COTTONWOOD CREEK HEALTHCARE COMMUNITY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice for one (Resident #35) of two residents observed for wound care.<BR/>The facility failed to ensure Resident #35 was resting in bed with her heels offloaded/elevated and puff boots on per physician order during an observation on 04/20/2023. <BR/>This failure could place residents at risk for the development or worsening of pressure ulcers; or not receiving the necessary treatment and services, consistent with professional standards of practice.<BR/>Findings Included:<BR/>Review of Resident #35's Face Sheet, dated 04/20/23, revealed she was a [AGE] year-old female re-admitted on [DATE] from the hospital. Relevant diagnoses included mental illness, leg fracture, hip replacement, DTI (deep tissue injury) of the right heel, Alzheimer's (progressive disease that destroys memory and mental functions) and dementia (loss of memory, language, or problem-solving skills).<BR/>Review of Resident #35's Quarterly MDS, dated [DATE] revealed she had both short and long-term memory problems, and that she was severely impaired regarding cognitive skills for daily decision making. Resident #35 required extensive assistance of one staff with bed mobility, toileting, and personal hygiene. Her MDS further stated she had unhealed pressure sores. Resident #35 had one stage III pressure sore upon assessment. <BR/>Record review of Resident #35's Comprehensive Care Plan dated 03/06/23 revealed, Focus, I have (Stage 3) pressure ulcer Right heel r/t decreased mobility with interventions that included to administer treatments as ordered and monitor for effectiveness. <BR/>Review of Resident #35's physician orders revealed:<BR/>Cleanse right heel with NS and 4x4 gauze, then apply anasept and collagen powder. Then cover with gauze island dressing every day . one time a day for DTI Right Heel with a start date of 01/07/2023.<BR/>Offload heels while in bed . every shift for heel protection with a start date of 11/09/2022.<BR/>Puff Boots on both feet while in bed to prevent skin breakdown . every shift for heel protection with a start date 11/09/2022.<BR/>During observation of LVN H performing wound care treatment on Resident #35 on 04/20/23 at 9:12am revealed the resident resting in bed. No puff boots observed and her heels were not elevated. <BR/>During interview with LVN H on 04/20/2023 at 9:30am, he stated that the resident did not have on her puff boots nor were her heels offloaded or elevated prior to performing the wound care treatment. He stated he was not able to find the puff boots that cushion the resident's heels and declined to further state why or what was the risk to the resident at this time. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. The ADON stated his expectations were for all staff to adhere to physician orders for safety purposes. The ADON stated that Resident #35 was to have her heels elevated and puff boots on per physician order. He stated that it could lead to a deterioration of the resident's wound if not properly off loaded/elevated and protected by the boots.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. <BR/>The facility did not ensure Resident # 1's smoking supplies were stored at Nurses' station on 05/01/25. <BR/>This failure could place residents who require supervision, at risk for a decreased quality of life or injury that could lead to an unnecessary hospitalization. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 4/15/2025 indicated Resident #1 was [AGE] years old female and admitted on [DATE] diagnoses of unspecified schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills).<BR/>Record review of Resident #1's MDS dated [DATE] revealed Resident #1's BIMS score of 14 (intact cognition). <BR/>Observation conducted on 5/1/25 at 5:15 a.m. revealed Resident #1 was observed in the nursing facility unit sitting near the nurse's station in resident's wheelchair holding a pack of cigarettes. <BR/>Interview with RN A on 05/01/25 at 5:30AM revealed the staff were aware of Resident #1 having the cigarettes but did not try to retrieve them because it would upset the resident. <BR/>Observation and interview conducted on 05/01/25 at 6:18 AM revealed Resident #1 still had cigarette pack in her hand when she entered the conference room and asked surveyor to take her outside to smoke. A lighter was not observed in Resident #1's possession, and Resident #1 stated she did not have a lighter. <BR/>During an interview on 5/1/25 at 4:43 p.m. with Administrator stated that the reason Resident#1 had a pack of cigarettes in her hand is that Resident #1 has a documented behavior of asking staff to take her outside to smoke. Administrator stated that when staff provide Resident #1 with a pack of cigarettes to hold, Resident #1 calms down. Administrator said that her expectation for staff was to not give residents cigarettes while in the facility but made an exception for Resident #1 due to her behaviors. When asked what could happen if Resident #1 obtained a lighter and cigarettes, the Administrator said Resident #1 could light herself on fire. <BR/>Interview with Resident #1 on 05/01/25 was unsuccessful due to her inability to comprehend the questions. Her responses were gibberish or inappropriate statements. <BR/>Record review on 05/01/25 at 7:00 AM of Resident #1's care plan initiated on 06/07/25 indicated Resident #1 has a behavior of sitting in front of the elevator (the entrance to the unit) and requesting cigarettes and lighters from any person who enters the facility. No documentation of allowing Resident #1 to hold her cigarette pack was noted on the care plan upon initial review. Intervention included was staff will redirect resident to her assigned room away from visitors, vendors as necessary. <BR/>Record review of Resident #1's smoking assessment shows that Resident #1 requires staff supervision while smoking due to Resident #1's cognitive status. <BR/>Follow up review of care plan on 05/01/25 at 4:30 PM revealed the behavior was added on the care plan after surveyor brought the issue to the administrator's attention. Intervention included Staff education (Resident #1 is allowed to have Cigarettes when she is exhibiting behaviors to calm her down. Retrieve the cigarettes when she finishes smoking. <BR/>Record review of facility's policy titled Smoking Policy- Residents revised July 2017, reflected, Cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles are kept secured at the nurse's station.; 14. Residents without independent smoking privileges may not have any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #35) of two residents observed for infection control. <BR/>1. <BR/>The facility failed to ensure LVN H performed hand hygiene during a wound care treatment on 04/20/23. <BR/>This failure could place residents at risk of cross-contamination and infections.<BR/>Findings Included:<BR/>Review of Resident #35's Face Sheet, dated 04/20/23, revealed she was a [AGE] year-old female re-admitted on [DATE] from the hospital. Relevant diagnoses included mental illness, leg fracture, hip replacement, DTI (deep tissue injury) of the right heel, Alzheimer's (progressive disease that destroys memory and mental functions) and dementia (loss of memory, language, or problem-solving skills.). <BR/>Review of Resident #35's Quarterly MDS, dated [DATE] revealed she had both short and long-term memory problems, and that she was severely impaired regarding cognitive skills for daily decision making. Resident #35 required extensive assistance of one staff with bed mobility, toileting, and personal hygiene. Her MDS further stated she had unhealed pressure sores. Resident #35 had one stage III pressure sore upon assessment. <BR/>Record review of Resident #35's Comprehensive Care Plan dated 03/06/23 revealed, Focus, I have (Stage 3) pressure ulcer Right heel r/t decreased mobility with interventions that included to administer treatments as ordered and monitor for effectiveness. <BR/>Review of Resident #35's physician orders revealed:<BR/>Cleanse right heel with NS and 4x4 gauze, then apply anasept and collagen powder. Then cover with gauze island dressing every day . one time a day for DTI Right Heel with a start date of 01/07/2023.<BR/>During observation of LVN H performing wound care treatment on Resident #35 on 04/20/23 at 9:12am revealed the resident resting in bed. LVN H performed hand hygiene upon entering resident room and prior to resident care. LVN H then donned gloves, obtained Resident #35's right foot, and then cleansed her right heel with normal saline and gauze. LVN H then removed his gloves and applied new gloves. LVN H did not perform hand hygiene between glove changes and going from a dirty to clean intervention/care. LVN H then applied anasept and collagen powder, then covered up the heel with an island dressing. LVN H then removed his gloves and lowered resident's bed, further contaminating resident's bed remote. LVN H then performed hand hygiene after assisting resident in her bed, further contaminating her bed linens and pillow. <BR/>During interview with LVN H on 04/20/2023 at 9:30am, he stated that he failed to perform hand hygiene between glove changes because he was nervous. He stated there was an infection control risk to the resident if proper hand hygiene was not performed during resident care, especially wound care treatments. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. He stated that his expectations were for all staff to comply with proper hand hygiene practices, as it was the best way to prevent infection. He stated that LVN H was expected to perform hand hygiene moving from a dirty to a clean procedure, and in between glove changes. <BR/>Review of facility policy, Handwashing/Hand Hygiene, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. Use an alcohol-based hand rub; or alternatively, and water for the following situations: .g. before handling clean . dressings, gauze pads, etc. h. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 #1 and Resident #2) of five residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure Resident #1's nasal canula (flexible tube used to deliver oxygen to the nose through two prongs) at the back of her wheelchair was properly stored when not in use on 04/22/2025. <BR/>2. <BR/>The facility failed to ensure Resident #2's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) and CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) mask were properly stored when not in use on 04/22/2025. <BR/>These failures could place residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Record review of Resident #1's Face Sheet, dated 04/22/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of Resident #1's Quarterly MDS Assessment, dated 03/10/2025, reflected the was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was on oxygen therapy.<BR/>Record review of Resident #1's Quarterly Care Plan, dated 03/16/2025, reflected the resident had chronic obstructive pulmonary disease and one of the interventions was to use of oxygen therapy as ordered.<BR/>Record review of Resident #1's Physician orders, dated 12/14/2025, reflected Oxygen every shift for O2 dependence @ 3 LPM via nasal cannula.