Every finding on record at The Park in Plano

Based on observation, interview, and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 3 residents (Resident #1) reviewed for right to receive written notification in that: The facility failed to follow their policy, which required a 5 day written notice of a room change, before Resident #1 was moved to a different room on 06/29/26. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. Findings included: Review of Resident #1's None of the Above MDS Assessment, dated 06/23/26, reflected she was a [AGE] year-old female who had recently readmitted on [DATE]. The MDS indicated she had a BIMS score of 15 indicating no cognitive impairment. Her diagnoses included heart failure (a chronic condition in which the heart cannot pump enough blood to meet the body's needs for oxygen and nutrients), hypertension (a common condition where the force of blood against the artery walls is consistently too high), and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Review of Resident #1's Progress Notes for June 2026 reflected the following:-The SW wrote on 06/29/26 at 9:10 AM: SW provided an update via email to all pertinent parties, including the resident, the resident's [family member], the VA RN Case Manager, the VA Social Worker, and facility leadership, including the DON, ADON, Administrator, Director of Rehab, Area Director of Operations, and Interim Administrator. The email provided a detailed explanation and formal notification of a necessary room change due to an increase in facility census and the inability to continue accommodating the resident in a private room. The communication also explained that the resident would be located to a larger semi-private room that could comfortably accommodate the resident's bed and Hoyer lift while continuing to meet the resident's care needs.-The SW wrote on 06/29/26 at 9:15 AM: Upon the conclusion of management's routine morning meeting, the Staffing Coordinator and ADON met with the resident in her current room and provided verbal notification of the planned room change. The resident verbally refused to move ot the new room andstated [sic] that she did not want anyone touching or moving her personal belongings. Interview and observation on 07/15/26 at 9:20 AM with Resident #1 who was in her room in her bed talking on the phone. Resident #1 said she was recently moved into this room a few weeks ago and she was not happy about it. Resident #1 said she received an email from the SW of the facility at 9:11 AM on 06/29/26 explaining to her that she was going to have to move rooms that day. Resident #1 said a few minutes later, staff came by to explain the move to her in person but she was refusing to move rooms because they did not give her proper notice. Resident #1 said staff came later in the day to start moving her items and it made her very upset because she had not agreed to move rooms since she liked her room where she was at. Resident #1 said she was told she had to move and the room she was moving to was down the hall. Resident #1 said when she looked at the facility's policy, it said she was supposed to receive a 5 day written notice but that was not what happened. Resident #1 said she was moved the same day to a different room on 06/29/26 and was in her new room now. Resident #1 said the way the facility went about moving her and providing only a few hours of notice really upset her, especially since they were not following their own policy. Interview on 07/15/26 at 11:08 AM with the SW who said every morning the facility had meetings to discuss new admissions coming to the facility and she sent an email to Resident #1 on 06/29/26, among others, to inform them a room change was needed due to an increase in census. The SW said Resident #1 had been in a room by herself for months but was supposed to be moved months ago to a different room and now the facility needed the room she was in. The SW said she notified Resident #1 that she would be moved later that day. The SW said Resident #1 refused to move after several attempts that day (06/29/26) to encourage a room change and provide an explanation for it. The SW said she also provided Resident #1 with the opportunity to stay in the room with a roommate and choose the side of the room she would stay in as well. The SW said Resident #1 refused all options given to her, but she eventually agreed to move to the new room around 6 PM that evening after staff had begged her all day to agree. The SW said the move was necessary that day because of the facility's operational needs which was not an emergency. The SW said usually she would give a longer length of notice for a room change like that. Interview via phone on 07/15/26 at 11:28 AM with Resident #1's VA RN Case Manager who said Resident #1 was very upset about the room change from a few weeks ago. Resident #1's VA RN Case Manager said the way the facility executed the move was very disruptive for Resident #1 and upset her greatly. Follow-up interview on 07/15/26 at 11:52 AM with the SW who said she was responsible for notifying a resident of a room change. The SW said the purpose of that was so they knew why they were moving and if it was clinical or operations guided or if it was a situation where the roommates were not getting along together. The SW said she was not sure what could happen if residents were not given advance notice of a room change. The SW said the admissions policy said the resident was supposed to have a 5 day written notification unless it was an emergency. The SW said Resident #1 was not given a 5 day written notification of the room change, that it was provided the day of the move on 06/29/26. The SW said it was a decision made from that morning's IDT meeting. The SW said she could imagine it would be disruptive to a resident if they were not notified timely based on the facility's policy and said it was a resident's right to informed of a room change. Interview via telephone on 07/15/26 at 2:03 PM with the Ombudsman who said Resident #1 showed her the paperwork she had which showed the facility's policy was to provide a 5 day written notice before a room change could be made. The Ombudsman said Resident #1 was notified of a room change that day (06/29/26) and was moved that evening. The Ombudsman said Resident #1 was extremely upset about the room change and did not want to move but the facility told them it was a census emergency. Interview on 07/15/26 at 3:23 PM with the DON who said that an issue came up on 06/29/26 where the facility had an influx of admissions. The DON said Resident #1 was sent an email that morning on 06/29/26 that discussed a room change due to the census increasing. The DON said a female resident was coming to the facility and they did not currently have an available bed for her and so the facility had to make some room changes to make sure there was a bed available for her. The DON said she knew it was going to be an issue to move Resident #1 who was irate and screaming down the hallway over the situation. The DON said Resident #1 was given choices of staying in the room and having a roommate or moving to the new room that day on 06/29/26. The DON said Resident #1 was not happy about her options but ultimately agreed to move to the new room. The DON said Resident #1 expressed to them she felt the facility was impeding on her rights by moving her to a new room. The DON said Resident #1 was upset since she was not given a 5 day written notification of the room change but the facility did not have to provide that if it was an emergency. The DON said the emergency was that the incoming resident did not have a bed to sleep in that night. The DON said the SW was responsible for providing residents the 5 day written notice of a room change. The DON said the purpose of this was to let someone know if someone was moving in or out of the room and that was common courtesy. The DON said a resident can get upset about the room change if they were not given proper notice for it. The DON said it was a resident's right to be informed of room changes and roommate changes. Interview on 07/15/26 at 4:11 PM with the Administrator who said he was out on leave on 06/29/26 when Resident #1 was moved rooms. The Administrator said he only found out about the move after he returned from leave. The Administrator said the SW was responsible for making room change notifications and he expected staff to follow the facility's policies. Review of the facility's policy titled Room Changes reflected: 4. If a resident is asked to relocate to another room, 5 days' notice must be given to the resident or responsible party prior to the move. The resident or responsible party can waive the 5 days and move earlier. 5. The notice must be in writing and include the reason for the change. 6. The resident has a right to refuse the change if the change is solely for staff convenience.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility's freezer and prep area were labeled and dated. These failures could affect residents by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 04/07/2026 at 9:35 a.m. revealed the following:*a plastic bag of chicken strips in the freezer was not labeled or dated,*a bag of frosting in the freezer was not labeled or dated,*a plastic bag with 6 slices of toast located in the prep area was not labeled or dated. In an interview on 04/09/2026 at 10:24 a.m., the Dietary Manager revealed that he was responsible for making sure all the items are labeled and dated, he stated he must have overlooked those items. He stated the risk to the residents was they could get sick. In an interview on 04/09/2026 at 11:05 a.m., the Administrator stated that he expected all food in the freezer to be labeled and dated. He stated the risk to the resident is that something could be past its date and someone could risk getting sick. Review of the facility policy Dietary Services Policy and Procedure [NAME] 2021 reflected the following, Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Food must be covered when stored, with a date label identifying what is in the container. Texas Chapter 228 Retail Food establishments adopts the US FDA food Code.3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation.(A)FOOD shall be protected from cross contamination by: (4)Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings; 3-302.12 Food Storage Containers, Identified with Common Name of Food.Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shallbe identified with the common name of the FOOD. 3-602.11 Food Labels.(A)FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 -Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #42) of five residents, reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #42. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: Review of Resident #42's Quarterly MDS Assessment, dated 02/06/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 11. His cognitive skills were moderately impaired. He was frequently incontinent of urine and always incontinent of bowel. His diagnoses included heart failure, end-stage kidney disease, and diabetes. Review of Resident #42's, Comprehensive Care Plans, dated 11/04/25, reflected:Resident #42 had bowel and bladder incontinence with facility interventions that included, provide peri-care after each incontinent episode. An observation on 04/08/26 at 11:38 AM of incontinence care for Resident #42 revealed CNA A prepared his supplies and positioned the resident. CNA A cleaned the resident's penis and scrotum, changed gloves, and did not perform hand hygiene. The resident turned to his right side and CNA A cleaned bowel movement off of the resident, changed gloves, and did not perform hand hygiene. CNA A applied barrier cream to the buttocks and peri-area, changed gloves, and did not perform hand hygiene. CNA A placed a clean brief, changed gloves, and did not perform hand hygiene. CNA A fastened the resident's brief. In an interview on 04/08/26 11:52 AM, CNA A revealed he was supposed to perform hand hygiene when he changed gloves. CNA A said he did not do it this time because, it slipped my mind. CNA A said it was important to perform hand hygiene for infection control. In an interview on 04/07/26 at 1:49 PM, the Infection Preventionist revealed staff were supposed to perform hand hygiene after glove changes. The Infection Preventionist said staff were trained to perform hand hygiene in March 2026. In an interview on 04/09/26 at 2:10 PM, the DON revealed staff were supposed to perform hand hygiene after glove changes and had completed training for hand hygiene in March 2026. The DON said she monitored hand hygiene by completing spot checks. The DON said failure to perform hand hygiene could lead to the resident getting infection. Record review of the facility policy, Infection Control Plan: Overview, updated March 2024, reflected: .Hand HygieneHand 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.