinformation about professional care provided. Findings included: 1. Record review of Resident #5's Admission Record, dated [DATE], revealed a [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of non-ST elevation myocardial infarction (type of heart attack that occurs when a coronary artery is partially blocked, reducing blood flow to the heart muscle), hypertensive heart disease without heart failure (group of heart conditions that are caused by long-term high blood pressure), peripheral vascular disease (a progressive disorder that occurs when blood vessels outside of the heart and brain narrow, block, or spasm), need for assistance with personal care, unsteadiness on feet, reduced mobility, and chronic atrial fibrillation (a type of heart arrhythmia that occurs when the heart's upper chambers beat irregularly and quickly). The admission record showed she was a DNR. Record review of Resident #5's quarterly change MDS assessment, dated [DATE], revealed the resident had mild cognitive impairment for daily decision making. Record review of Resident #5's care plan, dated [DATE], revealed the resident had peripheral vascular disease with a goal for extremities to be free from pain, pallor, rubor, coldness, and edema. With interventions of apply compression stockings as ordered. Record review of Resident #5's care plan, dated [DATE], revealed the resident had an order for do not resuscitate (DNR) with interventions that that all aspects of the DNR will be explained to resident or RP, in absence of b/p, pulse, respirations, will not be initiated. Record review of Resident #5's order summary, dated [DATE], revealed an order for DNR with a start date of [DATE] and no end date. Record review of Resident #5's OOH DNR was signed by the physician on [DATE] and was blank for the printed name of the physician. 2. Record review of Resident #25's Admission Record, dated [DATE], revealed a [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of Alzheimer's disease, chronic kidney disease stage 3, and seizures. The admission record showed she was a DNR. Record review of Resident #25's significant change MDS assessment, dated [DATE], revealed the resident's cognition was severely impaired. Record review of Resident #25's care plan, dated [DATE], revealed the resident had an order for DNR with an intervention that all aspects of the DNR will be explained to resident or RP. Record review of Resident #25's order summary, dated [DATE], revealed an order for DNR with a start date of [DATE], and no end date. Record review of Resident #25's OOH DNR was signed by the RP on [DATE] in section C. The RP signature was missing at the bottom of the document where all persons who have signed above must sign below. 3. Record review of Resident #40's Admission Record, dated [DATE], revealed a [AGE] year-old male admitted on [DATE], with peripheral vascular disease (a progressive disorder that occurs when blood vessels outside of the heart and brain narrow, block, or spasm), major depressive disorder, repeated falls, anxiety disorder, and chronic kidney disease stage 4. The admission record showed he had a DNR. Record review of Resident #40's quarterly change MDS assessment, dated [DATE], revealed the resident was intact cognitively for daily decision making. Record review of Resident #40's care plan, dated [DATE], revealed the resident had a DNR with interventions that that all aspects of the DNR will be explained to resident or RP, in absence of b/p, pulse, respirations, will not be initiated. Record review of Resident #40's order summary, dated [DATE], revealed an order for DNR with a start date of [DATE], and no end date. Record review of Resident #40's DNR was signed by the resident on [DATE] in section A. The resident signature was missing at the bottom of the document where all persons who have signed above must sign below. During a joint interview on [DATE] at 9:47 a.m. The DON, ADON, and Medical Records personnel stated medical records was helping residents with the DNRs. Medical Records stated she had helped complete Resident #25's DNR but the others were done by the previous Medical Records personnel. The ADON stated the facility's policy would ensure once a resident stated they wanted a DNR they would honor it even before the paperwork was completed. Medical Records stated she was not aware everyone needed to sign twice on the DNR paperwork. The ADON and DON stated they could see how it would be an issue with outside agencies not honoring the DNR if it was not filled out correctly. Record review of the facility's policy titled DNR, no date, stated There are 2 ways we can obtain a DNR order: 1. The Out of Hospital DNR used on the Texas form. This version is universally accepted for all medical personnel in all settings 2. Physician's order for DNR. This can only be honored by your facility . Below is a summary of requirements of a standalone physician order for DNR: (this does not apply to Out of Hospital DNR. That process remains unchanged) It can no longer just be a standalone physician