<BR/>Observation and interview on 04/22/2025 at 9:36 AM revealed Resident #1 was in her bed, awake. The resident was on oxygen administration via nasal cannula at 3 liters per minute. The nasal cannula was attached to an oxygen concentrator. It was observed that the resident had a portable oxygen tank at the back of her wheelchair with a nasal cannula attached to it. The nasal cannula was not bagged and the prongs of the nasal cannula was touching the left brake of the wheelchair Resident #1 said she used the nasal cannula on the wheelchair everytime she would go out of the room. <BR/>Observation and interview on 04/22/2025 at 9:57 AM, LVN B stated the nasal cannula should be bagged everytime Resident #1 was not using it to prevent infection. She went inside the room and saw a nasal cannula attached to the portable oxygen tank behind the resident's wheelchair. She observed that the nasal cannula was not bagged and was touching the left brake of the wheelchair. She disconnected the nasal cannula and threw it in a trash can. She said she would get a new nasal cannula and a plastic bag for it. She said she would also let the charge nurse of the hall what was observed.<BR/>2. <BR/>Record review of Resident #2's Face Sheet, dated 04/22/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure and obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep).<BR/>Record review of Resident #2's Quarterly MDS Assessment, dated 04/06/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident had respiratory failure and obstructive sleep apnea.<BR/>Record review of Resident #2's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had oxygen therapy related to respiratory failure and one of the interventions was to administer medications as ordered. Comprehensive Care Plan also indicated the resident had sleep apnea and one of the interventions was to apply CPAP at night and remove in the morning. <BR/>Record review of Resident #2's Physician Orders, dated 03/10/2025, reflected the following:<BR/>*Ipratropium-Albuterol Inhalation Solution 0.5 - 2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally two times a day for Wheezing.<BR/>* Start CPAP every night. Please have family bring in patient's home CPAP machine and use former settings. at bedtime related to OBSTRUCTIVE SLEEP APNEA.<BR/>Observation and interview on 04/22/2025 at 10:14 AM, revealed Resident #2 was in his bed, awake. It was observed that the resident was using oxygen at 2 liters per minute. He said he had been using oxygen for some time but could not remember for how long. He said he also received breathing treatment daily and used CPAP at night. He said he was not aware where the staff put his breathing mask and CPAP mask after they took it off. The resident's breathing mask was observed on top of the side table and the CPAP mask was inside the resident's drawer. Both masks were not bagged.<BR/>Observation and interview with LVN A on 04/22/2025 at 10:18 AM, LVN A stated he was made aware by LVN B about Resident #1's nasal cannula. He said he did not notice it when he did his morning round. He said the nasal cannula should be in a bag when the resident was not using it to prevent infection. He said he would also remind the aides that whenever they transfer the resident, they should put the nasal cannula inside a bag or call him so he could store the nasal cannula properly. LVN A then went inside Resident #2's and saw the breathing mask on top of the table and the CPAP mask inside the drawer. He said he would get a new breathing mask to replace the one on the table. He said he would get plastic bags for the breathing mask and the CPAP mask. He said he would clean the CPAP mask first before putting it inside the plastic bag. He said both the breathing mask and the CPAP mask should be bagged to prevent infection.<BR/>In an interview on 04/22/2025 at 12:49 PM, the DON stated the nasal cannula, the breathing mask, and the CPAP mask were supposed to be in a bag when the residents were not using them to prevent cross contamination and worsening of any respiratory issues the residents might already have. She said the expectation was for the staff to be mindful and make sure all the respiratory paraphernalia were bagged and kept clean. She said she would conduct an in-service about respiratory care immediately after the interview.<BR/>In an interview on 04/22/2025 at 12:56 PM, the Administrator stated everything that the residents use to supplement their breathing should be kept clean to prevent cross contamination and possible infection. She said, for this incident, the expectation was for the staff to bag the nasal cannula, breathing mask, and CPAP mask when not in use. She said she would coordinate with the DON to educate and re-educate the staff about the respiratory care issue. She said the facility do not have a policy specific for bagging the nasal cannula, breathing mask, and CPAP mask.<BR/>Policy for bagging the nasal cannula, breathing mask, and CPAP mask requested verbally on 04/22/2025 at 12:56 PM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. <BR/>The facility did not ensure Resident # 1's smoking supplies were stored at Nurses' station on 05/01/25. <BR/>This failure could place residents who require supervision, at risk for a decreased quality of life or injury that could lead to an unnecessary hospitalization. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 4/15/2025 indicated Resident #1 was [AGE] years old female and admitted on [DATE] diagnoses of unspecified schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills).<BR/>Record review of Resident #1's MDS dated [DATE] revealed Resident #1's BIMS score of 14 (intact cognition). <BR/>Observation conducted on 5/1/25 at 5:15 a.m. revealed Resident #1 was observed in the nursing facility unit sitting near the nurse's station in resident's wheelchair holding a pack of cigarettes. <BR/>Interview with RN A on 05/01/25 at 5:30AM revealed the staff were aware of Resident #1 having the cigarettes but did not try to retrieve them because it would upset the resident. <BR/>Observation and interview conducted on 05/01/25 at 6:18 AM revealed Resident #1 still had cigarette pack in her hand when she entered the conference room and asked surveyor to take her outside to smoke. A lighter was not observed in Resident #1's possession, and Resident #1 stated she did not have a lighter. <BR/>During an interview on 5/1/25 at 4:43 p.m. with Administrator stated that the reason Resident#1 had a pack of cigarettes in her hand is that Resident #1 has a documented behavior of asking staff to take her outside to smoke. Administrator stated that when staff provide Resident #1 with a pack of cigarettes to hold, Resident #1 calms down. Administrator said that her expectation for staff was to not give residents cigarettes while in the facility but made an exception for Resident #1 due to her behaviors. When asked what could happen if Resident #1 obtained a lighter and cigarettes, the Administrator said Resident #1 could light herself on fire. <BR/>Interview with Resident #1 on 05/01/25 was unsuccessful due to her inability to comprehend the questions. Her responses were gibberish or inappropriate statements. <BR/>Record review on 05/01/25 at 7:00 AM of Resident #1's care plan initiated on 06/07/25 indicated Resident #1 has a behavior of sitting in front of the elevator (the entrance to the unit) and requesting cigarettes and lighters from any person who enters the facility. No documentation of allowing Resident #1 to hold her cigarette pack was noted on the care plan upon initial review. Intervention included was staff will redirect resident to her assigned room away from visitors, vendors as necessary. <BR/>Record review of Resident #1's smoking assessment shows that Resident #1 requires staff supervision while smoking due to Resident #1's cognitive status. <BR/>Follow up review of care plan on 05/01/25 at 4:30 PM revealed the behavior was added on the care plan after surveyor brought the issue to the administrator's attention. Intervention included Staff education (Resident #1 is allowed to have Cigarettes when she is exhibiting behaviors to calm her down. Retrieve the cigarettes when she finishes smoking. <BR/>Record review of facility's policy titled Smoking Policy- Residents revised July 2017, reflected, Cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles are kept secured at the nurse's station.; 14. Residents without independent smoking privileges may not have any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision.

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure food in the refrigerator and freezer were dated and labeled.<BR/>The facility failed to ensure expired foods were discarded upon expiration date.<BR/>The facility failed to ensure food stored in the refrigerator and freezer were properly sealed.<BR/>The facility failed to ensure facility kitchen staff wore the proper hair and face restraint while preparing food in the facility only kitchen.<BR/>The facility failed to clean one of the dual ovens in the facility's only kitchen.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings include:<BR/>Observation on 04/18/23 at 9:49 AM in the Facility's only kitchen, revealed Corporate Culinary Director being observed assisting staff in the kitchen getting trays out to the residents. He was observed wearing a baseball hat to cover his head; however, he had approximately 1/2 inches in length of hair exposed along the back hairline of his head. He was also observed to have approximately a 1/4 inches in length of facial hair uncovered.<BR/>Observations on 04/18/2023 at 9:50 AM in the facility's only kitchen in the refrigerator and freezer revealed the following: <BR/>One 10-pound (lb.) box of unsealed pork sausage patties <BR/>One 10.25 lb. unsealed box of Fully Cooked Turkey Sausage Links<BR/>Three undated 2.5 lb. bags of Oven Roasted Sliced Roast Beef Eye Round<BR/>One opened and unsealed 2.5 lb. bag of Oven Roasted Sliced Roast Beef Eye Round<BR/>One ten lb. tube of Provolone Cheese with Smoke Flavor with an expiration date of 10/17/22<BR/>One opened but sealed 5 lb. bag of undated shredded parmesan cheese with no visible expiration date.<BR/> One 10.50 lb. block of Sharp Cheddar Cheese with an expiration date of 10/12/22<BR/>One unsealed bag of frozen beef patties (approximately 20 patties). <BR/>One undated 4 lb. bag of frozen Mediterranean Vegetable Blend.<BR/>One unsealed bag of frozen Salisbury steaks (approximately 6 patties)<BR/>One unsealed 5 lb. bag frozen tater tots that were freezer burned<BR/>One undated 5lb. bag of frozen French fries<BR/>One open and unsealed 5lb. bag of frozen potatoes that were freezer burned<BR/>One unsealed and undated 5lb. bag of French fries<BR/>One opened and undated bag of freezer burned frozen biscuits that were falling out of the bag and some of the biscuits were observed to have fallen on the freezer floor. <BR/>Two bags of undated refrigerated pancakes (approximately 18 in each bag)<BR/>Two half-gallon containers of Hill Country Heavy Whipping Cream with an expiration date of 04/13/2023.<BR/>Observations on 04/18/2023 at 10:00 AM in the facility's only kitchen in the dry food storage area revealed the following:<BR/>One undated 6lb. can of Great Northern Beans<BR/>One undated Gallon of Honey Mustard Dressing<BR/>Three one-gallon jars of Nacho Slices Jalapeno peppers dated 08/19 and no other expiration dates were visible on any of the jars.<BR/>One gallon container of mayonnaise dated 12/13/22.<BR/>One updated 12-ounce container of House Recipe Sugar free Pancake and Waffle Syrup with no visible expiration date.<BR/>One 12-ounce container of Smucker's Sugar Free Breakfast Syrup with an expiration date of 02/01/2023. <BR/>One 2.5 lb. container of Soda Fountain Malted Milk Powder dated 08/16 and no other expiration date of visible.