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 15 residents (Resident #1) reviewed for abuse. The facility failed to keep Resident #1 free from physical abuse by the Private Sitter on 01/30/2026. This failure could place residents at risk of abuse, harm, pain, mental anguish and emotional distress. Findings included: There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by F-600. Record review of Resident #1's face sheet, dated 02/05/2026 and reviewed 02//05/2026 at 2:30 p.m., revealed a [AGE] year-old male, admitted [DATE], diagnoses included urinary neoplasm (cancer), dementia (cognitive dysfunction), chronic kidney disease (loss of kidney function resulting in a buildup of fluid and/or electrolyte dysfunction), and aortic aneurysm (bulge in the wall of the hearts main artery). Record review of Resident #1's MDS, dated [DATE], revealed he was severely cognitively impaired with a BIMS score of 04. Resident #1 had no documentation of verbal or physical behavioral symptoms directed towards others. This MDS revealed Resident #1 did not exhibit rejection of care behaviors, used a walker and/or wheelchair for mobility, and was totally dependent upon staff for toileting, showers, and lower body dressing. Record review of facility's Event Nurses Note, dated 01/30/2026 at 3:21 p.m., revealed for Resident #1 that no pain was reported, but resident had a bruise noted to the top of left hand and the sitter was escorted out of the facility. Record review of Resident #1's Radiology Results (x-ray scan), dated 02/01/2026 at 1:40 p.m., of his left arm revealed no fracture or dislocation. During an observation and interview on 02/05/2026 at 10:30 a.m. and 3:37 p.m., Resident #1 did not respond to questions due to his cognition. During an attempted interview on 02/05/2026 at 1:40 PM and 3:38 p.m., a voicemail message was left for Resident #1's Private Sitter at the telephone number provided by the facility without a return call. Record review of facility provided Witness Statement, undated, revealed the Private Sitter's written statement revealed she worked for [AGENCY]. The Private Sitter's written statement revealed she, . brought [Resident #1] to the living area where all the residents were watching a movie and [Resident #1] began to act inappropriately while trying to. stop bringing his penis out. I stopped him by using my hand to tap on him. I was told to leave the facility because they feel it was wrong for me to hit/teach . his hands. During an interview on 02/05/2026 at 1:21 p.m., LVN A stated she was passing by Resident #1 with his Private Sitter in the hallway on 01/30/2026 and heard an audible pop similar to that of a slap. She stated she then went to determine where the sound came from and observed the Private Sitter's arm extended out towards Resident #1's hand. LVN A stated she asked Resident #1's Private Sitter what happened, and Resident #1's Private Sitter said hit Resident #1's hand because he was moving his hand towards his genital area. LVN A stated Resident #1's Private Sitter said she hit his (Resident #1's) hand to keep him from doing it [touching his genitals.] She stated she removed the sitter from the area and told the sitter, You don't do that, you are supposed to re-direct [behavior.] She stated the Private Sitter got upset and that was when the facility's Social Worker arrived to see what happened. During an interview on 02/05/2026 at 1:33 p.m., the Social Worker stated Resident #1 was newly admitted and the family was privately funding a private sitter from [Agency.] She stated the day of the incident, she was sitting in her office when she heard what sounded like a slap. She stated she arrived to the area and observed LVN A state to the Private Sitter that what she did was wrong. The Social Worker stated LVN A then reported to her that the Private Sitter hit the resident. She stated she and LVN A then reported this abuse to the Administrator and DON immediately. During an interview on 02/05/2026 at 2:13 p.m., the DON stated Resident #1 was recently admitted and did have a private sitter. She stated she never witnessed or was aware of any previously abusive behavior from the Private Sitter prior to 01/30/2026. She stated she did not witness the event, but staff did and reported it to her once the Private Sitter was removed from Resident #1's care. She stated she interviewed the Private Sitter and escorted her out of the facility. She stated she was able to receive a written witness statement from the Private Sitter outside of the facility on 01/30/2026 prior to her leaving the parking lot. She stated staff intervened immediately and reported it to her per facility policy and training. During an interview on 02/05/2026 at 4:17 p.m., the Administrator revealed he was notified of the incident promptly and stated the facility intervened immediately. He stated that Resident #1's provider, family, Private Sitter's employment, and local law enforcement were notified of the incident. Additionally, the facility conducted a QAPI meeting with leadership and completed facility-wide in-services on abuse, neglect, and exploitation policy and procedures. He stated Resident #1 was monitored closely after the incident for any trauma or decline in status. He stated he conducted a comprehensive investigation with the facility's DON in response to the incident; the resident was currently functioning at his baseline, and when interviewed Resident #1 did not recall the incident. Record review of a facility Ad Hoc QAPI Meeting signature sheet, dated 01/30/2026, revealed the Administrator, DON, Social Worker, and other leadership staff met in response to the incident. Record review of facility in-service, dated 01/30/2026, reflected Abuse/Neglect training was conducted on 01/30/2026. All staff were educated on the Abuse, Neglect, and resident rights policy. Further record review revealed documentation of multiple signatures from various disciplines via in person and electronic communication. Record review of Safe Surveys completed by the Social Worker, dated 01/30/2026, for eight residents revealed no abuse, neglect, and/or exploitation concerns. Record review of facility policy titled, Abuse/Neglect, dated rev. 05/09/2017, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident. Record review of facility policy titled, Private Sitter Policy, dated rev 01/15/2016 revealed, Resident sitters are employed by the resident and/or families for private duty sitting. Although the sitters are employees of the resident or responsible family member, the sitter must agree to uphold all facilities policy and procedures. 2. Each resident's medical care and supervision is the responsibility of the nursing facility. Sitters are to only perform such personal services as bathing, dressing, and grooming and/or ambulation assistance. The resident's responsible party will be responsible for outlining tasks for the sitter within the parameters of the facilities policy.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) of 4 residents reviewed for care plan review and revision. The facility failed to review and revise Resident #1's care plan after a fall on 05/06/2025 and a fall with major injury on 05/13/2025. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls. The findings included: Record review of Resident #1's Face Sheet, dated 06/05/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 initially admitted to the facility on [DATE] with diagnoses which included Alzheimer's (loss of memory and cognitive ability that interferes with daily life) disease, diabetes (high blood sugar), lumbosacral disc degeneration (spinal disks of lower back break down) with discogenic (between vertebrae of spine) back pain, and atherosclerotic (hardening of arteries) heart disease. Record review of Resident #1's Quarterly MDS (tool used to measure health status) Assessment, dated 05/23/2025, reflected the resident had severely impaired cognition with a BIMS (tool used to assess cognition) score of 00. Section J (active diagnoses) reflected Resident #1 had a fall with major injury. Section I (active diagnoses) reflected Resident #1 was treated for a left femur (bone in upper leg) closed fracture with routine healing. Record review of Resident #1's Comprehensive Care Plan, dated 05/06/2025, reflected a fall risk focus related to unsteady gait/balance, poor cognition regarding safety, and a history of falls. This focus area had an initiation date of 02/13/2024 and a revision date of 03/21/2025. The care plan did not reflect the resident's two recent falls. An intervention was not added to the care plan after each fall. During an observation and interview on 06/05/2025 at 9:47 AM, Resident #1 was lying in bed with the head of the bed slightly elevated. Resident #1 stated she fell a while ago but did not remember how it happened. During an interview on 06/05/2025 at 3:20 PM, the Interim MDS Coordinator stated a resident's care plan should be updated after a fall. She stated she worked in the facility 3 days a week and updated care plans based on the MDS report. She stated the DON also updated care plans. The Interim MDS Coordinator opened the resident's chart and stated the resident's fall risk care plan was not updated after the resident fell on [DATE] and 05/13/2025. She stated all fall risk interventions were included in the resident's care plan prior to the recent falls. She stated one fall risk intervention was for the therapy department to evaluate the resident after each fall. She stated therapy always evaluated residents after a fall to assess gait and safety awareness. She stated she would ask how to update a fall risk care plan when all fall interventions had been used. During an interview on 06/05/2025 at 3:55 PM, the DON stated care plans were updated after a resident fell. She stated it was important to do this because it reflected the resident's needs and their plan of care. The DON stated she did not update Resident #1's care plan because it already included all fall risk interventions. She stated she would find out what to do next and ensure the care plan was updated. During an interview on 06/05/2025 at 4:15 PM, the Administrator stated an intervention should be added each time a resident falls. He stated the resident's fall risk care plan included all interventions and he was unsure of what could have been added. The administrator stated the facility did not have an acute care plan policy. Record review of the facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This care plan also reflected Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. Undated.

Based on interview, observations, 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 for two (Resident #1 and Resident #2) of three residents reviewed for pharmacy services. The Charge Nurse failed to administer Resident #1 and Resident #2 medications within one hour before or after the scheduled medication time in the morning of 04/29/2025. 1. The facility failed to administer on time Resident #1's Ascorbic Acid Tablet 500 MG , Oral tablet two times a day as ordered on 03/24/2025. 2. The facility failed to administer on time Resident #1 Carvedilol Tablet 3.125 MG, 1 tablet by mouth two times a day for Hypertension on 04/29/25. 3. The facility failed to administer on time Resident # 1 Prostat , give 30cc two times a day for protein supplement. 4. The facility failed to administer on time Resident #1's Calcium Acetate Oral Tablet 667 MG (Calcium Acetate (Phosphate Binder-control high blood levels of phosphorus), 1 tablet by mouth three times a day for ESRD, take with meals. 5. The facility failed to administer on time Resident #1 Robaxin-750 Oral Tablet 750 MG (Methocarbamol-muscle relexant that calms overactive nerves in the body), 1 tablet by mouth three times a day related to Pain (Hold if drowsy). 