order. There are certain components that must be met. We need to have it documented in the clinical record: That the resident or resident representative is requesting the DNR. Where we contacted the physician with that request. The physician's response to the request. Use the [EMR] Request for DNR in order to have all the components. This is active in [EMR] now Scan completed Request for DNR forms into the residents document tab of [EMR]. The order: The DNR order takes effect at the time the order is issued. It does not need to be signed in order to be valid Input into [EMR] as verbal or telephone order so the physician can sign as soon as possible. After the order is entered, update the resident's care plan. If a resident or their representative request a DNR, we should start the process immediately for the OOH DNR. While we are awaiting all the signature requirements for the OOH DNR, we need to follow the process for the stand alone order. Again the stand alone physicians is only recognized by our staff, but we can respect the resident or representative wishes .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 medication carts (medication A hall cart, medication B hall cart, and medication C hall cart) and 1 of 1 medication storage room reviewed for medications and pharmacy services, in that 1. The facility failed to maintain glucometer logs. 2. The facility failed to ensure expired supplies were discarded. 3. The facility failed to ensure loose pills were not stored in the medication cart. 4.) The facility failed to ensure staff administered Resident #39's omeprazole (antacid) and the ordered dose of polyethylene glycol (laxative). This failure could place residents at risk for not receiving therapeutic effects of treatments. The findings included: 1. During an observation and interview on [DATE] at 2:29 p.m. Nursing medication cart for the B hallway contained a glucometer and log for [DATE]. The log was blank for the 4th and 5th of December. The log did not specify the glucometer that was being tested . LVN A stated night shift would check the glucometers nightly to ensure they were working properly. LVN A stated she never checked to see if the nightly controls were being done. LVN A stated if the meter was ever not working, she would just use the one from the other nursing cart. During an observation on [DATE] at 2:37 p.m. Nursing medication cart for the C hallway contained a glucometer and log for [DATE]. The log was blank for the 4th, 5th, and 6th of December. The log did not specify the glucometer that was being tested . LVN C stated night shift would check the glucometers nightly to ensure they were working properly. LVN C stated she never checked to see if the nightly controls were being done. LVN C stated there was no way to know which glucometer went to which log because the log did not specify. 2. During an observation on [DATE] at 2:25 p.m. the medication storage room contained a box of IV alcohol caps with an expiration date of [DATE]. 3. During an observation on [DATE] at 2:10 p.m. medication cart for the A hallway had a medication cup with 2 pills in it. LVN B stated she had put them there to give to a resident who was due to take them at 1 p.m. LVN B stated she should not keep the pills like that and would discard them. During an interview on [DATE] at 1:20 p.m. the DON stated staff cannot store pills ahead of time because of infection control, they could lose track of what they gave, and give the medication again, or miss a dose. The DON stated staff should go through the MAR at the time of medication administration, dispense the pill, and then document what you administered. The DON stated the IV caps should be discarded. The DON stated they started new logs for the glucometers that contain an area for which meter was being checked and the meters were also labeled. The DON stated night shift was expected to check the glucometers each night to ensure they were working properly. The DON stated they are tested to ensure they are in the appropriate range so when you test a resident's blood glucose you know you are getting an accurate reading for treatment. Record review of the facility's policy titled Medication Administration Procedures, dated [DATE], stated .3.Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from its unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination . 4. Record review of Resident #39's Admission Record, dated [DATE], revealed an [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of fractured sacrum, hypertension, Alzheimer's Disease, and depression. Record review of Resident #39's quarterly MDS assessment, dated [DATE], revealed the resident's cognition was severely impaired. Record review of Resident #39's care plan, dated [DATE], revealed the resident had bladder incontinence, Parkinson's, took an antidepressant, and potential for uncontrolled pain related to fracture of sacrum and to monitor for constipation. Another area stated she had an alteration in gastrointestinal status related to vascular disorder of intestine and to avoid snacks that aggravate the condition. Record review of Resident #39's order summary, dated [DATE], revealed orders for: - polyethylene glycol 3350 give 17 grams orally one time a day for constipation mix in ,d+[DATE] oz fluid, with a start date of [DATE], and no end date. -20 mg of omeprazole give 1 capsule orally one time a day for indigestion do not crush or chew in the morning with meals. Record review of Resident #39's nursing progress notes, dated [DATE], revealed no nursing notes about any deviations in medication administration from physician orders on [DATE]. During an observation on [DATE] at 7:36 a.m. LVN B prepared to administer medications to Resident #39. LVN B had 4 blister packs of medication outside of her cart to administer. LVN B had 3 pills in the medication cup. LVN B put all the medication back in the cart and locked it. LVN B did not dispense the 20 mg capsule of omeprazole. This surveyor asked LVN B how many pills she was supposed to be giving. LVN B went back to her computer to look at the MAR. LVN B then removed the medication blister packs and stated she forgot the omeprazole. LVN B then went to give Resident #39 her medications. The resident was eating in the dining room. LVN B stated she needed to take her medications. Resident #39 stated she did not want to take all the polyethylene glycol mixture. LVN B stated okay and discarded the remaining amount. About ,d+[DATE] of the medication was discarded. LVN B documented all the polyethylene glycol mixture was administered. During an interview on [DATE] at 1:14 p.m. the DON stated there are different options to choose from when a resident refuses a medication. The DON stated staff should go back and document what the resident took. The DON stated staff should be looking at the MAR at the time they are dispensing medications to ensure they are giving the right medications. The DON stated the resident took omeprazole for a chronic gastrointestinal problem and it could cause the resident to have an upset stomach if she missed a dose. Record review of the facility's policy titled Medication Administration Procedures, dated [DATE], stated .5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used. Check marks are not acceptable. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse. All nurses administering medication must sign and initial the designated area of each resident's medication/treatment administration record or resident specific master signature log for identification of all initials used in charting. If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record .

Based observation, interview, and record review, the facility failed to 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 3 (Resident #25, Resident #26, Resident #43) of 16 residents and 1 (Hall A Medication cart) of 3 medication carts observed for infection control. 1. The facility failed to initiate enhanced barrier precautions for Resident #25, #26 and #43 who all required enhanced barrier precautions. 2. The facility failed to ensure an employee's name tag was not stored in a box of clean disposable wooden spoons used to mix crushed medications with food. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #25 Record review of Resident #25's Admission Record, dated 12/13/24, revealed an [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of Alzheimer's disease, chronic kidney disease stage 3, and seizures. Record review of Resident #25's significant change MDS assessment, dated 12/4/24, revealed the resident's cognition was severely impaired. Section M showed the resident had a skin tear and used a pressure reducing device for bed, application of nonsurgical dressings, application of ointments/medications for treatments. Record review of Resident #25's care plan, dated 12/11/24, revealed the resident had potential for pressure ulcer development due to decreased mobility, impaired cognition, and frequently incontinent with interventions to assess skin condition weekly and as needed, record all findings. Enhanced barrier precautions were not mentioned in the care plan. Record review of Resident #25's nursing progress notes, dated 11/13/24, revealed: -11/29/24 Initial skin assessment written by ADON .Skin Tear Present: Yes. Location, measurements of skin tear: Left ankle, 3cm in length . -12/03/24 Nursing note written by LVN A Res had order for Monitor skin tear to left ankle with steri strips in place; res has open area to left lower leg. Hospice wrote new order for Left Lower Leg- Cleanse with wound cleanser- apply TAO and cover with non-adherent dressing daily and prn. Family notified. -12/12/24 Nursing note written by LVN A RECEIVED CLARIFICATION TX ORDER FROM HOSPICE NURSE. CLARIFICATION TX ORDER: FULL THICKNESS WOUND TO LEFT LOWER LEG-- CLEANSE WITH WOUND CLEANSER, APPLY CALCIUM ALGINATE AND COVER WITH SECONDARY DRESSING OF CHOICE 3X WEEKLY AND PRN. Record review of Resident #25's order summary, dated 12/11/24, revealed an order for cleanse left lower leg with wound cleanser, apply medihoney and calcium