<BR/>Observation on 04/19/23 at 11:30 AM revealed a dual oven in the facility's only kitchen. The left oven was heavily soiled with dirt, grease, and spills. <BR/>Interview with the Dietary Manager on 04/20/23 at 01:54 PM revealed, she had been the DM for two weeks at the facility. She was advised of the findings of the kitchen and shown pictures of the foods that were left exposed, food that had expired dates, and foods not labeled and dated. She advised that no particular person was responsible for ensuring items stored were properly stored. She stated that she had already went into the freezer, refrigerator, and dry food area and corrected some of the concerns. She advised that she had spoken with the Corporate Culinary Director, and he had placed on the appropriate head and face coverings. She stated she was not really paying attention to his hair not being fully covered nor his failure to wear a face covering. She was advised of the condition of the oven, and she stated she was not sure when the last time it was cleaned, and she had been at the facility for two weeks and it had not been cleaned. She stated she had since assigned this task to her dishwasher to clean at least weekly. She stated the risk to the residents of the facility not following the proper food storage, head and face coverings, and cleaning guidelines could in residents getting sick from foodborne illness.<BR/>Interview with the Interim Administrator on 04/20/23 at 4:00 PM revealed she was made aware of the findings in the kitchen by the Dietary manager. She stated her expectation was for the kitchen staff to ensure that they were following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. <BR/>Record Review of facility's policy and procedures for Food Receiving and Storage (Undated), revealed Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>Record Review of facility's policy and procedures for Hair Restraints, dated 02/21/2017, revealed Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 1 of 5 residents (Resident #35) observed for environment.<BR/>1. <BR/>The facility failed to ensure Resident #29's room remained free of pests during observation on 04/18/2023. <BR/>This failure could place residents at risk of not receiving a safe, clean, comfortable and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings Included:<BR/>Record review of facility roster, Census Report, dated 04/17/2023 revealed:<BR/>Resident #29 resided in room [ROOM NUMBER]B in Hall D.<BR/>Review of the most recent pest control visit 04/11/2023 titled Service Report, revealed Pests . Ants . Cockroaches . Other Notes: Regular service was done today in hallway D & E .<BR/>Review of facility Pest Service Agreement, dated 05/25/2020 revealed a current contract. <BR/>In observation on 04/18/2023 at 12:09pm an approximately 3-4'', oval, dark brown to black, six legged insect was observed walking down hall D and entered room [ROOM NUMBER], approximately 3' from where Resident #29 was sitting in her wheelchair watching television. <BR/>In observation and interview with CNA G at 12:13pm, she was informed by surveyor that there was a large insect in room [ROOM NUMBER]. CNA G entered Resident #29's room and stepped on the pest, resulting in the cockroaches' demise. CNA G stated that she sometimes sees cockroaches on the hall. She stated when she sees pests, she reports it to the nurse and they put in in the bug book and then they will come and spray. <BR/>In interview with Resident #29 on 04/18/2023 at 12:13pm she stated she will occasionally see large cockroaches in her room. She stated she would rather not have any pests in her room. <BR/>In interview with MTSPVSR on 04/20/2023 at 2:21pm, he stated there was a work order system at the facility [Telis] and his expectations were for any staff to report pest control sightings. He stated that he was not aware of any pest sightings and denied any evidence of reports of insects this week. He stated it was important for the facility to maintain a pest-free environment for safety and resident right purposes. <BR/>Record review of the facility [Telis] work order log dated from 04/17/2023 - 04/20/2023 provided by MTSPVSR on 04/20/2023 revealed no documentation of pest sightings at the facility. <BR/>In interview with HKSPVSR on 04/20/2023 at 2:43pm, she stated there was a work order system at the facility [Telis] and her expectations were for any staff to report pest control issues. She stated the risk to the resident regarding pests was not having a clean environment would be demeaning for the resident in addition to a cross-contamination risk for infection. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. He further stated there was a work order system at the facility [Telis] and his expectations were for any staff to report any pest control sightings. He declined to answer further questions at this time. <BR/>Review of facility policy, Pest Control, undated, provided by the facility on 04/20/2023 revealed Policy Statement . Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation . 1. This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents.<BR/>Review of facility policy, Homelike Environment, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review the facility failed to develop and implement comprehensive person-centered care plans that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 4 (Resident #14, Resident #237, and Resident #18) resident's care plans reviewed.<BR/>The facility failed to develop a comprehensive person-centered, measurable, and time-based care plan to address specialized services and interventions to address PASARR recommendations, as appropriate for Resident #14 including problems, goals, and interventions.<BR/>The facility failed to develop a comprehensive person-centered, measurable, and time-based care plan to address Hospice for Resident #237 including problems, goals, and interventions.<BR/>The facility failed to implement care plan interventions across all shifts (6A - 2P; 2P - 10P; and 10P - 6A) in a 24-hour period, as reflected in Resident #18's care plan related to risk for falls.<BR/>These failures could negatively impact the resident's quality of life, as well as the quality of care and services received if care planning is not complete or is inadequate.<BR/>Findings included:<BR/>RESIDENT #14<BR/>A record review of Resident #14's Annual MDS assessment dated [DATE] revealed a [AGE] year-old male admitted on [DATE]. Resident #14 had diagnoses of Traumatic Spinal Cord Dysfunction (when an external physical impact acutely damages the spinal cord), Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), Anxiety, Depression, Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and Schizophrenia (a serious mental health condition that affects how people think, feel, and behave). Resident #14's BIMS score was 15, which indicated intact cognition. The Annual MDS assessment indicated Resident #14 did not have mental illness considered by the state level II Preadmission Screening and Resident Review (PASRR).<BR/>Record review of Resident #14's PASRR Level 1 Screening, dated 06/25/24, reflected Yes there was evidence or an indicator that Resident #14 had a Mental Illness.<BR/>Record review of Resident #14's PASRR Evaluation (PE), dated 06/26/24, revealed Resident #14 met the PASRR definition of mental illness based on the Qualified Mental Health Professional (QMHP) assessment.<BR/>Record review of Resident #14's care plan initiated 04/26/24 did not reflect or identify PASRR needs or services provided.<BR/>RESIDENT #237<BR/>A record review of Resident #237's admission MDS assessment dated [DATE] revealed a [AGE] year-old male admitted on [DATE]. Resident #237 had diagnoses of Medically Complex Conditions, Colon Cancer, BPH (age-associated prostate gland enlargement that can cause urination difficulty), Unspecified Kidney Failure, and CVA (Damage to the brain from interruption of its blood supply). The admission MDS indicated Resident #237's cognition was severely impaired per staff assessment for mental status.<BR/>Record review of Resident #237's uploaded documents revealed a signed and dated Facility Notification of admission to admit Resident #237 to Hospice on 07/09/24.<BR/>Record review of Resident #237's care plan initiated 07/01/24 did not reflect or identify Hospice needs or services provided.<BR/>RESIDENT #18<BR/>A record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #18 had diagnoses of Non-Traumatic Brain Dysfunction (causes damage to the brain by internal factors), Alzheimer's Disease, Anxiety, Depression, and Schizophrenia (a serious mental health condition that affects how people think, feel, and behave). The admission MDS indicated Resident #18's cognition was severely impaired per staff assessment for mental status.<BR/>Record review of Resident #18's comprehensive care plan reflected a Risk for Falls last revised on 07/09/24. The goal indicated Resident #18 would be free of falls with major injuries through review period (Initiated: 09/20/22; Revised 03/21/24; Target: 09/10/24). Interventions included Low bed and mats incorporated.<BR/>Record review of an incident report dated and signed on 07/08/24 at 7:51 AM by the DON reflected [the DON] was notified by the ADON that Resident #18 had a fall-related raised area and discoloration to the left forehead. The incident report reflected immediate action taken by nursing staff. The incident report did not indicate if fall interventions were in place at the time of Resident #18's fall.<BR/>Observation on 07/28/24 at 10:30 AM, Resident #18 was not present in the room. Resident #18's room did not reveal a fall mat at bedside or visibly stored anywhere in the room.<BR/>Observation on 07/28/24 at 4:11 PM revealed Resident #18 lying in bed. The bed was in the lowest position. The call light was on the bedside dresser, not within Resident #18's reach. A fall mat was not placed at bedside or anywhere in the room.<BR/>Observation on 07/29/24 at 2:30 PM, Resident #18 was not present in the room. Resident #18's room did not reveal a fall mat at bedside or visibly stored anywhere in the room.<BR/>Observation on 07/30/24 at 7:15 AM, Resident #18 was not present in the room. Resident #18's room revealed a fall mat at Resident #18's bedside.<BR/>On 07/28/24, the DON disclosed that LVN A was no longer employed by the facility. On 07/29/24 at 6:00 PM an outbound call was placed to LVN A that was unanswered. On 07/30/24 at 11:00 AM an outbound call was placed to LVN A that was unanswered.<BR/>During an interview on 07/30/24 at7:39 AM, the ADON stated that the MDS nurse was responsible for preparing and updating care plans. The ADON said that she assisted with updating care plans in the absence of a facility MDS nurse but was not solely responsible for updating care plans. The ADON indicated the purpose of care plans was to inform direct care staff about resident care needs and preferences. The ADON said that the risk to Resident #14 was the failure to receive PASRR related services; the risk to Resident #237 was the failure to receive care and services provided by Hospice; and the risk to Resident #18 was the injury sustained from a fall without the fall mat in place.<BR/>During an interview 07/30/24 at 8:23 AM, the DON stated that it was a collaborative effort with the Regional MDS nurse to implement and update care plans. The DON said that the interdisciplinary team reviewed the 24-hour report and reviewed care plans following an acute incident to ensure the care plan was consistent with the resident's disease process, risks, needs, preferences, and behaviors. The DON said the Regional MDS nurse took on the responsibilities until a facility MDS nurse was hired. The DON said the vacant MDS position placed the facility at risk for the care plan concerns identified. The DON said that she conducted surveillance daily of the environment and resident rooms to ensure clean, safe environments and that appropriate precautions were in place. The DON indicated that during walking rounds (07/30/24 at 7:00 AM) observed Resident #18 did not have a fall mat at the bedside. The DON said that she retrieved a fall mat from the storage area and placed at Resident #18's bedside and educated staff about fall precautions. The DON said that she was unaware that Resident #14's care plan did not reflect PASRR recommendations or that Resident #237's care plan did not reflect Hospice services. The DON indicated that care plans should be person-centered, developed, and implemented to meet the preferences and goals of the resident.