6. The facility failed to administer on time Resident #2 Ciprofloxacin HCl Oral Tablet 250 MG (Ciprofloxacin HCI-bacerial infection treatment), 1 tablet by mouth two times a day for UTI for 7 days. 7. The facility failed to administer on time Resident #2 Gabapentin Oral Capsule 400 MG (Gabapentin), 1 capsule by mouth three times a day for pain. The failure could affect residents by placing them at risk for a delay in medical treatment or worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 04/29/25, reflected a [AGE] year-old female, with an initial admitted [DATE]. Resident #1 had a diagnosis of Osteomyelitis of Vertebra (bacteria or fungal infection of the spine) Lumbar Region, Morbid (Severe) Obesity due to Excess Calories (body mass index of 40 or higher), Chronic Respiratory Failure with Hypoxia (respiratory system unable to provide enough oxygen to the blood), Hyperlipidemia (Unspecified) (elevated levels of lips, or fats, in the blood), Other Specified Depressive Episodes (depressive symptoms that don't fully meet the criteria for Major Depressive Disorder or Persistent Depressive Disorder), Essential (Primary) Hypertension(high blood pressure), Constipation (Unspecified) (infrequent bowel movements), Discitis (Unspecified) Lumbar Region (infection or inflammation of intervertebral discs), End Stage Renal Disease, Pain (Unspecified) (musculoskeletal pain followed by dialysis and nerve related pain), Other Fracture of Second Lumbar Vertebra (broken bone in L2 vertebra), Other Long-Term (Current) Drug Therapy (taking a medication on long-term basis), Acquired Absence of Other Specified Parts of Digestive Tract (absence of other parts of digestive system), Acquired Absence of Other Organs (organ lost due to post-procedural or post-traumatic event), Psoas Muscle Abscess (collection of pus in lower lumbar region), Wedge Compression Fracture of Second Lumbar Vertebra Sequela (long-term consequences of a fracture). Record review of Resident #1's physician's order dated 03/03/25 reflected an order for Calcium Acetate Oral Tablet 667 MG (Calcium Acetate (Phosphate Binder), 1 tablet by mouth three times a day for ESRD, take with meals. Record review of Resident #1's physician's order dated 03/03/25 reflected an order for Carvedilol Tablet 3.125 MG, give 1 tablet by mouth two times a day for Hypertension. Hold for SBP less than 110, DBP less than 60, HR less than 60. Record review of Resident #1's physician's order dated 03/06/25 reflected for an order for Robaxin-750 Oral Tablet 750 MG (Methocarbamol), give 1 tablet by mouth three times a day related to Pain, (Hold if drowsy). Record review of Resident #1's MDS, dated [DATE], reflected a BIMS score of 09 which meant Resident #1 had moderate cognition. Record review of Resident #1's physician's order dated 03/10/25 reflected an order for Prostat, give 30cc two times a day for protein supplement. Record review of Resident #1's physician's order dated 03/24/25 reflected an order for Ascorbic Acid Tablet 500 MG, give 1 tablet by mouth two times a day for wound healing. Record review of Resident #1's MAR, dated 04/29/25, reflected the following medications were to be administered at 08:00 AM: Ascorbic Acid Tablet 500 MG, Carvedilol Tablet 3.125 MG, Prostat 30cc, Calcium Acetate Oral Tablet 667 MG, and Robaxin-750 Oral Tablet 750 MG. Record review of Resident #2's face sheet, dated 04/29/25, reflected a [AGE] year-old female, with an admitted [DATE]. Resident #2 had a diagnosis of Acute Diastolic (Congestive) Heart Failure (sudden onset heart failure), Acute Pulmonary Edema (buildup of fluid in lungs), Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (sudden worsening of COPD), Depression (Unspecified) (symptoms of depression that don't meet criteria for specific type of depressive disorder), Anxiety Disorder (Unspecified) (experience anxiety but not specific), Other Thyrotoxicosis without Thyrotoxic Crisis or Storm (elevated thyroid hormone levels), Generalized Anxiety Disorder (persistent and excessive worry), Hereditary and Idiopathic Neuropathy (Unspecified) (nerve disorder), Coronary Atherosclerosis Due to Calcified Coronary Lesion (calcium build up), Esophageal Obstruction (prevention of food and liquid to pass normal through esophagus), Constipation (Unspecified)(infrequent bowel movements), Muscle Weakness (Generalized) (muscle fatigue throughout body), Difficulty Walking (Not Elsewhere Classified) (problem with balance, coordination, or pain when walking), Adult Failure to Thrive (adult decline in physical, psychological, functional well-being), Major Depressive Disorder (Recurrent, Moderate) (mood disorder), Essential (Primary) Hypertension (high blood pressure with unknown cause), Dyspnea (shortness breath or difficulty breathing). Record review of Resident #2's MDS, dated [DATE], reflected a BIMS score of 15 which indicated that Resident #2 was cognitively intact. Record review of Resident #2's physician order dated 04/22/25 reflected an order for Gabapentin Oral Capsule 400 MG (Gabapentin), give 1 capsule by mouth three times a day for pain. Record review of Resident #2's physician order dated 04/24/25 reflected an order for Ciprofloxacin HCL Oral Tablet 250 MG (Ciprofloxacin HCI), give 1 tablet by mouth two times a day for a UTI for 7 days. Record review of Resident #2's MAR, dated 04/29/25, reflected the following medication Ciprofloxacin HCl Oral Tablet 250 MG was to be administered at 08:00 AM and Gabapentin Oral Capsule 400 MG at 09:00 AM. In an interview and observation on 04/29/25 at 10:08 AM, the Charge Nurse was observed as she passed medications that were in red for Resident #1 and Resident #2. The medications that was listed in red for Resident #1 was Ascorbic Acid Tablet 500 MG, Carvedilol Tablet 3.125 MG, Prostat 30cc, Calcium Acetate Oral Tablet 667 MG, and Robaxin-750 Oral Tablet 750 MG. The medications that was listed in red for Resident #2 was Ciprofloxacin HCl Oral Tablet 250 MG and Gabapentin Oral Capsule 400 MG (which were her last two residents left to complete medication pass. During observation of medication pass, the Charge Nurse stated the color red was an indication that the medication was administered over the one hour grace period after the scheduled time. The Charge Nurse stated passing medications late was not the norm. She stated she had seven additional residents to medicate. The Charge Nurse stated the facility is one nurse short now but another nurse from a sister facility would be transferred to the current facility. She stated the Director of Nursing and the Assistant Director of Nursing usually assisted when they were short staffed. The Charge Nurse stated one of risks of late medication pass was medications ran close together. The Charge Nurse stated the insulin medications were not late, because she did all the insulin first thing in the morning. In an interview on 04/30/25 at 11:01 AM, the Assistant Director of Nursing stated medications should be administered one hour before or one hour after the scheduled medication time. She stated she was not aware residents received their medications late on 04/29/25. The Assistant Director of Nursing stated not all the medications she passed herself were on time. The Assistant Director of Nursing stated by the time she was informed that help was needed on the floor, the nurses were already behind on the medication pass. The Assistant Director of stated usually when help is needed the Assistant Director of Nursing or the Director of Nursing stepped in and assisted with medication pass. The Assistant Director of Nursing stated as an example, a staff person called in today and the Assistant Director got on the floor and assisted with medication pass. She stated the risk of a late medication pass or according to physician's order was medications were given too close together. She also stated another risk was the effectiveness of the medication. In an interview on 04/30/25 at 1:15 PM, the Director of Nursing stated she was made aware on today of the late medications pass on 04/29/25. The Director of Nursing stated the nurses did have to take on more residents due to losing staff. She stated the facility usually had 4 nurses and 67 residents which was usually based on the facility census. She stated on 04/29/25 each nurse had 23 residents which was more than their normal of 19 residents each. The Director of Nursing stated the Charge Nurse did not inform her she needed help on the floor passing medications. She stated she was unaware of how far behind the Charge Nurse was on the medication pass. She stated protocol was medications were passed one hour before or after the liberalized time frame. She stated the risk with late medications was the medications ran close together. She stated one of the risks was late blood pressure medication which could have caused an elevated heart rate. She also stated the risk of giving a diabetic medication late was high or low sugar levels. In an interview on 04/30/25 at 3:21 PM, the Administrator stated he was not aware the Charge Nurse passed the medications late on 04/29/25. The Administrator stated that the facility gave medications one hour before or one hour after but anything after that was considered late. The Administrator stated the risk was that could have caused a reverse effect of whatever the doctor was doing with the resident. Record review of the facility's undated policy titled Medication administration Procedures reflected the following: The five rights of medication should always be adhered to: 1. Right drug 2. Right dose 3. Right resident 4. Right time 5. Right route The Defining the schedules for administering medications to: Maximize the effectiveness (optimal therapeutic effect) of the medication.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #3) of 3 residents reviewed for infection control. 1. The Charge Nurse failed to sanitize the blood pressure cuff and the pulse oximeter between Resident #2 and Resident #3 on 04/29/25. This failure could put residents at risk of infection from cross contamination. Findings included: Record review of Resident #2's face sheet, dated 04/29/25, reflected a [AGE] year-old female, with an admitted [DATE]. Resident #2 had a diagnosis of Acute Diastolic (Congestive) Heart Failure (sudden onset heart failure), Acute Pulmonary Edema (buildup of fluid in lungs), Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (sudden worsening of COPD), Depression (Unspecified) (symptoms of depression that don't meet criteria for specific type of depressive disorder), Anxiety Disorder (Unspecified) (experience anxiety but not specific), Other Thyrotoxicosis without Thyrotoxic Crisis or Storm (elevated thyroid hormone levels), Generalized Anxiety Disorder (persistent and excessive worry), Hereditary and Idiopathic Neuropathy (Unspecified) (nerve disorder), Coronary Atherosclerosis Due to Calcified Coronary Lesion (calcium build up), Esophageal Obstruction (prevention of food and liquid to pass normal through esophagus), Constipation (Unspecified)(infrequent bowel movements), Muscle Weakness (Generalized) (muscle fatigue throughout body), Difficulty Walking (Not Elsewhere Classified) (problem with balance, coordination, or pain when walking), Adult Failure to Thrive (adult decline in physical, psychological, functional well-being), Major Depressive Disorder (Recurrent, Moderate) (mood disorder), Essential (Primary) Hypertension (high blood pressure with unknown cause), Dyspnea (shortness breath or difficulty breathing). Record review of Resident #3's face sheet, dated 04/29/25, reflected a [AGE] year-old female, with an admitted [DATE]. Resident #3 had a diagnosis of Alzheimer's Disease (disorder that affects memory, thinking, and behavior), Hypothyroidism (thyroid gland does not produce enough thyroid hormone), Hypertension (high blood pressure), and Muscle Weakness. In an observation 04/29/25 at 10:30 AM, The Charge Nurse was observed as she went into Resident #2's room and took the blood pressure and pulse of Resident #2. The Charge Nurse was then observed as she returned to the medication cart and placed the blood pressure cuff and pulse oximeter on the cart. The Charge Nurse did not sanitize the blood pressure cuff or the pulse oximeter. The Charge Nurse was then observed as she took the same blood pressure cuff and pulse oximeter into Resident #3's room and checked her vital signs. In an interview on 04/29/25 at 3:15 PM, The Charge Nurse stated she forgot to sanitize the blood pressure cuff and the pulse oximeter. She stated the expectation was for the cuff and the oximeter to be sanitized after each resident usage. The Charge Nurse stated she risked cross-contamination when she failed to sanitize the cuff and the oximeter before she checked the vitals of the next resident. In an interview on 04/30/25 at 11:01 AM, the Assistant Director of Nursing stated she was not aware the Charge Nurse failed to sanitize the blood pressure cuff or the pulse oximeter. She stated the staff were trained and required to sanitize the equipment between residents. The Assistant Director of Nursing stated the risk of not sanitizing the equipment was the spread of germs. In an interview on 04/30/25 at 1:15 PM, the Director of Nursing stated she was not aware the Charge Nurse failed to sanitize the blood pressure cuff or the pulse oximeter between residents. She stated the staff were expected to sanitize items like the blood pressure cuff and oximeter after each resident usage. The Director of Nursing stated the risk of not sanitizing the cuff or the oximeter was infection. In an interview on 04/30/25 at 3:22 PM, the Administrator stated The Charge Nurse should have sanitized the blood pressure cuff and the oximeter. The Administrator stated risk was infection. Record review of the facility's policy, titled, Infection Control Plan Overview, with an original date of 2019 and a revised date of 03/2024, reflected the following: Infection Control The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Ensures that reusable equipment is appropriately cleaned, disinfected, or reprocessed.

Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 5 of 12 resident rooms (room [ROOM NUMBER], #2, #3, #4, and #5) reviewed for environment. The facility failed to ensure Resident Rooms #1, #2, #3, #4, and #5 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 01/28/25 at 10:28 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt debris. An observation on 01/28/25 at 10:50 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt debris. The unit's cover appeared to be separating from the wall and black dirt and grime could be observed. A wall near a wastebasket, had dark stains splattered on the lower part of the wall. An observation on 01/28/25 at 10:54 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt debris. An observation on 01/28/25 at 11:03 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt debris. An observation on 01/28/25 at 11:08 AM of the Resident room [ROOM NUMBER] reflected dark stains on the wall alongside the resident's bed. Inside the mini fridge had [NAME] reddish stains on the bottom inside of the fridge. In an interview on 01/30/25 at 08:48 AM, the Housekeeping Supervisor stated it was his second day at the facility. He stated he managed in housekeeping for 7 years. He was shown the pictures of the concerns with Resident rooms #1, #2, #3, #4, and #5, and he stated he would meet with staff to address the concerns. He stated he was unsure if his staff were responsible for cleaning the resident's refrigerators, but he would find out. He stated that risk of the concerns not being addressed could result in infections. In an interview on 01/30/25 at 9:00 AM, Housekeeping/Laundry Aid D stated he had been at the facility a month. He stated the floor technician and himself cleaned the halls, and he cleaned the resident rooms. He stated they were responsible for cleaning the walls, air condition units and refrigerators in the resident rooms. He was shown the pictures of the concerns observed in Resident rooms #1, #2, #3, #4, and #5, and he stated he would take care of the areas mentioned. He stated the risk of not addressing the issue could result in residents having trouble breathing. In an interview on 01/30/25 at 10:05 AM, the Administrator was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, and #5. He stated he had just hired a new housekeeping supervisor and would meet with him to ensure the area of concerns were addressed. He stated the risk of these concerns not being addressed could result in an infection. Record review of the facility's policy on General Cleaning (2021) revealed It is the policy of this facility to maintain cleanliness in an orderly manner. The goal is to keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image. Following cleaning tasks should be completed daily. 2. Resident Room(s) o Each Room (including Closets)

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 20 residents (Resident #11, #27, and Resident #29) reviewed for ADL care provided to dependent residents. 1. The facility failed to ensure Resident #11 received proper podiatry care to treat feet. 2. The facility failed to provide fingernail care for Residents #27 and #29. These failures could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Include: 1. Record review of Resident #11's face sheet, dated 01/28/25, reflected an [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #11 had relevant diagnoses which included need for assistance for personal care, and muscle wasting and atrophy. Record review of Resident #11's Quarterly MDS assessment, dated 12/23/24, reflected the resident had a BIM score of 12, which indicated moderate impairment. The resident was dependent for all personal hygiene needs. Record review of Resident #11's Comprehensive Care Plan, dated 01/09/25, reflected the resident was care planned for having ADL self-care performance deficit and the goal for the resident was The resident will maintain or improve current levels of function in (Specify Bed Mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene). An observation on 01/28/25 at 10:27 AM revealed Resident #11 laying in his bed. The resident's toenails were long and there was thick crust built up on the toenails of both feet. In an interview and resident observation on 01/29/25 at 10:15 AM, LVN V observed Resident #11's toes and stated he needed podiatry care. She stated the nursing staff were to monitor the resident's feet to ensure that it was manicured to avoid his feet from getting an infection. She stated she would contact the podiatrist to schedule an appointment for the resident. In an interview on 01/30/25 at 10:22 AM, the Social Worker stated she was responsible to setting up podiatry appointments. She stated staff, the resident, or family member could request for podiatry to see a resident. She stated no one notified her there was a concern with Resident #11's feet and toes because she would have scheduled for him to see the podiatrist the next time the podiatrist was scheduled to visit the facility on 02/05/25. In an interview on 01/30/25 at 10:22 AM, the DON stated the nurses were to conduct weekly skin assessments from head to toe, and one of the areas observed were the resident's feet. She stated Resident #11 did need to see a podiatrist to ensure his feet were manicured to avoid any infections. 2. Record review of Resident #27's face sheet, dated 01/30/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting the left side of the body. Record review of Resident #27's Quarterly MDS Assessment, dated 01/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident was dependent for personal hygiene. Record review of Resident #27's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had ADL self-care performance deficit and one of the interventions was to assist with personal hygiene. The Comprehensive Care Plan did not indicate the resident was refusing nail care. Record review of Resident #27's Progress Notes, dated 11/672024, to 01/28/2025 reflected no documented attempts or refusals for nail care. Observation and interview with Resident #27 on 01/28/2025 at 10:20 AM revealed the resident was in his bed, awake. It was observed his nails on both hands were long and dirty. When asked when was the last time his nails were cut, the resident did not reply. Observation on 01/28/2025 at 10:20 AM revealed CNA G was walking in the hallway and heard Resident #27 calling for help. CNA G went inside the room to check on the resident and saw the resident was throwing up . She went out of the room and said she would call the nurse. She came back to the room with LVN C behind her. LVN C assessed the resident, raised the head of the bed, and put a pillow on the resident's left side so the resident would be on a semi-side-[NAME]-lying position. She further assessed the resident to check how much was the secretion was and if there were secretions on the resident's body, clothing and beddings. While LVN C was assessing the resident, CNA G went to the bathroom to get a bucket of water and a face towel and said she would clean the resident. Nobody noticed the resident's fingernails were long and dirty. LVN C went out of the room and said she would notify the physician. Observation on 01/29/2025 at 10:16 AM revealed Resident #27's nails were still dirty. 3. Record review of Resident #29's face sheet, dated 01/30/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #27 Parkinsonism (umbrella term for conditions affecting movement). Record review of Resident #29's Quarterly MDS Assessment, dated 11/11/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated the resident was dependent to staff for personal hygiene. Record review of Resident #29's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had an ADL self-care performance deficit and one of the interventions was the resident required one staff participation with personal hygiene. The Comprehensive Care Plan did not indicate the resident was refusing nail care. Record review of Resident #27's Progress Notes, dated from 11/07/2024 to 01/28/2025, reflected no documented attempts or refusals for nail care. Observation and interview with Resident #29 on 01/28/2025 at 9:20 AM revealed the resident was sitting in his wheelchair, awake. When asked if his nails could be seen, the resident raised both hands. It was observed the resident's nails were visibly dirty with a black unknown substance under some of the nails. When asked when the last time was his nails were cut, the resident shrugged his shoulders. Observation on 01/29/2025 at 10:18 AM revealed Resident #29's nails were still dirty. Observation and interview with LVN C on 01/29/2025 at 10:19 AM, LVN C stated nail care checks should be done by everyone and nails were mostly checked during showers but could also be done in between showers when the nails were seen dirty. LVN C went inside Resident #29's room and looked at Resident #29's fingernails and saw the dirty fingernails. She said the resident's hands and fingernails should always be clean because the resident would sometimes pick-up his food. She said the resident might have stomach issues when he picked up food with dirty fingernails. She said she would get a trimmer and nail filer and would take care of Resident #29's nails. LVN C then went inside Resident #27's room and checked on the resident's fingernails. She said Resident #27's fingernails were long and dirty. LVN C said she did not notice the resident's fingernails were dirty when she assessed the resident the day before. She said long and dirty nails could lead to skin infections if the dirty nails were used to scratch the skin. She said she would take care of Resident #27's nails after she was done with Resident #29's nails. She said the nurses and the aides were responsible in ensuring the nails of the residents were clean. In an interview with CNA F on 01/30/2025 at 10:38 AM, CNA F stated basic nail care could be done by nurses or CNAs. CNA F said if the resident was diabetic or required more than basic nail care, she would notify a nurse. She said nail checking was done during showers . She said the nails should be clean because sometimes the residents picked their food or scratched their skin. She said dirty nails could result to stomach or skin problems. She said she was the CNA assigned for Resident #27 and #29. She said she would check the resident nails . In an interview with CNA G on 01/30/2025 at 11:33 AM, CNA G stated nail care was provided by CNAs, but the nurses would do the nail care if the resident was diabetic. She said she assisted LVN C when Resident #27 was throwing up two days before. She said she did not notice the resident's fingernails were long and dirty. She said if the fingernails were long and dirty, it should be trimmed and cleaned even if the resident was not scheduled for shower. In an interview with the DON on 01/29/2025 at 12:12 PM, the DON stated fingernail care should be provided by the CNAs during shower days. She said nails should be checked, trimmed, and cleaned especially if residents scratch themselves. She said the CNAs could provide nail care to residents who were not diabetic. She said long and dirty fingernails not only affected the dignity of the residents because their visitors could see that their fingernails were dirty and could also be a cause of infection. The DON said diabetic residents' fingernails were cut by the nurses or the podiatrist. She said her expectation was for staff to check the nails and do nail care as appropriate. She said if a CNA saw dirty nails of diabetic residents, at least let the nurses know so the nurses could take care of it or put them on the list for the podiatrist. She said the nails should be checked during showers. She said she would do an in-service regarding ADLs specific for nail care and would also check the nails of the other residents. In an interview with the Administrator on 01/30/2025 at 8:34 AM, the Administrator stated the expectation was for the staff to do nail care. He said he would coordinate with the DON regarding the nail care issue. Record review of the facility's, undated, policy Dressing and Personal Grooming Nursing Policy & Procedure, reflected Purpose: The purposes of this procedure . promote cleanliness

Based on observation, interviews and record review the facility failed to store, prepare, distributed, and serve in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the date the product was received from the vendor or date the product was stored after being used. 2. The facility failed to ensure the food stored in the freezer was properly sealed from air-borne contaminants. 3. The facility failed to ensure the ice machine in the dining area was cleaned. 4. The facility failed to cover a large trash can stored in the kitchen area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 01/28/25 from 9:22 AM to 9:25 AM in the facility's only kitchen revealed: The ice machine door had white and brown dirt stains inside the door and a white plastic piece located above the ice had black dirt on them. One large trash can, which contained food and trash, in the kitchen area, was uncovered. One large zip locked bag of cooked meat, stored in the refrigerator, did not have the month, date and year the food was stored after use. Two bags of tortillas stored in the refrigerator, did not have the month, date, and year the food was stored when received from the vendor. One container of pie shells, stored in the freezer, did not have the month, date, and year the food was stored when received from the vendor. One large box of frozen sausages, located in the freezer, was unsealed and exposed to airborne contaminants. Two loaves of French bread, located in the freezer did not have the month, date, and year product was received from the vendor. In an interview on 01/29/25 at 01:35 PM, the DM stated he had been the DM for nearly 4 months. He was shown pictures of the concerns observed in the kitchen area. He stated he cleaned the ice machine at least once a month but would check it for cleanliness more frequently. He stated the trash can in the kitchen area should have been covered to avoid airborne contaminants. He stated he worked with staff to ensure all foods were dated and labeled properly but still had some items that may have been overlooked. He stated he would get with his team to remind them of the need for the complete month, date, and year when storing foods. He stated the following concerns could result in food contamination. In an interview on 01/30/25 at 10:05 AM, the Administrator was shown pictures of the concerns observed in the facility's only kitchen. He stated this was his first week as the Administrator at the facility, but he would follow up with the DM to address the concerns. He stated the concerns observed could result in residents experiencing food contamination. Record review of the facility's policy on Dietary Services Policy & Procedure Manual 2012, revealed 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened .6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a 'best by' or 'use by' date . If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year . All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Record review of Title 21--Food And Drugs Chapter I--Food And Drug Administration Department Of Health And Human Services Subchapter b - Food For Human Consumption part 110 -- current good manufacturing practice in manufacturing, packing, or holding human food.

Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for nine (Resident #5, Resident #6, Resident #18, Resident #26, Resident #27, Resident #33, Resident #39, Resident #43 and Resident #52) of eighteen residents reviewed for Infection Control. 1. The facility failed to ensure CNA G performed hand hygiene before checking on Resident #27 on 01/28/2025. 2. The facility failed to ensure LVN A did not bring the whole container of test strips used for checking blood sugar inside Resident #33's room on 01/28/2025. 3. The facility failed to ensure LVN A sanitized the diaphragm of the stethoscope before checking for Resident #52's g-tube placement during medication administration on 01/28/2025. 4. The facility failed to ensure LVN B sanitized her hands and the blood pressure cuff while administering medications to Residents # 6, #18, #26, #39, and #43 on 01/29/2025. 5. The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 01/29/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #27's Face Sheet, dated 01/30/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #27 was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting the left side of the body. Record review of Resident #27's Quarterly MDS Assessment, dated 01/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident was dependent for activities of daily living. Record review of Resident #27's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had ADL self-care performance deficit and one of the interventions was to assist with personal hygiene. Observation on 01/28/2025 at 10:20 AM revealed CNA G was walking in the hallway and heard the Resident #27 calling for help. CNA G went inside the room to check on the resident, put on a pair of gloves, and saw the resident was throwing up. She went out of the room and said she would call the nurse. She removed her gloves before going out of the room. She came back to the room and put on a pair of gloves. She did not do hand hygiene before providing care. She assisted the nurse in placing the resident in a side lying position to prevent aspiration. In an interview with CNA G on 01/30/2025 at 11:33 AM, CNA G stated hand hygiene should be done before providing care to a resident. She said hand hygiene was done to avoid infection. 2. Record review of Resident #33's Face Sheet, dated 01/30/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #33's Comprehensive MDS Assessment, dated 05/01/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin injections. Record review of Resident #33's Comprehensive Care Plan, dated 12/27/2024, reflected the resident had diabetes mellitus and one of the interventions was to acquire the fasting serum blood sugar (test that measures the amount of sugar in the blood) as ordered. Record review of resident #33's Physician Order, dated 09/15/2022, reflected FSBS checks two times a day related to DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITHOUT COMPLICATIONS. Observation and interview with LVN A on 01/28/2025 at 11:32 AM, LVN A said she was going to check Resident #33's blood sugar. She sanitized her hands and prepared the things needed to check the resident's blood sugar. LVN A sanitized the glucometer, prepared two alcohol wipes, a push button safety lancet, and the container of test strips. LVN A went inside Resident #33's room and told the resident she would be checking her blood sugar. LVN A brought with her the wipes, the push button safety lancet, the glucometer, and the whole container of the test strips inside Resident #33's room and placed them on the resident's overbed table. LVN A put on a pair of gloves, took a strip from the container, and inserted it on the glucometer. She wiped the resident's left index finger, waited for it dry up, and then pricked the left index finger with the push button safety lancet. LVN A scooped a drop of blood from the resident's index finger with the tip of the test strip that was inserted in the glucometer. After scooping the blood, the glucometer displayed 168. She went back to her cart and put the container of strips on top of her cart. She turned on her computer and checked the resident's order for insulin. She said the resident would get 5 units of insulin. In an interview with LVN A on 01/28/2025 at 11:39 AM, LVN A said she brought with her the container of the test strips in case she needed another test strip. She said she should have left the container of test strips on top of the cart and just brought with her 2 strips in case the glucometer displayed error. She said bringing an item inside the resident's room, putting it on the resident's table, and then putting it on the cart again could result to cross contamination. She said she would make sure she would not bring the container of strips inside the room of the residents. 3. Record review of Resident #52's Face Sheet dated 01/28/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #52's Comprehensive MDS Assessment, dated 12/13/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach). Record review of Resident #52's Quarterly Care Plan, dated 12/24/2024, reflected the resident required tube feeding related to dysphagia and one of the interventions was check for placement. Record review of Resident #52's Physician Order, dated 10/13/2023, reflected check for placement. An observation on 01/28/2025 at 12:03 PM revealed LVN A was about to give Resident #52 his 12 PM medication. LVN A sanitized her hands, prepared the medications and the water needed for medication administration through g-tube. She put on a gown and a pair of gloves, took the stethoscope hanging on the laptop stand of the medication cart, and went inside the resident's room. She took the stethoscope from around her neck and placed the diaphragm of the stethoscope on the resident's abdomen. She did not sanitize the diaphragm of the stethoscope before placing it on the resident's abdomen to check for placement. During an observation and interview with LVN A on 01/28/2025 at 12:32 PM, LVN A stated the diaphragm of the stethoscope should be sanitized as because it was used on other residents. She said the blood pressure cuff and the pulse oximeter should be sanitized to prevent cross contamination and infection. 4. Record review of Resident #43's Face Sheet, dated 01/30/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with hypertensive emergency (very high blood pressure). Record review of Resident #43's Comprehensive MDS Assessment, dated 11/08/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had hypertension (high blood pressure). Record review of Resident #43's Comprehensive Care Plan, dated 12/24/2024, reflected the resident had hypertension and one of the interventions was to monitor for signs and symptoms of hypertension. Record review of Resident #43's Physician Orders, dated 09/24/2024, reflected Hydralazine HCl Oral Tablet 100 MG (Hydralazine HCl) Give 1 tablet by mouth one time a day related to HYPERTENSIVE EMERGENCY. HOLD IF SBP<110, DBP<60, P<60. Observation on 01/29/2025 at 6:54 AM revealed LVN B was preparing Resident #43's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #43. She did not sanitize the blood pressure cuff and did not do hand hygiene before preparing the medications. Review of Resident #6's Face Sheet, dated 01/30/2025, reflected resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertensive heart disease. Review of Resident #6's Comprehensive MDS Assessment, dated 11/30/2024, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had hypertension. Review of Resident #6's Comprehensive Care Plan, dated 12/24/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #6's Physician's Order, dated 01/28/2025, reflected Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth every day shift for Hypertension Hold for SBP less than 110, DBP less than 60 and HR less than 60. Observation on 01/29/2025 at 7:12 AM revealed LVN B was preparing Resident #6's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #6. She did not sanitize the blood pressure cuff and did not do hand hygiene before preparing the medications. Record review of Resident #18's Face Sheet, dated 01/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #18 was diagnosed with hypertension. Record review of Resident #18's Comprehensive MDS Assessment, dated 12/04/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had hypertension. Record review of Resident #18's Comprehensive Care Plan, dated 12/24/2024, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Record review of Resident #18's Physician Orders, dated 01/27/2025, reflected Vital signs every shift Notify provider for temp >101, pulse >110, or SBP < 90 Observation on 01/29/2025 at 7:41 AM revealed LVN B was preparing Resident #18's medication. Before she went inside the room, the Director Of Rehabilitation (DOR) approached LVN B and gave her a container of sanitizer. She took the container of sanitizer and put it on the last drawer of the nurse's cart. She picked up the other blood pressure cuff from the medication cart and went inside Resident #18's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #18. She did not sanitize the blood pressure cuff and did not do hand hygiene before preparing the medications. Review of Resident #39's Face Sheet, dated 01/28/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with depression. Review of Resident #39's Comprehensive MDS Assessment, dated 05/01/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #39 had depression. Review of Resident #39's Comprehensive Care Plan, dated 12/01/2024, reflected resident had potential had depression and interventions were administer medications as ordered and observe side effects like hypotension. Review of Resident #39's Physician's Order, dated 06/21/2023, reflected Bupropion HCl ER Oral Tablet Extended Release 12 Hour 150 MG (Bupropion HCl) Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED. Observation on 01/29/2025 at 7:56 AM revealed LVN B was preparing Resident #39's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #39. She did not sanitize the blood pressure cuff and did not do hand hygiene before preparing the medications. Review of Resident #26's Face Sheet, dated 01/30/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Review of Resident #26's Comprehensive MDS Assessment, dated 05/01/2024, reflected Resident #26 had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had hypertension. Review of Resident #26's Comprehensive Care Plan, dated 01/16/2025, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications. Review of Resident #26's Physician's Order, dated 05/21/2024, reflected Amlodipine Besylate Tablet 5 MG. Give 1 tablet by mouth one time a day for Hypertension hold for systolic <110, Diastolic <60, pulse < 60. Observation on 01/29/2025 at 8:16 AM revealed LVN B was preparing Resident #26's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #26. She did not sanitize the blood pressure cuff and did not do hand hygiene before preparing the medications. In an interview with LVN B on 01/29/2025 at 8:53 AM, LVN B stated she obtained the blood pressures of the residents before giving the medication for hypertension to know if the medication needed to be held or not. LVN B said the proper thing to do was to wash or sanitize her hands before and after giving medications. LVN B said the blood pressure cuff should be sanitized as well after using it and before using it on another resident. LVN B then acknowledged she forgot to sanitize the blood pressure cuff in between residents when she passed the medications. LVN B stated not sanitizing the blood pressure cuff in between residents could cause infection to transfer from one resident to another. LVN B added if a resident already had an infection, that infection could be transferred to another resident because the reusable item was not sanitized. In an interview with DOR on 01/30/2025 at 8:10 AM, the DOR stated she gave LVN B the sanitizer so she could use it to sanitize her blood pressure cuff and pulse oximeter. She said that was what they do in therapy. They sanitized the blood pressure cuff in between residents to prevent cross contamination and infection. 5. Review of Resident #5's Face Sheet, dated 01/30/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Review of Resident #5's Comprehensive MDS Assessment, dated 05/01/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Review of Resident #5's Comprehensive Care Plan, dated 12/24/2024, reflected the resident was incontinent for bladder and bowel and one of the interventions was provide peri care after each incontinent episode. Observation on 01/29/2025 at 8:23 AM revealed CNA D was about to assist Resident #5 to go to the bathroom for a bowel movement. CNA D sanitized her hands and put on a pair of gloves. She transferred the resident from bed to wheelchair and ushered the resident to the bathroom. CNA D then transferred the resident from wheelchair to the toilet bowl and waited for the resident to be done with her bowel movement. When the resident was done with her bowel movement, CNA D instructed the resident to stoop forward so she could clean her bottom. After cleaning the resident's bottom, she washed her hands and changed her gloves. CNA D instructed the resident to stand up and hold on the arm rest of the wheelchair. She took a couple of wipes and cleaned the resident's perineal area. After cleaning the resident's perineal area, she took the brief that she hung by the railing and put it on the resident. She did not do hand hygiene before touching the new brief. In an interview with CNA D on 01/29/2025 at 8:38 AM, CNA D stated she washed her hands before incontinent care and sanitized her hands when she changed her gloves. She said after cleaning Resident #5's perineal area she was not able to change her gloves before touching the new brief. She said she was supposed to change her gloves from dirty to clean. She said her gloves were already considered soiled because she used them to clean the bottom of the resident. She said she would be mindful with incontinent care to not compromise the residents' health and cause infection. In an interview with the DON on 01/29/2025 at 12:12 PM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection. She said hands should be washed before and after any care. She said the staff should not bring the container of strips for blood sugar check inside the resident's room. She said the staff could bring two or three strips inside and then discard what were not used. She added the blood pressure cuff and the diaphragm of the stethoscope should be sanitized before using or every after use. She said gloves should be changed after cleaning the resident's perineal area and before touching the new brief. She said there might be no policy regarding sanitizing the blood pressure cuff and stethoscope or about not bringing the container of strips inside the room, but they were obviously infection control issues. She said the above issues could cause cross contamination and different kinds of infections. She said the expectations were for the staff to be mindful with how they take care of the residents. She said she would do an in-service regarding infection control and would specifically focus on the issues mentioned. In an interview with the Administrator on 01/30/2025 at 8:34 AM, the Administrator stated the staff should follow the policies and procedures of any procedure to prevent infection. He said he would collaborate with the DON with regards to infection control. Record review of facility policy, Hand Hygiene, undated, revealed Hand hygiene continues to be the primary means of preventing the transmission of infection. When to perform hand hygiene . Upon and after coming in contact with a resident's intact skin Record review of facility policy, Perineal Care Policies and Procedure created 04/25/2022 revealed Purpose: This procedure aims . providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . Procedure Content . 10) Perform hand hygiene 11) [NAME] gloves . 24) Doff gloves and PPE . 25) Perform hand hygiene. Record review of facility policy, Infection Control Plan: Overview Infection Control Policy & Procedure Manual 2019 updated 3/2023 revealed Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection . Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination . Fundamentals of Infection Control Precautions . Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection . Before and after assisting a resident with personal care . After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves . Resident care equipment . Non-invasive resident care equipment is cleaned daily or as need between use.