alginate and cover with dry dressing three times a week, every day shift Tuesday, Thursday, and Saturday for wound healing, with a start date of 12/6/24, and no end date. No order for EBP was found. During an observation on 12/10/24 at 10:10 a.m. no Enhanced Barrier Precaution signs or PPE bins were observed outside any resident rooms for Resident #25, #26 or #43. Unidentified staff were observed pushing Resident #25 into her room to transfer her to bed. The staff did not have on gowns or gloves when touching the resident. During an observation on 12/12/24 at 1:32 p.m. Resident #25 had a sign added that showed she was on EBP and a PPE cart was located outside the resident's room. Resident #25 had drainage on her left sock. The resident had an approximately dime size wound that was 2-3 cm deep on her lateral lower left leg above her ankle. At 12:44 p.m. A nurse provided wound care while wearing a gown and gloves to the wound. Resident #26 Record review of Resident #26's Admission Record dated 12/13/24 documented a [AGE] year-old female admitted on [DATE] with diagnoses that included end stage renal disease, emphysema (chronic lung disease), chronic systolic (congestive) heart failure (a condition where the left ventricle of the heart is weakened and can't pump blood effectively), renal osteodystrophy (a complication of chronic kidney disease that weakens the bones) and dependence on renal dialysis. Record review of Resident #26's 5-day Medicare Part A MDS assessment dated [DATE] showed a BIMS score of 14 indicating resident was cognitively intact. During an interview with Resident #26 on 12/11/24 at 10:51 am, resident stated she goes to dialysis 3 times per week. She has a dialysis port in her arm but also has a temporary central port in her chest. Resident #26 stated staff have never worn gowns during her care. Record review of Resident #26's Care Plan revealed a Focus of Resident is on enhanced barrier precautions with an initiated date of 12/12/24. Record review of Resident #26's current Physicians Orders active as of 12/12/24 did not reveal an order for Enhanced Barrier Precautions. Resident #43 Record review of Resident #43's Admission Record dated 12/13/24 documented an [AGE] year-old male admitted to facility 11/19/24 with diagnoses that included muscle weakness; localized swelling, mass and lump, lower limb, bilateral; and other spondylosis with myelopathy, lumbar region (a neurological condition that occurs when spinal cord is compressed due to age-related changes). Record review of Resident #43's Physician Orders with active orders as of 12/13/24, included Provide catheter care every shift and to change foley catheter using 16 Fr or coude (a type of catheter with a curved tip used to navigate the urethra) 10 cc bulb as needed. There was no order for Enhanced Barrier Precautions. Record review of Resident # 43's Baseline Care Plan dated 12/11/24 had a Focus of The resident has indwelling catheter. New catheter placed 11/30/24. There were no interventions or focus areas for ensuring enhanced barrier precautions were implemented. Record review of Resident #43's Revised Care Plan dated 12/11/24 had a Focus of Resident is on enhanced barrier precautions with Date Initiated: 12/10/24. Observation of Resident #43's room on 12/10/24 at 2:32 pm did not reveal any signs or a PPE bin for Enhanced Barrier Precautions. Observation of Resident #43's room on 12/11/24 revealed a sign regarding Enhanced Barrier Precautions and a PPE bin had been placed in front of resident's door. Record review of Resident #43's physicians order summary report with active orders as of 12/13/24 did not reveal an order for Enhanced Barrier Precautions. During an interview on 12/12/24 at 12:53 p.m. the DON stated she was unaware Resident #25 had an open draining wound until 12/12/24. The DON stated Resident #25 should have been on EBP. The DON stated she was unaware that Resident #26 had a central port because they had not accessed it. The DON stated Resident #43 had a catheter and should have been on enhanced barrier precautions but was not until 12/10/24. The DON stated EBP should be used for any residents with an open area to prevent infections. 2. During on observation on 12/11/24 at 2:20 p.m. a box of disposable wooden spoons used to mix residents medication with food was on the bottom of the A hall nursing cart. In the box was a name tag from a CNA. The name tag was sitting on top of the spoons and touching them. During an interview on 12/11/24 at 2:21 p.m. LVN B and the DON stated the name tag should not be in the box and they would throw away the whole box because it was contaminated. The DON took the box out of the medication cart. Record review of facility document titled Enhanced Barrier Precautions, dated 4/1/24, stated Multidrug-resistant organism ([NAME]) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP . Record review of the facility's policy titled Fundamentals of Infection Control Precautions, dated 03/24, stated A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions . 45857