<BR/>During an interview on 07/30/24 at 8:46 AM, the LSW stated that Resident #14 refused PASRR services during the PE meeting on 07/08/24. The LSW said that PASRR services and evaluator recommendations would be discussed during care plan meetings and the person responsible for care plans would update accordingly. The LSW could not identify the responsible person to develop and update care plans. The LSW said that she was not sure if PASRR should reflect on the care plan if the resident refused services.<BR/>Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022 reflected, . care plan includes but is not limited to initial goals of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility; and consistent with the resident's rights and will incorporate resident-centered goals and wishes about their care, activities, and lifestyle to include measurable short-term and long-term objectives and time frames. The resident's goals for admission and desired outcomes.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 2 (medication cart #1 and medication cart #2) of 2 medication carts reviewed for pharmacy services in that:<BR/>The facility failed to ensure controlled medications in unsecure containers were immediately removed from medication cart #1 and medication cart #2.<BR/>These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.<BR/>Findings Included:<BR/>During an interview, observation, and record review of medication cart #1 on 07/29/24 at 11:45 AM revealed a pill blister packaging card filled with Tramadol 50 mg tablets (controlled medication used for pain). The seals that secured 2 pill blisters (#8 and #21) were not intact. A white, round tablet was noted inside each blister. There were 25 pills remaining. The narcotic log count sheet reflected the appropriate count. During a continued observation of medication cart #1, a full pill blister packaging card (30 pills) filled with Hydrocodone-Acetaminophen 10 mg-325 mg (controlled medication used for pain) had 1 seal (#12) that was not intact. A white, oblong tablet was inside the blister. The narcotic log count sheet reflected the appropriate count. During an interview, LVN B indicated that controlled medications were counted at the beginning and at the end of shift. LVN B said that controlled medications must be secured in a separately locked compartment within the medication cart. LVN B said that she was a new hire and was not sure what the specific protocol was at the facility but would report to the DON to determine what actions to take when the seal of a blister pack was broken, torn, or ripped. LVN B said that best practice would be to discard the pill with a second nurse. LVN B said the risk of an exposed pill was exposure, cross-contamination, the pill could be stolen, or replaced with a similar looking pill.<BR/>During an interview, observation, and record review of medication cart #2 on 07/29/24 at 12:20 PM revealed a pill blister packaging card filled with Lorazepam 0.5 mg (a controlled substance used to relieve anxiety) with 1 seal (#16) not intact. A white, round tablet was noted inside the blister. There were 23 pills remaining. The narcotic log count sheet reflected the appropriate count. During an interview LVN C stated she was unaware that the blister seal was broken or when it happened. LVN C stated the risk of a damaged blister would be a potential for drug diversion. LVN C stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. LVN C stated the count was done at shift change and the count was correct. LVN C stated she did not see the broken blisters during the count. LVN C stated when a broken seal was observed, two nurses should discard the medication.<BR/>During an observation on 07/29/24 at 3:30 PM revealed the disposal method of the controlled medications into an authorized collection receptacle with LVN B and LVN C. The pills were verified by the identifiers printed on the blister packaging card before destroyed. Both nurses signed the appropriate narcotic count sheet, entered the date, time, amount destroyed and amount remaining.<BR/>During an interview on 07/30/24 at 8:23 AM, the DON said that nurses were responsible for following the medication rights (the right resident, right medication, right dose, right form, right time) and review expiration dates. The DON said if a nurse discovered the seal of a medication was altered (opened, torn, ripped) then the nurse should notify [the DON] and discard the pill with a second nurse. The DON said that the second nurse witnessed the pill disposal of controlled medications as a secure and safe method to prevent diversion.<BR/>Review of the facility's policy Storage of Medications, revised April 2019 reflected the following: . 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure residents had a safe, clean, comfortable, and homelike environment for 5 of 5 residents (Resident #6, Resident #24, Resident #29, Resident #35, and Resident #53) reviewed for environment.<BR/>1. <BR/>The facility failed to ensure Resident #6, Resident #24, and Resident #53 had clean floors, free of dirt, dust, debris, and sticky sediment accumulation. <BR/>2. <BR/>The facility failed to ensure Resident #29's room remained free of pests, including a large cockroach. <BR/>3. <BR/>The facility failed to ensure Resident #35 had a footboard on her bed free from damage. <BR/>These failures could place residents at risk of not receiving a safe, clean, comfortable, and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings Included:<BR/>Record review of facility roster, Midnight Census Report, dated 04/17/2023 revealed:<BR/>Resident #6 resided in room [ROOM NUMBER]B in Hall D.<BR/>Resident #24 resided in room [ROOM NUMBER]A in Hall D.<BR/>Resident #29 resided in room [ROOM NUMBER]B in Hall D.<BR/>Resident #35 resided in room [ROOM NUMBER]A in Hall E.<BR/>Resident #53 resided in room [ROOM NUMBER]B in Hall D.<BR/>Review of the most recent pest control visit dated 04/11/2023 from , titled Service Report, revealed Pests . Ants . Cockroaches . Other Notes: Regular service was done today in hallway D & E .<BR/>Review of the facility's Pest Service Agreement, dated 05/25/2020 revealed a current contract <BR/>Resident #6<BR/>In observation on 04/18/2023 at 11:41am revealed Resident #6 resting in bed in room [ROOM NUMBER]. Resident's floor was noticeably sticky. A significant amount of white powdery substance was observed along the perimeter of the wall. Drywall damage was present above white powdery substance. There were dirt, dust, debris, and sticky sediment accumulated on the flooring.<BR/>In observation and interview with Resident #6 on 04/19/2023 at 11:11am revealed her resting in bed. Resident floor was noticeably sticky. A significant amount of white powdery substance was observed along the perimeter of the wall. Drywall damage was present above white powdery substance. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. Resident #6 stated that housekeeping does mop in her room, but she thought they could do a lot better. She stated she would be happier if her floors were more clean. <BR/>In observation and interview with ADON on 04/19/2023 at 11:11am he stated that he believed the white powdery substance in Resident #6's room was drywall. He stated that maintenance recently performed repairs, but he was not sure when or what was repaired specifically. He stated that the substance should not be on the floor and it was the maintenance departments responsibility to always clean up after themselves to prevent any risk to the residents. <BR/>Resident #53<BR/>In observation on 04/18/2023 at 11:52am revealed Resident #53 resting in bed in room [ROOM NUMBER]. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. Resident was non-verbal and not able to be interviewed. <BR/>In observation on 04/19/2023 at 11:21am revealed Resident #53 resting in bed. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring.<BR/>In observation on 04/20/2023 at 12:30pm revealed Resident #53 resting in bed. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. A laminate tile was displaced due to the stickiness of the floor by surveyor's shoe. <BR/>Resident #24<BR/>In observation and interview with Resident #24 on 04/19/2023 at 9:11am revealed her resting in bed in room [ROOM NUMBER]. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. She stated that her dirty room bothers her and she would be happier if her flooring was properly cleaned. <BR/>In observation and interview with MA A on 04/19/2023 at 9:11am, he stated that Resident #24's room was sticky most times, as she spills a lot of things. He further stated that he does not know the cleaning schedule of housekeeping, but they do not clean each room daily, and stated that they could do a lot better than they were doing currently. <BR/>Resident #29<BR/>In observation on 04/18/2023 at 12:09pm an approximately 3-4'', oval, dark brown to black, six-legged insect was observed walking down hall D and entered room [ROOM NUMBER], approximately 3' from where Resident #29 was sitting in her wheelchair watching television. <BR/>In observation and interview with CNA G at 12:13pm, she was informed by surveyor that there was a cockroach in room [ROOM NUMBER]. CNA G entered Resident #29's room and stepped on the pest and resulted in the cockroaches' demise. CNA G stated that she sometimes sees cockroaches on the hall. She stated when she sees pests, she reports it to the nurse and they put in in the bug book and then they will come and spray. <BR/>In interview with Resident #29 on 04/18/2023 at 12:13pm, she stated they will occasionally see large cockroaches but it was not frequent. She stated she would rather not have any pests in her room. <BR/>Resident #35 <BR/>In observation and interview on 04/20/2023 at 9:05am revealed Resident #35 resting in bed in room [ROOM NUMBER]A. Resident #35's bed was positioned against the wall with the resident's left side of the bed positioned towards the open area of the room. Resident #35's foot board had significant amount of damage on the left side, with jagged particle board exposed. The resident stated the bed being broken bothers her and when asked if she would like it repaired, she stated yes. <BR/>In observation and interview with LVN H on 04/20/2023 at 9:30am, he stated that he was not sure how long Resident #35's bed has been broken. He stated she does get up in a wheelchair and stated it could pose a risk to the resident for a laceration or other injury. <BR/>In interview with MTSPVSR on 04/20/2023 at 2:21pm, he stated there was a work order system at the facility [Telis] and his expectations were for any staff to report maintenance or pest control issues. He stated that he was not aware of any pest sightings and denied any evidence of reports of insects this week. Additionally, he was not aware of any furniture concerns reported this week. He stated it was important for resident furniture to be in good, working condition for safety. <BR/>Record review of the facility [Telis] work order log dated from 04/17/2023 - 04/20/2023 provided by MTSPVSR on 04/20/2023 revealed no documentation of relevant concerns. <BR/>In interview with HKSPVSR on 04/20/2023 at 2:43pm, she stated there was a work order system at the facility [Telis] and her expectations were for any staff to report maintenance or pest control issues. She stated that the cause of the sticky flooring was that the natural wax on the floor had worn off and anything acidic makes the floor sticky. She stated the risk to the resident regarding not having a clean environment would be the resident would feel demeaned and have a cross-contamination risk for infection. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. He further stated there was a work order system at the facility [Telis] and his expectations were for any staff to report maintenance or pest control issues. He started he expected resident floors to be clean and free of dirt, dust, debris, and sticky sediment accumulation. He declined to answer further questions at this time. <BR/>Review of facility policy, Maintenance Service, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 1. The Maintenance Department is responsible for maintaining the . and equipment in a safe and operable manner at all times. 2 . b. Maintaining the building in good repair and free from hazards.<BR/>Review of facility policy, Homelike Environment, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure food in the refrigerator and freezer were dated and labeled.<BR/>The facility failed to ensure expired foods were discarded upon expiration date.<BR/>The facility failed to ensure food stored in the refrigerator and freezer were properly sealed.<BR/>The facility failed to ensure facility kitchen staff wore the proper hair and face restraint while preparing food in the facility only kitchen.<BR/>The facility failed to clean one of the dual ovens in the facility's only kitchen.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings include:<BR/>Observation on 04/18/23 at 9:49 AM in the Facility's only kitchen, revealed Corporate Culinary Director being observed assisting staff in the kitchen getting trays out to the residents. He was observed wearing a baseball hat to cover his head; however, he had approximately 1/2 inches in length of hair exposed along the back hairline of his head. He was also observed to have approximately a 1/4 inches in length of facial hair uncovered.<BR/>Observations on 04/18/2023 at 9:50 AM in the facility's only kitchen in the refrigerator and freezer revealed the following: <BR/>One 10-pound (lb.) box of unsealed pork sausage patties <BR/>One 10.25 lb. unsealed box of Fully Cooked Turkey Sausage Links<BR/>Three undated 2.5 lb. bags of Oven Roasted Sliced Roast Beef Eye Round<BR/>One opened and unsealed 2.5 lb. bag of Oven Roasted Sliced Roast Beef Eye Round<BR/>One ten lb. tube of Provolone Cheese with Smoke Flavor with an expiration date of 10/17/22<BR/>One opened but sealed 5 lb. bag of undated shredded parmesan cheese with no visible expiration date.<BR/> One 10.50 lb. block of Sharp Cheddar Cheese with an expiration date of 10/12/22<BR/>One unsealed bag of frozen beef patties (approximately 20 patties). <BR/>One undated 4 lb. bag of frozen Mediterranean Vegetable Blend.<BR/>One unsealed bag of frozen Salisbury steaks (approximately 6 patties)<BR/>One unsealed 5 lb. bag frozen tater tots that were freezer burned<BR/>One undated 5lb. bag of frozen French fries<BR/>One open and unsealed 5lb. bag of frozen potatoes that were freezer burned<BR/>One unsealed and undated 5lb. bag of French fries<BR/>One opened and undated bag of freezer burned frozen biscuits that were falling out of the bag and some of the biscuits were observed to have fallen on the freezer floor. <BR/>Two bags of undated refrigerated pancakes (approximately 18 in each bag)<BR/>Two half-gallon containers of Hill Country Heavy Whipping Cream with an expiration date of 04/13/2023.<BR/>Observations on 04/18/2023 at 10:00 AM in the facility's only kitchen in the dry food storage area revealed the following:<BR/>One undated 6lb. can of Great Northern Beans<BR/>One undated Gallon of Honey Mustard Dressing<BR/>Three one-gallon jars of Nacho Slices Jalapeno peppers dated 08/19 and no other expiration dates were visible on any of the jars.<BR/>One gallon container of mayonnaise dated 12/13/22.<BR/>One updated 12-ounce container of House Recipe Sugar free Pancake and Waffle Syrup with no visible expiration date.<BR/>One 12-ounce container of Smucker's Sugar Free Breakfast Syrup with an expiration date of 02/01/2023. <BR/>One 2.5 lb. container of Soda Fountain Malted Milk Powder dated 08/16 and no other expiration date of visible.<BR/>Observation on 04/19/23 at 11:30 AM revealed a dual oven in the facility's only kitchen. The left oven was heavily soiled with dirt, grease, and spills. <BR/>Interview with the Dietary Manager on 04/20/23 at 01:54 PM revealed, she had been the DM for two weeks at the facility. She was advised of the findings of the kitchen and shown pictures of the foods that were left exposed, food that had expired dates, and foods not labeled and dated. She advised that no particular person was responsible for ensuring items stored were properly stored. She stated that she had already went into the freezer, refrigerator, and dry food area and corrected some of the concerns. She advised that she had spoken with the Corporate Culinary Director, and he had placed on the appropriate head and face coverings. She stated she was not really paying attention to his hair not being fully covered nor his failure to wear a face covering. She was advised of the condition of the oven, and she stated she was not sure when the last time it was cleaned, and she had been at the facility for two weeks and it had not been cleaned. She stated she had since assigned this task to her dishwasher to clean at least weekly. She stated the risk to the residents of the facility not following the proper food storage, head and face coverings, and cleaning guidelines could in residents getting sick from foodborne illness.<BR/>Interview with the Interim Administrator on 04/20/23 at 4:00 PM revealed she was made aware of the findings in the kitchen by the Dietary manager. She stated her expectation was for the kitchen staff to ensure that they were following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. <BR/>Record Review of facility's policy and procedures for Food Receiving and Storage (Undated), revealed Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>Record Review of facility's policy and procedures for Hair Restraints, dated 02/21/2017, revealed Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 8 residents (Resident # 19) reviewed for quality of care. <BR/>The facility failed to ensure Resident #19 had his call light within his reach while he was laying in bed. <BR/>This failure could place residents at risk of not receiving immediate care if assistance was needed. <BR/>Findings Included:<BR/>Review of Resident #19's Face Sheet, dated 04/20/23, revealed he was a 76 -year-old male admitted on [DATE]. Relevant diagnoses included Cerebral Infarction (Brain Stroke), Neuromuscular Dysfunction of Bladder (bladder malfunction, and history of falling. <BR/>Review of Resident #19's MDS, dated [DATE] revealed he was not cognitively intact with a BIMS score of 0. He required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. <BR/>Record review of Resident #19's Comprehensive Care Plan, dated 02/03/2023 revealed the resident required a one person assist for transfers, bathing/showering, toilet use, dressing, eating, and personal hygiene. <BR/> Observation and interview on 04/18/23 at 12:01 PM revealed Resident #19 laying in his bed and his call light button was not observed near him. He was asked where his call light button was located, and he advised that he did not know. The call light button was observed on the floor, wrapped around an IV pole in the floor.<BR/>Observation and interview with the Corporate Nurse on 4/18/23 at 12:21 PM, revealed Resident #19 laying in his bed and his call light being wrapped around his IV pole. The Corporate Nurse took the call light button and placed it on the bed alongside the resident. She did not want to indicate any risk to the resident of the call light not being in reach, and she stated I know what you are wanting to hear but I am not going to say it.<BR/>Interview on 04/20/23 at 4:00 PM with the ADON revealed he was made aware of Resident #19's call light button not being in reach of the resident. He advised that Resident #19 did have a history of fall and was encouraged to use his call light button. He advised that he thinks one of the Aides had provided assistance to the resident and had forgotten to place the call light button back within reach of the resident. He stated leadership was required to conduct Angel rounds, which involves leadership being assigned rooms to check to ensure the resident needs have been met. The ADON stated that he completes his rounds and one of the things he checks for were call light buttons being in reach. He did not want to indicate the risk to the resident with the call light not being in reach. <BR/>Interview on 04/20/23 at 06:00 PM with the Interim Administrator revealed she was made aware of Resident #19 not having his call light button within reach. She stated that it was the right of all residents to receive quality care and the resident should always have his call light within reach just in case he needs assistance or if he was having an emergency. She advised staff should check for things like call light buttons being within reach of the residents whenever they complete resident observations, which occurs at least every two hours. She advised the nursing leadership was responsible for ensuring overseeing this effort. <BR/>Review of the facility's policy and procedure on Call Light dated June 14, 2006, revealed, Answer all call lights promptly whether you are assigned to the patient or not. When providing care to patients, be sure to position the call light conveniently for patient's use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and records review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 5 Residents (Resident #1) reviewed for provision of care and services by staff.<BR/>The facility did not follow their policy reporting Abuse and Neglect by not notifying local law enforcement when Resident #1 had an allegation of physical abuse reported on 11/28/23.<BR/>This failure could place residents in the facility at risk for abuse or neglect. <BR/>Findings included:<BR/>A record review of Resident #1's face sheet dated 12/02/23 reflected an [AGE] year-old female admitted on [DATE] with diagnoses : Schizoaffective Disorder (mental disorder abnormal thought process), Systolic congestive heart failure (heart failure long term condition), Hypertension (high blood pressure), Depression (mental state low mood), Dementia (cognitive decline), Type 2 Diabetes Mellitus (change in flood insulin) Psychotic disturbance (mental conditions of the mind difficulty determining real and not real) and mood disturbance (mental and behavioral disorder), and anxiety (feeling of worry, nervousness or unease).<BR/>Review of Resident #1's quarterly MDS assessment, dated 10/13/23, reflected resident has frequent behaviors of yelling out, and confusion, she has a BIMS score of 04 indicating she was severely impaired cognitively. Resident Requires total assistance with ADL's with two adults. <BR/>Review of Resident #1's Care Plan, dated 10/27/23, reflected: I have impaired cognitive function r/t.<BR/>Dementia and CVA .interventions Administer medications as ordered. Monitor/document for side effects and<BR/>effectiveness. Anticipate needs and prompt or give reminders as needed consistent routines to decrease confusion monitor changes in cognitive function. Medication review I am at risk for side effects to antidepressants medications and antipsychotic medications .monitor changes in mood and cognition and report immediately. Administer medication as ordered by the physician .Resident makes false allegations of abuse and neglect .staff will continue to provide nursing care interventions include 2 staff members providing care, social services involvement, psychiatric evaluations. I have a communication problem related to Expressive aphasia (unable to comprehend or formulate language), stuttering allow ample time for communication, anticipate needs.