Based on , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental nad psychosocial well-being for 1 of 5 residents (Resident #53) reviewed for care plans. The facility failed to ensure Resident #53 was care planned for the weekly psychological services being received based on physician orders dated 11/24/2024. This failure could place residents at risk of not receiving the necessary care and services needed. Findings include: Record review of Resident #53's face sheet, dated 01/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #53 was diagnosed with Post Traumatic Stress Disorder (stressful event). Record review of Resident #53's Quarterly MDS Assessment, dated 11/20/2024, reflected the resident had a severe cognitive impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had an active diagnosis of PTSD. Record review of Resident #53's Physician Order, dated 01/29/25, reflected Evaluate and treat for psychology. Record review of Resident #53's Comprehensive Care Plan, dated 12/06/2024, did not reflect the resident received services for weekly psychological services. In an interview and record review on 01/29/25 at 10:00 AM, the MDS nurse stated Resident #53 saw a psychologist to treat his mental illness. She stated the resident's care plan did not indicate the resident saw a psychologist at least monthly, and it should be care planned to ensure the resident was receiving care. She stated she thought the psychiatrist care planning was sufficient for the mental therapy the resident received. She confirmed that the resident was seeing a psychiatrist and psychologist. In an Interview on 01/29/25 at 09:55 AM, the DON was advised there was no care plan for Resident #53 seeing a psychologist to treat his PTSD. She stated the resident's care plan should indicate the resident saw a psychologist weekly and it should have been care planned to ensure the resident was receiving care. Record review of the facility's, undated, policy, Comprehensive Care Planning revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - o The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for one of three residents (Resident #5) reviewed for Incontinent Care. The facility failed to ensure CNA D used proper technique to clean Resident 5's perineal area (area between the legs) on 01/29/2025. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings include: Record review of Resident #5's face sheet, dated 01/30/2025, reflected an [AGE] year-old female who was admitted on the facility on 06/03/2024. Resident #5 had a diagnosis which included generalized muscle weakness. Record review of Resident #5's Comprehensive MDS Assessment, dated 12/24/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated Resident #5 was incontinent for bowel and bladder. Record review of Resident #5's Comprehensive Care Plan, dated 12/31/2024, reflected the resident was incontinent for bowel and bladder and one of the interventions was to provide peri care after each incontinent episode. Observation on 01/29/2025 at 8:23 AM revealed CNA D was about to assist Resident #5 to go to the bathroom for a bowel movement. She sanitized her hands and put on a pair of gloves. She transferred the resident from the bed to the wheelchair and ushered the resident to the bathroom. CNA D then transferred the resident from the wheelchair to the toilet bowl and waited for the resident to be done with her bowel movement. When the resident was done with her bowel movement, CNA D instructed the resident to stoop forward so she could clean her bottom. The wipes used to clean the bottom had feces on it. After cleaning the resident's bottom, she washed her hands and changed her gloves. CNA D instructed the resident to stand up and hold on the arm rest of the wheelchair. She took a couple of wipes and cleaned the resident's perineal area. She cleaned the perineal area from back to front, from front to back, and then back to front again using the same wipes. She took some more wipes and did the same thing. She then took a brief and put it on the resident. In an interview with CNA D on 01/29/2025 at 8:38 AM, CNA D said the proper way of cleaning a female resident was from front to back to prevent whatever germs from the bottom to go the perineal area and cause infection. She said she cleaned Resident #5's bottom first but the probability the bottom still had feces was high. She said she should still clean the perineal area from front to back and not the other way around. She said she would be mindful with incontinent care to not compromise the residents' health. In an interview with the DON on 01/29/2025 at 12:12 PM, the DON stated the proper way to clean the bottom was from front to back to prevent the contaminants from the bottom to eventually come in contact with the resident's perineal area. She said cleaning the perineal area from back to front could cause urinary tract infections. The DON said the expectation was for the staff to do the proper perineal care to prevent infections. She said she would do an in-service about perineal care. In an interview with the Administrator on 01/30/2025 at 8:34 AM, the Administrator stated the staff should follow the right procedure in cleaning the residents to prevent cross contamination and infection. He said he would collaborate with the DON on how to go about the said issue. He said the staff would be monitored closely. Record review of facility policy, Perineal Care Policies and Procedure created 04/25/2022 reflected Purpose: This procedure aims . providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . Procedure Content . 17. Gently perform perineal care, wiping from clean,' urethral area, to 'dirty,' rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! . Female resident: Working from front to back.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #52) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure LVN A cleaned the syringe and flushed the g-tube during Resident #52's medication administration through gastrostomy tube (G-tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) on 01/28/2025. These failures could place residents with G-tubes were at risk for infection, dehydration, and drug-to-drug interaction. Findings included: Record review of Resident #52's Face Sheet dated 01/28/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #52's Comprehensive MDS Assessment, dated 12/13/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach). Record review of Resident #52's Quarterly Care Plan, dated 12/24/2024, reflected the resident required tube feeding related to dysphagia and one of the interventions was see orders for water flushes. Record review of Resident #52's Physician Order, dated 10/13/2023, reflected every shift Flush tube with 30 ml water before and after medication and feedings. Record review of Resident #52's Physician Order, dated 10/13/2023, reflected every shift Flush with at least 5mls of water between each medication. Record review of Resident #52's Physician Order, dated 12/26/2024, reflected Baclofen Oral Tablet 5MG (Baclofen). Give 1 tablet via G-Tube two times a day for MUSCLE SPASMS. Record review of Resident #52's Physician Order, dated 12/26/2024, reflected Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa). Give 1 tablet via G-Tube three times a day for Parkinson's Disease (a disorder in the brain that affect movement). An observation on 01/28/2025 at 12:03 PM revealed LVN A was about to give Resident #52 his 12 PM medication. She said the resident will have baclofen and carbidopa. LVN A sanitized her hands, put each of the medication on a small plastic cup, crushed them one by one, and returned each crushed medication to their respective cups. She went inside the room to get the water that the resident's family provided for the resident's use. She poured 20 ml to a plastic calibrated cup. She said she would incorporate 10 cc to each medication to dissolve it. She did not sanitize her hands before preparing the medications. She put on a gown and a pair of gloves, took the stethoscope hanging on the laptop stand of the medication cart, went inside the resident's room with the cups of crushed medication and the 20 ml water, and placed them on the resident's overbed table. She took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. The barrel of the syringe was observed with residuals. She put 10 ml to one cup and put the other 10 ml to the other cup. She disconnected the g-tube from the formula, pulled the plunger of the syringe, took the stethoscope from around her neck and placed the diaphragm of the stethoscope on the resident's abdomen. She then attached the syringe on the g-tube, pushed the plunger of the syringe to check for placement, and pulled the plunger to check for residual. After checking for the residual, she detached the syringe, pulled the plunger of the syringe, and attached again the syringe to the g-tube. She then poured the medication one at a time. After pouring the medications, she detached the syringe and connected the g-tube to the formula. She placed the syringe inside its plastic bag. LVN A did not flush the g-tube before giving the medications, in between each medication, and after administering the medications. She washed her hands and left the room. LVN A left the syringe on overhead table and did not clean it after she used it. During an observation and interview with LVN A on 01/28/2025 at 12:32 PM, LVN A stated she used the same syringe on Resident #52's morning medications and she was not sure if she cleaned it. She said the syringe should be cleaned after every use to prevent bacterial growth inside the syringe. She said she forgot to clean the syringe again after the 12 PM medications. She said she would get a new syringe. She said the g-tube should be flushed to prevent clogging and to ensure the medications were pushed throughout the tube. She opened the Resident #52's profile and saw the orders for flushing before and after medications, as well as flushing in between medications. In an interview with the DON on 01/29/2025 at 12:12 PM, the DON stated the syringe should be cleaned after every use to prevent contamination and potential infection. She said cleaning the syringe after use could also prevent build-up of residual on the syringe. She said the g-tube should be flushed to prevent clogging, to separate the medications just in case there was a drug-to-drug interactions, and to ensure the tube was patent and functioning properly. She also said the amount of water used for the residents with g-tube were calculated to prevent dehydration. She said the expectation was for the staff to clean the syringes after every use and to flush the g-tube accordingly. She said she would do an in-service about g-tube. In an interview with the Administrator on 01/30/2025 at 8:34 AM, the Administrator stated the expectation was for the staff to follow the procedure in administering medications through g-tube. He said he would collaborate with the DON with regards to doing an in-service about g-tube. Review of the facility's policy Enteral (food or medication administration directly through the digestive system) Medication Administration Pharmacy Policy & Procedure manual revised 1/25/13 revealed 7. Flush the tube with 30 ml water or according to physician order . 8. Administer one medication at a time with a flush of 5-10 ml water or the amount ordered by the physician, between each medication and after the final medication is administered . 12. Change the medication syringe as directed by the manufacturer's label. If the syringe is used for 24 hours, clean after each use.

Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #18) of twelve residents reviewed for Respiratory Care. The facility failed to ensure Resident #18's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/28/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #18's Face Sheet, dated 01/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #18 was diagnosed with coronary heart disease (the blood vessels supplying blood to the heart get blocked). Record review of Resident #18's Comprehensive MDS Assessment, dated 12/04/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had coronary heart disease. Record review of Resident #18's Comprehensive Care Plan, dated 12/24/2024, reflected the resident had coronary artery disease and one of the interventions was to monitor for shortness of breath. Record review of Resident #18's Physician Orders, dated 01/27/2025, reflected May use oxygen @ 2 l/m via nasal canula every shift. Observation on 01/28/2025 at 9:27 AM revealed Resident #18 was not inside his room. An oxygen concentrator was observed at bedside with a nasal cannula connected to it. The nasal cannula was sitting on top of the oxygen concentrator and was not bagged. Observation and interview with LVN H on 01/28/2025 at 9:48 AM, LVN H stated the nasal cannula should be inside the bag to prevent cross contamination and respiratory infection. She went inside Resident #18's room and saw the nasal cannula sitting on top of the oxygen concentrator. She disconnected the nasal cannula and threw it on the trash can. She went out of the room, went to the storage room and took a plastic bag and a new nasal cannula. She said Resident #18 had an amputation and needed assistance during transfer. She said whoever transferred the resident should have made sure the nasal cannula was stored properly. Observation and interview with Resident #18 on 01/29/2025 at 8:16 AM revealed the resident was sitting in his bed, awake. It was observed that the resident had an above the knee amputation and was on oxygen administration via nasal cannula. The resident stated he used oxygen on a need basis only. He also said that he needed assistance during transfer from bed to wheelchair. He said whoever assisted him during transfers had also assisted him in taking off his nasal cannula. He said whoever assisted him should put the nasal cannula in the plastic bag tied to the railing of his bed. In an interview with the DON on 01/29/2025 at 12:12 PM, the DON stated the nasal cannulas should be bagged when the residents were not using them to prevent cross contamination and probable respiratory infection. She said whoever was caring for Resident #18 should check if the nasal cannula was bagged when not in use or needed to be changed because it touched something dirty. She said the expectation was for the nasal cannula be bagged when not in use. She said she would do an in-service about bagging the nasal cannula. In an interview with the Administrator on 01/30/2025 at 8:34 AM, the Administrator stated the nasal cannula should be properly stored to prevent respiratory infections. He said he would coordinate with the DON about doing an in-service regarding respiratory care. Review of facility policy, Oxygen Administration Nursing Policy & Procedure manual 2003 revised March 21, 2023 revealed Goals 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. 2. The resident will maintain an effective breathing pattern with administration of oxygen. 3. The resident will be free from infection.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two (Resident #1 and Resident #20) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was care planned for oxygen administration. 2. The facility failed to ensure Resident #20 was care planned for oxygen therapy (oxygen delivered through a flexible tube to the nose through two prongs) and droplet precautions (prevent infection with germs that can be spread by speaking, sneezing, or coughing). These failures could place the residents at risk of not receiving the necessary care and services. Findings included: 1. Record review of Resident #1's Face Sheet, dated 12/18/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #1 was diagnosed with acute respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body) with hypoxia (insufficient amount of oxygen in the body). Record review of Resident #1's Quarterly MDS Assessment, dated 10/13/2024, reflected that Resident #1 had severe impairment in cognition with a BIMS score of 00. Resident #1's Quarterly MDS Assessment indicated that the resident had oxygen therapy while a resident of the facility. Record review of Resident #1's Physician Order, dated 07/30/2024, reflected O2 at (3) liters per minute via nasal cannula. Record review of Resident #1's Physician Order, dated 07/30/2024, reflected May use oxygen @ 3 l/m via nasal canula every shift. Record review of Resident #1's Comprehensive Care Plan, dated 10/13/2024, reflected no care plan for oxygen therapy. Observation on 12/18/2024 at 10:09 AM revealed Resident #1 was not inside the room. It was noted that there was an oxygen concentrator at the resident's bedside. In an interview with LVN A on 12/18/2024 at 11:09 AM, LVN A stated the resident was in therapy. She said the resident had respiratory failure that was why there was a stand-by oxygen concentrator inside his room. She said the resident would not usually use it. Observation and interview with the DON on 12/18/2024 at 12:54 PM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. She said the purpose of the care plan was to make sure the staff would be on the same page when providing care. She said the care plan should be resident-centered and should show what specific care the resident needed. She turned her computer, looked at Residents #1's care plan section and saw he did not have care plan for oxygen. She said the resident had a diagnosis of respiratory failure, had an oxygen concentrator inside the room, had an order for oxygen, then he should have a care plan for oxygen. She said she would make one for Resident #1. She said without the care plan, the staff could have confusion with regards to the resident's care. She said, the MDS Nurse was sick and she was responsible in doing and overseeing the care plans of the residents. She said the expectation was for all residents to have a complete and detailed care plan. She said she would check if those residents that were using oxygen had care plans for oxygen therapy. In an interview with the Administrator on 12/18/2024 at 1:26 PM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. She said since the MDS Nurse was sick, the DON was responsible in doing the care plan. 2. Review of Resident #20's Face Sheet, dated 12/18/2024, reflected Resident #20 was an [AGE] year-old female admitted on [DATE]. Resident # 20 had a diagnosis of dementia and respiratory failure. Review of Resident #20's Quarterly MDS (tool used to measure health status) Assessment, dated 12/05/2024, reflected a BIMS (tool used to measure cognitive status) Assessment was not conducted because resident was rarely/never understood. Section C reflected was severely impaired related to cognitive skills for daily decision making. The Quarterly MDS Assessment was completed prior to the order of oxygen therapy and isolation precautions and does not reflect these. Review of Resident #20's Comprehensive Care Plan, dated 09/20/24, did not reflect any care plan for administration of oxygen and droplet precautions status for a respiratory illness. An observation 12/18/24 at 09:25 AM revealed a sign on the outside of Resident #20's door instructing to follow droplet precautions when in the room. A plastic unit with drawers was sitting outside Resident #20's door and stocked with PPE items (protective equipment worn to prevent the spread of infection). This surveyor used hand sanitizer and put on PPE items prior to entering Resident #20's room. Resident #20 was the only resident in that room and observed lying in bed asleep. An oxygen concentrator was next to the resident's bed and the Resident #20 was receiving oxygen at 2 liters per minute. PPE was removed and discarded in a trash bin near the door. Hand hygiene was performed in Resident #20's restroom before exiting the room. Record review of Resident #20's physician's order, dated 12/10/24, reflected to administer oxygen at 2 liters via nasal cannula. Record review of Resident #20's progress note, dated 12/13/24, reflected Resident #20 tested positive for RSV (virus that infects the respiratory tract and lungs) and was placed on droplet precautions. During an interview on 12/18/24 at 11:40 AM, the DON stated Resident #20 tested positive for RSV over the weekend and was placed on droplet precautions. The DON reviewed Resident #20's electronic medical record and stated the care plan should have included Resident #20 used oxygen and was on droplet precautions for RSV. The DON stated the MDS Coordinator was responsible for overseeing the care plans but had been out for a couple of weeks due to illness. The DON stated it was important for residents to have a care plan that reflected their needs, so everyone knew how to care for the residents. She stated that information was also included in the care plan meeting to let the family know how staff was providing care for their loved one. Review of facility's policy Comprehensive Care Planning reflected The facility will establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Undated.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #1 and Resident #5) of twenty residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #1 and Resident #5 on 11/05/2024. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #1's Face Sheet, dated 11/05/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #1's pertinent diagnoses included metabolic encephalopathy (changes in how the brain works due to underlying conditions) and history of falls. Review of Resident #1's Quarterly MDS Assessment, dated 09/02/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident required dependent for toileting, dressing, and personal hygiene and the resident had highly impaired vision, but eyes could follow objects. Review of Resident #1's Comprehensive Care Plan, dated 09/02/2024, reflected the resident was at risk for fall and one of the interventions was to a safe environment with a working and reachable call light. Observation on 11/05/2024 at 9:28 AM revealed Resident#1 was in his bed, sleeping. It was observed that the resident's call light was on the floor, behind his roommate's side table. Observation and interview with CNA C on 11/05/2024 at 9:39 AM revealed CNA C went inside Resident #1's room and saw the resident's call light was behind his roommates. CNA C pulled Resident #1's call light and placed it beside the resident. She said she did not notice the resident's call light was not with the resident. She then said the resident did not need the call light because the resident was blind. When asked to repeat what she said, CNA C repeated the resident did not need the call light because the resident was blind. She said the resident was being assisted in feeding and every time she would assist him, she would put the resident's glass of juice on the same spot and the resident would know where his drinks would be. When asked if this technique would be applicable with the call light, CNA C did not answer. In an interview with LVN B on 11/05/2024 at 9:46 AM, LVN B stated Resident 1's vision was diminished, but he could still see. She said she already gave the resident his medications but did not notice the resident's call light was also on the floor when she was with the resident. She said the call light should be in a place accessible to the residents because the residents needed them to call the staff. LVN B said if the call lights were not within reach, the residents would not be able to call the staff and their needs would not be met. She said the call lights should be with the residents, regardless of their conditions. In an interview with the Interim Administrator on 11/06/2024 at 7:48 AM, the Interim Administrator stated the call lights should not be on the floor because the residents needed them to call the staff. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should make sure the call lights were within reach every time they leave the room. The Administrator said he would coordinate with the DON regarding call lights and would constantly remind them to make sure the call lights were with the residents. The Administrator concluded that they would re-educate the staff about call lights within reach. In an interview with the DON on 11/06/2024 at 8:15 AM, the DON stated call lights were important for the residents and they should be placed where the residents could reach them. The DON said, for most residents, the call lights were their mode of security, that if they needed something, they could call the staff. She said the call lights should be the residents even the residents seldom use them. She said the call lights were for the dependent and independent residents, blind or not. She said all the staff were responsible in ensuring that the call lights were within reach of the residents. The DON said the expectation was for the staff would be mindful that every time they leave the residents' room, the call lights were within reach. The DON said she would conduct an in-service and check-off about the call lights for all the staff of the facility. Review of Resident #5's Face Sheet, dated 11/06/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #5 was diagnosed with left non-dominant side hemiplegia (paralyzed on one side of the body) following a stroke (blood flow to brain is blocked), cognitive deficits following a stroke, and repeated falls. Review of Resident #5's Quarterly MDS Assessment, dated 09/27/2024, reflected the resident had moderate cognitive impairment with a BIMS score of 10. Section GG indicated that the resident was dependent on staff for personal hygiene needs, toileting, and mobility. Review of Resident #5's Comprehensive Care Plan, dated 10/30/2024, reflected the resident was at high risk for falls related to left side hemiplegia. One intervention was to keep call light in reach at all times. An observation on 11/05/2024 at 9:30 AM revealed Resident #5's call light on the floor near the head of her bed. Resident #5 was lying in bed and stated she had just finished eating breakfast. Resident #5 stated that sometimes they move the call light where she can't reach it. Resident #5 stated that she feels safe here and they take great care of me. During an interview on 11/05/2024 at 11/06/24 at 9:33 AM, CNA C stated that the resident's call light should not have been on the floor. She stated that resident should be able to call the staff anytime she needs something. CNA C stated that it might cause a resident to feel neglected if they need us and cannot reach their call light. In an interview 11/06/24 at 11:05 AM, LVN B stated that keeping the call light within the resident's reach can save a life. She stated that if a resident is short of breath, they should be able to grab their call light. LVN B stated that some of their residents are forgetful, and staff must remind them where the call light was and how to call if they need anything. During an interview 11/06/24 at 11:18 AM, the DON stated that the call light should have been placed where the resident could reach it. She stated that staff should only move a call light when they are providing care for the resident and then put it back before leaving the resident's room. She stated that her expectation was for staff to ensure the residents' call lights are always within reach so residents can let staff know if they need anything. Facility's policy for call light requested on 10/05/2024 but was not provided prior to exit. The Interim Administrator said in his email on 11/06/2024 at 7:44 AM revealed The company does not have a specific policy on call lights.