<BR/>Record review of resident #1's MD orders reflected orders dated 11/13/23 Norco Oral Tablet 5-325 MG Give 1 tablet by mouth two times a day for Pain, 11/13/23 Tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for Pain rated 6-10 <BR/>Record review of facility self-report dated 11/28/23 reflected, Pertinent Medical Diagnosis: Schizoaffective Disorder, Depression, dysphagia (difficulty swallowing) following cerebral infarction, unspecified dementia .Incident Details. Date/Time you first learned of incident: 11/28/23 4:50 PM Date/Time the incident occurred: 11/28/23 4:40 PM. Resident #1 alleged that CNA slapped her .No witness. The date and time of the assessment: 11/28/23 5:00 PM Name and title of person who completed assessment: ADON Alleged Perpetrator .CNA M Actions and notifications .Alleged perpetrator was immediately suspended, and Administrator interviewed resident and performed safe survey. Head-to-toe assessment was performed. No physical injuries noted, and resident indicated that they felt safe, and psychological distress was not noted.<BR/>Review of Resident #1's progress notes by LVN B reflected dated 11/28/23 at 3:00 PM Resident # 1 in bed at this time, resident RP visiting, no acute distress not complaint of pain at this time, res call light off at this time, Around 7:05 PM, [RLE] police officer in facility. Stated he was in the facility because resident called them, this nurse showed rest room to police officer, res requested for this nurse to stay out of the room while she speaks with police office. DON notified<BR/>An observation and interview on 12/02/23 at 12:40 PM with Resident #1 revealed resident sitting in her wheelchair. She stated that she was hit in the mouth, side, and back by CNA M with a fist. She said she did not know if she had bruising. Resident #1 was observed to have no injuries, around her eye, a bruise, scratches, bleeding, or swelling. <BR/>In an interview on 12/04/23 at 11:10 AM the ADON revealed on 11/28/23 at approximately 5:00 PM she was notified by the DON that Resident #1 alleged physical abuse (CNA M hit her in the mouth), ADON immediately located CNA M and suspended her immediately pending investigation results. The ADON and LVN V assessed Resident #1 for injuries, neuro and risk assessment Resident #1 had no injuries and was not observed to be in distress. The ADON directed LVN V to notify family and MD. The MD was notified the family member was not.<BR/>In an interview with CNA J on 12/04/23 at 11:20 AM revealed on 11/28/23 he entered Resident #'s #1's room and she reported that CNA M hit her in the mouth. He reported the incident to LVN V. CNA J did not observe any injuries on the resident.<BR/>An interview on 12/04/23 at 2:50 PM with the Administrator revealed he submitted a self-report on 11/28/23. He said he did not contact law enforcement. He said that the need to report the incident to law enforcement was not performed as the resident did not have any injuries. He said that once the POA arrived at the facility and found out about the incident, he addressed the failure to report with DON, ADON, and POA. CNA M was suspended immediately when the allegation was made to the ADON. He reported the incident within the 2-hour timeframe, completed, an investigation, and initiated training. The It is his expectation for the nurses to notify the POA and family of all incidents concerning their family member. The DON and ADON are responsible for training staff and monitoring to ensure resident safety. He said it was his expectation for the ADON and DON to assure the task was completed. <BR/>In an interview with the POA on 12/04/23 at 10:55 AM revealed she was not notified of the abuse allegation Resident #1 reported to staff. She found out about the incident from Resident #1 on 11/30/23. She said she immediately notified the law enforcement of the incident and they responded to the facility.<BR/>In an interview on 12/04/23 at 11:04 AM with RLE confirmed that a report was submitted on 11/28/23 and the report numbers was (Police Report# 202300088038). Once the responding officer left the facility the case was assigned to him to investigate. The stated that the POA reported that a staff named [CNA M] punched Resident #1 in the mouth, and Resident #1 had a swollen lip. RLE observed the responding officers' body cam footage, and the images did not depict bruising, cuts, tears, and bleeding on the resident lips or face. He stated his investigation concluded that no charges would be filed, as there was no proof of an assault. He stated he would send the police report to the state surveyor with information from the arriving officer.<BR/>In an interview with RLE on 12/04/23 at 11:55 AM he stated that he was notified of the incident by the responding officer, and he reviewed the body cam (portable camera worn by officers) and the resident did not have any injuries. He will be investigating the incident and has notified the POA.<BR/>Record review of LVN V disciplinary/counseling report completed by the DON dated 12/04/23 at 12:12 PM reflected LVN V received a verbal coaching on policy and procedure violation .On 11/28/23 above employee failed to notify family regarding and incidents .Goals/Corrective behavior: To make sure all notifications are made on all incidents or changes of condition. <BR/>An interview on 12/04/23 at 12:40 PM with the DON revealed she was told by LVN V that Resident #1 alleged that CNA M hit her in the mouth. The DON directed the ADON to suspended CNA M immediately and she notified the Administrator of the incident. The DON assessed Resident #1 on 11/29/23 and the resident did not have any injuries or distress. The DON said that LVN V was directed to call the POA, and she has received a written disciplinary for failing to follow procedures. She said that CNA M has been terminated and will not return. It is her expectation for the nurse to notify family of incidents of abuse. <BR/>Record review of RLE incident report was received on 12/06/23 and further review reflected Report # 202300088038 dated 11/30/23 reflected call from POA of injury of elderly with bodily injuries. Responding officer LE B On 11/30/2023 at approximately 6:53 P.M., Officer B #1475 was dispatched to the CWCHC, for a report of an assault that had occurred earlier in the day. Contact was made with the complainant, who was in Resident #1's with the victim. <BR/>Record review of in-service on reporting abuse and neglect dated 09/20/23, 10/20/23, 10/23/23, 10/09/23, 11/8/23, 11/6/23, 11/28/23, and 12/02/23 presented by the DON. LVN V's name was observed on the in-service documents listed above. <BR/>Record review of CNA M's employee file reflected that she attended ANE and abuse reporting training on 10/06/23 during new employee training and 11/6/23.<BR/>Review of the facility Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult protective services (where state law provides jurisdiction in long-term care); Law enforcement officials; The resident's attending physician; and the facility medical director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure residents had a safe, clean, comfortable, and homelike environment for 5 of 5 residents (Resident #6, Resident #24, Resident #29, Resident #35, and Resident #53) reviewed for environment.<BR/>1. <BR/>The facility failed to ensure Resident #6, Resident #24, and Resident #53 had clean floors, free of dirt, dust, debris, and sticky sediment accumulation. <BR/>2. <BR/>The facility failed to ensure Resident #29's room remained free of pests, including a large cockroach. <BR/>3. <BR/>The facility failed to ensure Resident #35 had a footboard on her bed free from damage. <BR/>These failures could place residents at risk of not receiving a safe, clean, comfortable, and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings Included:<BR/>Record review of facility roster, Midnight Census Report, dated 04/17/2023 revealed:<BR/>Resident #6 resided in room [ROOM NUMBER]B in Hall D.<BR/>Resident #24 resided in room [ROOM NUMBER]A in Hall D.<BR/>Resident #29 resided in room [ROOM NUMBER]B in Hall D.<BR/>Resident #35 resided in room [ROOM NUMBER]A in Hall E.<BR/>Resident #53 resided in room [ROOM NUMBER]B in Hall D.<BR/>Review of the most recent pest control visit dated 04/11/2023 from , titled Service Report, revealed Pests . Ants . Cockroaches . Other Notes: Regular service was done today in hallway D & E .<BR/>Review of the facility's Pest Service Agreement, dated 05/25/2020 revealed a current contract <BR/>Resident #6<BR/>In observation on 04/18/2023 at 11:41am revealed Resident #6 resting in bed in room [ROOM NUMBER]. Resident's floor was noticeably sticky. A significant amount of white powdery substance was observed along the perimeter of the wall. Drywall damage was present above white powdery substance. There were dirt, dust, debris, and sticky sediment accumulated on the flooring.<BR/>In observation and interview with Resident #6 on 04/19/2023 at 11:11am revealed her resting in bed. Resident floor was noticeably sticky. A significant amount of white powdery substance was observed along the perimeter of the wall. Drywall damage was present above white powdery substance. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. Resident #6 stated that housekeeping does mop in her room, but she thought they could do a lot better. She stated she would be happier if her floors were more clean. <BR/>In observation and interview with ADON on 04/19/2023 at 11:11am he stated that he believed the white powdery substance in Resident #6's room was drywall. He stated that maintenance recently performed repairs, but he was not sure when or what was repaired specifically. He stated that the substance should not be on the floor and it was the maintenance departments responsibility to always clean up after themselves to prevent any risk to the residents. <BR/>Resident #53<BR/>In observation on 04/18/2023 at 11:52am revealed Resident #53 resting in bed in room [ROOM NUMBER]. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. Resident was non-verbal and not able to be interviewed. <BR/>In observation on 04/19/2023 at 11:21am revealed Resident #53 resting in bed. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring.<BR/>In observation on 04/20/2023 at 12:30pm revealed Resident #53 resting in bed. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. A laminate tile was displaced due to the stickiness of the floor by surveyor's shoe. <BR/>Resident #24<BR/>In observation and interview with Resident #24 on 04/19/2023 at 9:11am revealed her resting in bed in room [ROOM NUMBER]. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. She stated that her dirty room bothers her and she would be happier if her flooring was properly cleaned. <BR/>In observation and interview with MA A on 04/19/2023 at 9:11am, he stated that Resident #24's room was sticky most times, as she spills a lot of things. He further stated that he does not know the cleaning schedule of housekeeping, but they do not clean each room daily, and stated that they could do a lot better than they were doing currently. <BR/>Resident #29<BR/>In observation on 04/18/2023 at 12:09pm an approximately 3-4'', oval, dark brown to black, six-legged insect was observed walking down hall D and entered room [ROOM NUMBER], approximately 3' from where Resident #29 was sitting in her wheelchair watching television. <BR/>In observation and interview with CNA G at 12:13pm, she was informed by surveyor that there was a cockroach in room [ROOM NUMBER]. CNA G entered Resident #29's room and stepped on the pest and resulted in the cockroaches' demise. CNA G stated that she sometimes sees cockroaches on the hall. She stated when she sees pests, she reports it to the nurse and they put in in the bug book and then they will come and spray. <BR/>In interview with Resident #29 on 04/18/2023 at 12:13pm, she stated they will occasionally see large cockroaches but it was not frequent. She stated she would rather not have any pests in her room. <BR/>Resident #35 <BR/>In observation and interview on 04/20/2023 at 9:05am revealed Resident #35 resting in bed in room [ROOM NUMBER]A. Resident #35's bed was positioned against the wall with the resident's left side of the bed positioned towards the open area of the room. Resident #35's foot board had significant amount of damage on the left side, with jagged particle board exposed. The resident stated the bed being broken bothers her and when asked if she would like it repaired, she stated yes. <BR/>In observation and interview with LVN H on 04/20/2023 at 9:30am, he stated that he was not sure how long Resident #35's bed has been broken. He stated she does get up in a wheelchair and stated it could pose a risk to the resident for a laceration or other injury. <BR/>In interview with MTSPVSR on 04/20/2023 at 2:21pm, he stated there was a work order system at the facility [Telis] and his expectations were for any staff to report maintenance or pest control issues. He stated that he was not aware of any pest sightings and denied any evidence of reports of insects this week. Additionally, he was not aware of any furniture concerns reported this week. He stated it was important for resident furniture to be in good, working condition for safety. <BR/>Record review of the facility [Telis] work order log dated from 04/17/2023 - 04/20/2023 provided by MTSPVSR on 04/20/2023 revealed no documentation of relevant concerns. <BR/>In interview with HKSPVSR on 04/20/2023 at 2:43pm, she stated there was a work order system at the facility [Telis] and her expectations were for any staff to report maintenance or pest control issues. She stated that the cause of the sticky flooring was that the natural wax on the floor had worn off and anything acidic makes the floor sticky. She stated the risk to the resident regarding not having a clean environment would be the resident would feel demeaned and have a cross-contamination risk for infection. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. He further stated there was a work order system at the facility [Telis] and his expectations were for any staff to report maintenance or pest control issues. He started he expected resident floors to be clean and free of dirt, dust, debris, and sticky sediment accumulation. He declined to answer further questions at this time. <BR/>Review of facility policy, Maintenance Service, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 1. The Maintenance Department is responsible for maintaining the . and equipment in a safe and operable manner at all times. 2 . b. Maintaining the building in good repair and free from hazards.<BR/>Review of facility policy, Homelike Environment, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 5 residents (Resident #2) reviewed for ADLs.<BR/>The facility failed to provide Resident #2 assistance with showers on a consistent basis.<BR/>This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status. <BR/>Findings include:<BR/>Record review of Resident #2's electronic face sheet, dated 06/28/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included unspecified dementia, unsteadiness on feet, muscle weakness, arthritis, and repeated falls. <BR/>Record review of Resident #2's Comprehensive MDS assessment, dated 04/20/23, revealed Resident #2 had a BIMS score of 12, which indicated his cognition was moderately impaired. Further review revealed section G0120. Bathing indicated code 4 (Total Dependency), which meant full staff performance every time during entire 7-day period. <BR/>Record review of Resident #2's care plan, dated 04/25/23, revealed Resident #2 required assistance from staff with ADLs. Requires assist from staff . transfers; . bathing . The intervention included Staff will assist with bathing and will encourage Resident to participate as able. <BR/>A record review of Resident #2's bathing ADLs in her electronic clinical record revealed Resident #2's revealed from 05/31/23 to 06/28/23 staff aided with a bath on 06/08/23, 06/14/23, 06/16/23, and 06/21/23. Further review of the bathing ADL chart revealed Resident #2 only refused a bath on 06/09/23. <BR/>A record review of Resident #2's electronic Progress Notes, from 05/31/23 to 06/28/23, revealed no documentation which reflected the resident refused baths. <BR/>In an interview on 06/27/23 at 12:34 PM with Resident #2 and Resident #2's Family Member (FM), the FM stated Resident #2 was supposed to receive baths 3 days per week and she was not getting them. The FM stated Resident #2 usually received 1 bath a week and that's only when CNA D worked. Resident #2 stated her last bath was either Tuesday (06/20/23) or Wednesday (06/21/23) of last week. Resident #2 stated she was supposed to receive a bath this morning, but CNA D was not at work, so she knew she was not going to get one. Resident #2 stated she received baths about once a week. She stated she had not been refusing baths and the CNAs were just not coming to give them to her. The FM stated CNA D is off today (06/27/23) and she did not know who was the CNA for Resident #2's hall. The FM stated she had been at the facility since about 9:30/10:00 AM and not one CNA had come to Resident #2's room, so she knew she was not going to get a bath today. The FM stated she was going to give Resident #2 a bath today because it had been a week since she last received one and she really needed it. The FM stated she brought this concern to the DON's attention about 1 month ago. The FM stated the DON said she would take care of it, but nothing ever changed. The FM said this DON was no longer working at the facility and she had not said anything to the new DON because she felt they did not do anything about it the first time, so she believe nothing would change this time as well. <BR/>In an interview on 06/28/23 at 12:50 PM, LVN E stated she did not receive any complaints from Resident #2 that she was not receiving baths. She stated none of the CNAs had ever told her Resident #2 was refusing baths. LVN E stated after the CNAs gave resident's baths, they were supposed to document it in their electronic clinical record. She stated if a resident refused, then the CNAs were supposed check off in their electronic chart that they refused and to notify her. LVN E stated if they confirmed they refused, then she was supposed to verify and document it in the resident's clinical record. <BR/>In an interview on 06/28/23 at 12:59 PM, CNA D stated her scheduled changed each week but on her scheduled days, she mainly worked on Resident #2's hall. She stated Resident #2 and her FM had complained to her that other CNAs were not giving her baths. CNA D stated the days she worked, she always gave Resident #2 a bath and she had never refused. CNA D stated after they gave resident's a bath, they were supposed to document it in their electronic clinical record. She stated if a resident refused, there is an area in the electronic record that says refused, which they were supposed to check off and they were supposed to notify the nurse. CNA D stated she could tell Resident #2 was not receiving baths when she didn't work because the resident would tell her and when she provided her a bath she would smell like urine, and she was visibly not clean. She stated she did not report this to the nurse or management because she did not want to get other CNAs in trouble .<BR/>In an interview on 06/28/23 at 3:27 PM, the Administrator stated he was not aware there was an issue with residents receiving baths. He stated CNAs were supposed to document if baths were received or refused in the resident's electronic clinical record. He stated he would conduct an in-service regarding this issues and he was going to add to the process in which CNAs would have to fill out a sheet if resident refused and the nurse would have to sign off and document in the resident's electronic clinical record. The Administrator stated he was not a nurse, so he did not know the medical effects of resident's not being bathed, but he did know resident's not receiving baths was a concerns of the resident's dignity not being upheld. <BR/>A record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, undated, reflected Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with eh plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. <BR/>The facility did not ensure Resident # 1's smoking supplies were stored at Nurses' station on 05/01/25. <BR/>This failure could place residents who require supervision, at risk for a decreased quality of life or injury that could lead to an unnecessary hospitalization. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 4/15/2025 indicated Resident #1 was [AGE] years old female and admitted on [DATE] diagnoses of unspecified schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills).<BR/>Record review of Resident #1's MDS dated [DATE] revealed Resident #1's BIMS score of 14 (intact cognition). <BR/>Observation conducted on 5/1/25 at 5:15 a.m. revealed Resident #1 was observed in the nursing facility unit sitting near the nurse's station in resident's wheelchair holding a pack of cigarettes. <BR/>Interview with RN A on 05/01/25 at 5:30AM revealed the staff were aware of Resident #1 having the cigarettes but did not try to retrieve them because it would upset the resident. <BR/>Observation and interview conducted on 05/01/25 at 6:18 AM revealed Resident #1 still had cigarette pack in her hand when she entered the conference room and asked surveyor to take her outside to smoke. A lighter was not observed in Resident #1's possession, and Resident #1 stated she did not have a lighter. <BR/>During an interview on 5/1/25 at 4:43 p.m. with Administrator stated that the reason Resident#1 had a pack of cigarettes in her hand is that Resident #1 has a documented behavior of asking staff to take her outside to smoke. Administrator stated that when staff provide Resident #1 with a pack of cigarettes to hold, Resident #1 calms down. Administrator said that her expectation for staff was to not give residents cigarettes while in the facility but made an exception for Resident #1 due to her behaviors. When asked what could happen if Resident #1 obtained a lighter and cigarettes, the Administrator said Resident #1 could light herself on fire. <BR/>Interview with Resident #1 on 05/01/25 was unsuccessful due to her inability to comprehend the questions. Her responses were gibberish or inappropriate statements. <BR/>Record review on 05/01/25 at 7:00 AM of Resident #1's care plan initiated on 06/07/25 indicated Resident #1 has a behavior of sitting in front of the elevator (the entrance to the unit) and requesting cigarettes and lighters from any person who enters the facility. No documentation of allowing Resident #1 to hold her cigarette pack was noted on the care plan upon initial review. Intervention included was staff will redirect resident to her assigned room away from visitors, vendors as necessary. <BR/>Record review of Resident #1's smoking assessment shows that Resident #1 requires staff supervision while smoking due to Resident #1's cognitive status. <BR/>Follow up review of care plan on 05/01/25 at 4:30 PM revealed the behavior was added on the care plan after surveyor brought the issue to the administrator's attention. Intervention included Staff education (Resident #1 is allowed to have Cigarettes when she is exhibiting behaviors to calm her down. Retrieve the cigarettes when she finishes smoking. <BR/>Record review of facility's policy titled Smoking Policy- Residents revised July 2017, reflected, Cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles are kept secured at the nurse's station.; 14. Residents without independent smoking privileges may not have any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 5 (Resident #1) residents reviewed for abuse and neglect.