Based on interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #4) of 4 residents reviewed for (ADLs) care provided to dependent residents. The facility failed to ensure Resident #4 received scheduled bed baths reviewed from October 1, 2024 - October 31, 2024. This failure placed the resident at risk of not receiving necessary services to maintain good personal hygiene, skin breakdown, and decreased self- esteem. Findings included: Record review of Resident #4's Face Sheet, dated 11/06/2024, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, history of falling, and unsteadiness on feet. Record review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 12 (moderate impairment) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Record review of Resident #4's Comprehensive care plan dated 07/15/24 revealed the resident was care planned for potential for ADL selfcare performance, and an intervention included the resident requiring Limited Assist by 1 staff with showering on Monday, Wednesday, and Friday on shift 6:00 AM-2:00 PM and as necessary. In an interview on 11/06/24 at 12:00 PM, Resident #4 stated that she was scheduled to receive three showers a week, but she was lucky to get just one or two a week. She stated she had concerns with not getting her three showers a week. Resident #4 appeared to be clean without any odors at the time of the interview. Record review of the facility's shower sheet for Resident #4 from 10/01/24 to 10/31/24 reflected the following shower sheets: 10/14/24 10/16/24 10/21/24 10/23/24 10/25/24 In an interview on 11/06/24 at 10:54 AM, CNA S stated she had been at the facility for a month. She stated she did provide Resident #4 some of her scheduled showers but she was only at the facility on an as-needed-basis. She stated the resident was scheduled to receive her showers on Monday, Wednesday, and Friday. She stated she normally completed the resident's shower first thing in the morning. She stated the resident never refused any showers with her. She stated the CNA were required to complete shower sheets for all residents, regardless of if a shower was provided or refused. She stated she did not know why the resident only had 5 shower sheets on file for the month of October. She stated she risk of the resident not receiving her scheduled showers could result in bacteria growth, skin breakdown, and staff infections. In an interview on 11/06/24 at 11:08 AM, LVN C stated she was the nurse for the hall of Resident #4. She stated she had been at the facility since February 2024, and she was familiar with the resident. She stated she resident was scheduled to receive her showers on Monday, Wednesday, and Friday. She was advised that the resident was only showing five shower sheets on file for the month of October. She stated that during her shift, the resident often was not ready for her showers, but none of the CNAs went back to check with her later in the day. She stated the CNAs were required to complete shower sheets for all residents when they were scheduled. She stated the risk of the resident not receiving her showers could result in skin breakdown and she could get an infection. In an interview on 11/06/24 at 11:26 AM, The DON stated she was advised of Resident #4 not receiving her scheduled showers for the month of October 2024. She stated the resident would sometimes refuse showers because she may not be ready. She stated the CNAs were required to complete shower sheets for all residents, regardless of if they received a shower or refused a shower. She stated she did not know why the resident only had 5 shower sheets on file for the month. She stated the risk of the resident not receiving her showers could result in skin breakdown and it was a dignity issue. The facility's policy Bath, Tub/Shower (2003), reflected Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation. A medicated tub bath can also be provided to treat skin conditions. The aging skin becomes dry, wrinkled, thinner and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics. The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 ( unknown Resident) of 68 residents at the facility reviewed for accident prevention . The facility failed to secure a coffee station on 11/06/24 that allowed for residents to self-serve coffee, which could result in skin burns. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: In an observation on 11/06/24 at 8:25 AM, an unknown resident was observed walking to a cart in front of the nurse's station, which contained hot coffee, and poured herself a cup of coffee (no lid) and walked away. The coffee at the station was poured into a cup for a temperature check using the index finger and withdrawn within seconds because of the heat. The coffee was not Lukewarm. In an interview and observation on 11/06/24 at 8:27 AM, Staffing Coordinator/CNA R stated the cart with the hot coffee had been placed there for resident to self-serve since she had been at the facility, which was one year. She stated they had not had a resident burn themselves since she was here. She stated the kitchen was supposed to check the temperature to ensure that it would not be too hot for the resident, but the nursing staff did not recheck the temperature to ensure that it was safe for the resident. She stated the risk of not checking the temperature of the coffee prior to allowing resident to get the coffee could result in the resident burning themselves. In an interview and observation on 11/06/24 at 8:30 AM, the DON stated that she had been at the facility for over a year and the self-serve coffee cart was always there and so far no resident had burned themselves. She stated the kitchen was responsible for checking the temperature to ensure that it was not a risk to the resident. She stated they did not have lids for the cups, and she stated they did have residents with skin integrity concerns and lacked coordination. She stated staff served those residents. She was advised that a resident was observed serving herself and no staff member was around. She stated they had removed the coffee cart from being in front of the nurse's station to now being located behind the nurse's stated where it would be more secured from the residents and prevent them from burning themselves. In an interview and observation on 11/06/24 at 9:00 AM, the Interim Administrator and Administrator in Training was advised of the self-serve coffee cart was left unsecured from residents that could potentially burn themselves. They advised that they had spoke with the DON and was advised that the coffee cart was moved to a more secured location that would prevent residents from burning themselves. Review of the facility's policy Guidelines on Serving Coffee in the Nursing Facility (undated), reflected 1. As there is no published federal or state regulation for minimum or maximum coffee temperature, the decision as to the temperature at which to serve the coffee rests with the administration of each facility, based on their resident's stated preferences, and the physical layout of their building, but balanced against the safety of their individual residents and their physical and mental limitations. 2. The standard for coffee service will be 140 degrees, unless the facility's residents have stated an overwhelming preference for coffee to be served at a higher temperature and additional safety measures have been implemented, or the safety of residents warrants a lower temperature. If coffee is served at 140 degrees, it will cool to 135 degrees when dispensed into a room-temperature coffee cup or mug, and per Time and Temperature Relationship to Serious Burns from the American Burn Association website, this temperature will allow approximately 15 seconds before a serious burn will occur, based on the physical condition of the individual person. 3. Any residents who have risk factors for coffee burns, such as significant cognitive impairment or extreme shaking may be evaluated for additional safety precautions using a hot beverage risk assessment. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability. 4. If coffee is served and held at a temperature lower than 140 degrees, then it will be discarded after four hours and its dispenser cleaned and sanitized before fresh coffee is added. 5. An investigation and evaluation will be performed for any resident who receives a coffee burn, and a plan to reduce this resident's risk of receiving future burns will be developed and implemented. 6. If local, state, or federal regulations or guidance for coffee temperatures are developed and/or published, then these standards will become the practice at the facility. Until that time, the facility administration must honor the resident's right to make risky decisions but balances these decisions against individual safety.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #2 and Resident #6) of twelve residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored on 11/05/2024. 2. The facility failed to ensure that Resident #6's oxygen concentrator (machine that produces oxygen) had a humidification bottle (adds moisture to reduce nasal irritation) connected to it on 11/05/2024. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #2's Face Sheet, dated 11/05/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #2's Comprehensive MDS Assessment, dated 10/06/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. Resident #2's Comprehensive MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #2's Comprehensive Care Plan, dated 10/23/2024, reflected the resident had COPD and one of the interventions was give oxygen therapy as ordered. Review of Resident #2's Physician Order, dated 06/19/2023, reflected O2 . NC @ HS + prn if O2 drops < 90% or c/o SOB. Observation and interview on 11/05/2024 at 9:16 AM revealed Resident #2 was in her wheelchair, awake. It was observed that there was an oxygen concentrator inside the room and a nasal cannula was connected to the oxygen concentrator. The nasal cannula was coiled on top of the oxygen concentrator and was not bagged. Resident #2 said she was the one using the oxygen. She said she seldom use it. She said she never saw a plastic bag for her nasal cannula and said it was not her responsibility to put the nasal cannula inside the bag. Observation and interview with LVN A on 11/05/2024 at 11:43 AM, LVN A stated Resident #2 was not on continuous oxygen and would only sometimes use it at night. LVN A entered the resident's room and saw the resident's nasal cannula coiled on top of the oxygen concentrator. LVN A proceeded to disconnect the nasal cannula, threw it in a trash can, and said she would get a new one and would make sure it would be inside a bag when the resident was not using it. She said she did not notice the nasal cannula was not inside a bag and was just placed on top of the oxygen concentrator. She said a dirty nasal cannula could result to more respiratory issues. In an interview with the Interim Administrator on 11/06/2024 at 7:48 AM, the Interim Administrator stated the nasal cannula should be kept clean to prevent any respiratory infection. He said he would coordinate with the DON regarding the needed in-service about respiratory care. He said the expectation was for the staff to bag the nasal cannula every time the resident was not using it. In an interview with the DON on 11/06/2024 at 8:15 AM, the DON stated the nasal cannula should be stored properly when not in use to keep them clean. She said if the nasal cannula was not bagged, exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and compromised oxygen administration. She said the expectation was for the staff to be mindful in making sure that the nasal cannula was properly stored. She said she would make an in-service and re-educate the staff about storing the nasal cannula was properly. She concluded it was the responsibility of the staff to make sure the nasal cannula was stored properly and not the residents. 2. Review of Resident #6's Face Sheet, dated 11/05/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #6 was diagnosed with chronic respiratory failure (airway to lungs becomes narrow and damaged) with hypoxia (low oxygen level) and dependence on supplemental air. Review of Resident #6's Comprehensive MDS Assessment, dated 10/10/2024, reflected the resident had moderate cognitive impairment with a BIMS score of 12. Resident #6's Comprehensive MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #6's Comprehensive Care Plan, dated 10/23/2024, reflected the resident had COPD (a chronic lung disease) and one of the interventions was to give oxygen therapy as ordered by the physician. Review of documentation in Resident #6's Progress Notes, dated 11/05/24 at 9:09 AM, reflected The resident takes off her oxygen humidifier when one was put to her oxygen. Review of Resident #6's Physician Order, dated 06/04/24, reflected the resident may use oxygen at 3 liters per minute via nasal cannula every shift related to acute and chronic respiratory failure with hypoxia. An observation on 11/05/2024 at 9:05 AM revealed Resident #6 sitting on the side of her bed eating breakfast. Resident #6 was wearing the nasal cannula and receiving oxygen. The oxygen concentrator did not have a humidifier bottle attached to it. Resident #6 was unable to answer questions appropriately because of her cognitive status. An observation on 11/05/24 at 10:30 AM revealed a humidifier bottle was connected to Resident #6's oxygen concentrator. During an interview on 11/06/24 at 11:05 AM, LVN B stated there should have been a humidifier bottle attached to Resident #6's oxygen concentrator. She stated the moisture is needed so the resident does not get nose and throat dryness. She stated that she was told the resident removed it. She stated that residents cannot be forced to do anything, so the facility care plans a concern like that. During an interview on 11/06/24 at 11:18 AM, the DON stated that Resident #6's oxygen concentrator was supposed to have a humidifier bottle connected to it. She stated that this adds moisture and purifies the oxygen. She stated that the resident removed the humidifier bottle from the oxygen concentrator. She stated that staff educated the resident and told her the nurse is the only one that can do that. The DON stated that the resident doesn't remember, and that staff was responsible for monitoring the resident. Record review of facility's policy, Oxygen Administration Nursing Policy & Procedure Manual 2003 rev February 13, 2007, revealed Goals . 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen . 3. The resident will be free from infection. Facility's policy for bagging the nasal cannula requested on 10/05/2024 but was not provided prior to exit. The Interim Administrator said on his email on 11/06/2024 at 7:44 AM revealed The company does not have a specific policy about bagging the nasal cannula.