<BR/>The facility failed to report to the state agency Resident #1's allegation of LVN A refusing to help him after he fell and telling him he had to sleep on the floor.<BR/>This failure could place residents at risk of injuries, abuse, and/or neglect.<BR/>Findings included:<BR/>Record review of Resident #1's electronic Face Sheet, dated 06/28/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, unsteadiness on feet, age-related cataract (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), gout (a common form of inflammatory arthritis that is very painful), lack of coordination, acquired absence of left leg below knee, muscle weakness, difficulty in walking, and history of falling. <BR/>Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 required one-person physical assistance for the following ADLs: bed mobility, transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. <BR/>Record review of Resident #1's care plan, last revised on 06/05/23, revealed Resident #1 had a history of falls with current risk secondary to decreased activity/ mobility, decreased balance associated with L (left) BKA (below knee amputation), decreased vision acuity associated with cataracts and potential side effects to medications. An intervention included Staff assist as needed during transfers, encourage calling for assistance and use of gait belt as tolerated. Further review revealed, Resident #1 required ADL assistance due to amputation, with transfers, bed mobility, bathing, and dressing. The intervention included assistance from staff and encourage the resident to use bell to call for assistance. <BR/>Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 06/01/23 at 9:42 AM which reflected Resident sent to ER for Eval/TX (evaluation/treatment) r/t (related to) AMS (altered mental status), fall, and critical high lab values at this time. Transferred via stretcher by paramedics X2 (2 assistants) being transported by [EMS]. Resident is alert and oriented 1-2 with confusion noted. No distress noted. Resident in stable condition. <BR/>In an interview on 06/28/23 at 1:11 PM, Resident #1 stated he pressed the call light and wanted his PRN pain medication. He stated when he did not receive his pain medication , he felt dizzy from the pain. He stated LVN A went to his room but would not provide the medication. Resident #1 stated he started screaming he needed his medication. He stated when no one responded he attempted to get in his wheelchair to go into the hall to find the nurse to ask for his pain medication. Resident #1 stated while trying to get in his wheelchair he fell on the floor. He stated he slide towards the door and screamed for help. Resident #1 stated he believed this was about 3-4 AM. He stated LVN A came into his room and told him he should not have attempted to get out of bed by himself and he would have sleep on the floor. Resident #1 stated LVN A closed the door. He stated he slept on the floor and then at about 6-7 AM, when the shift changed, morning shift nurses came to help him. Resident #1 stated he told RN C that LVN A left him on the floor after he fell. He stated he did not have injuries. Resident #1 stated he also told the DON that LVN A left him on the floor . He stated he did not understand how LVN A was still working at the facility and when she saw him, she would look at him with a smirk on her face.<BR/>In an interview on 06/28/23 at 1:32 PM, RN C stated she provided RN coverage on 06/01/23 and was called to Resident #1's room, by LVN B, because he was found on the floor . She stated LVN B was taking Resident #1's vitals and assessing him for injuries. RN C stated Resident #1 told her he had been on the floor for several hours. RN C stated Resident #1 told her LVN A knew he fell and refused to help him off the floor. She stated Resident #1 told her LVN A told him to sleep on the floor. RN C stated Resident #1 did not have injuries from the fall but was sent to the hospital because labs were high for white blood cell count. RN C stated Resident #1's allegations about LVN A's actions were considered abuse & neglect; so, she did report to the DON what Resident #1 said about LVN A leaving him on the floor. <BR/>In an interview on 06/28/23 at 2:18 PM, the DON stated she was aware that Resident #1 fell on [DATE]. She stated while RN C was assessing him, she did go into Resident #1's room. The DON stated Resident #1 was very confused and when she attempted to ask him what happened he was not providing a coherent statement. She stated Resident #1 did not tell her that he was left on the floor by LVN A. The DON stated all she remembered him saying about the incident was something about a big African woman and this shouldn't have happened. She stated she was not sure what these statements meant. The DON stated Resident #1 returned to the facility from the hospital the same day and was more oriented. She stated she did not follow up with Resident #1 about his comments of the big African woman and this shouldn't have happened. The DON stated she did not recall RN C telling her that Resident #1 alleged LVN A left him on the ground after he fell. She stated she was not saying RN C did not tell her, but that she just did not remember her saying it because it was so much going on. The DON stated this would be an allegation of abuse and neglect. She stated when there is an allegation of abuse and neglect, it was supposed to be investigated by the facility and reported to the state.<BR/>In a phone interview on 06/28/23 at 3:12 PM, LVN A stated Resident #1 did not fall on her shift. LVN A stated Resident #1 never requested PRN medications on the day he fell, and she never went into his room, after he went to bed. LVN A stated the CNAs complete rounds through the night and had not reported he fell or was on the floor. LVN A stated she was made aware of Resident #1's allegation by RN C, when she reported to work on 06/01/23 at 6:00 PM. She stated the allegations were not true. She stated the DON, nor the Administrator asked her about the allegations.<BR/>In an interview on 06/28/23 at 3:27 PM, the Administrator stated he was just made aware of Resident #1's allegations regarding LVN A. He stated these allegations would be considered abuse & neglect and should be investigated and reported to the state. The Administrator stated he was going to suspend LVN A, and the DON pending the investigation and file a report with the State. The Administrator stated he would start an in-service regarding abuse and neglect. He stated the risk to the residents would be a potential of reoccurring abuse and/or neglect. <BR/>In a phone interview on 06/29/23 at 12:21 PM, LVN B stated she was covering Resident #1's hall on 06/01/23. She stated she was an agency employee but had worked at the facility prior to returning as an agency employee, so she was familiar with Resident #1 and knew he was usually alert and oriented. LVN B stated she took Resident #1's breakfast tray to his room between 7:00 to 7:30 AM and found him on the floor near the door. LVN B stated Resident #1 was alert but was confused and was making random statements. She stated she asked Resident #1 what happened, and he kept saying he was on the floor for a long time, and no one would help him. LVN B stated she took his vitals and once she assessed him and he did not have injuries or fractures they got him off the floor. She stated while she was assessing him, RN C came to Resident #1's room. LVN B stated she left the room to get something and when she returned, she heard Resident #1 telling RN C that the overnight nurse knew he fell and left him on the floor. She stated RN C was his normal nurse and she believed he was more comfortable with her, so he told her what happened. LVN B stated RN C confirmed to her that Resident #1 stated LVN A knew he fell and left him on the floor. LVN B stated she was not sure if RN C reported the incident to the DON, but she heard the two of them talking about the incident in the hallway, so she assumed RN C told the DON. She stated when LVN A reported to work at 6:00 PM, RN C told her Resident #1's allegations asked LVN A about the situation. LVN B stated LVN A was very nonchalant about the situation and didn't say much other than denying the situation happened. She said she found it strange that LVN A did not seem shocked or asked for any additional information. LVN B stated she believed LVN A and Resident #1 had issues because 1-2 days before this incident she witnessed an incident between the two. LVN B stated she started her shift at 6 AM and Resident #1 asked her for pain medication. LVN B stated they were in the process of changing shifts and LVN A was sitting next to her at the nurse's station. LVN B stated Resident #1 said to her, in front of LVN A very loudly, that LVN A would not give him his pain pill and he was in pain all night. She stated LVN A did not deny it and just didn't respond at all. LVN B stated she knew LVN A heard him because she was sitting right next to her, and Resident #1 was loud and complaining. LVN B stated she checked the MAR and saw the medication had not provided, so she gave Resident #1 the pain medication . LVN B stated at the time she assumed there was a reason she didn't provide the medication and just chose not to interact with Resident #1 because he was upset. <BR/>A record review of the facility's policy titled Abuse Investigation and Reporting, undated, reflected All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence that all allegations of abuse were thoroughly investigated and failed to report the results of all investigations to the State Agency within five working days for 1 of 5 residents (Residents #1) reviewed for allegations of abuse and neglect. <BR/>The facility failed to complete a thorough investigation and provide the results of the investigation to the State Agency regarding Resident #1's allegation of LVN A refusing to help him after he fell and telling him he had to sleep on the floor.<BR/>These failures could place residents at risk of injuries, abuse, and/or neglect.<BR/>Findings included:<BR/>Record review of Resident #1's electronic Face Sheet, dated 06/28/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, unsteadiness on feet, age-related cataract (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), gout (a common form of inflammatory arthritis that is very painful), lack of coordination, acquired absence of left leg below knee, muscle weakness, difficulty in walking, and history of falling. <BR/>Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 required one-person physical assistance for the following ADLs: bed mobility, transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. <BR/>Record review of Resident #1's care plan, last revised on 06/05/23, revealed Resident #1 had a history of falls with current risk secondary to decreased activity/ mobility, decreased balance associated with L (left) BKA (below knee amputation), decreased vision acuity associated with cataracts and potential side effects to medications. An intervention included Staff assist as needed during transfers, encourage calling for assistance and use of gait belt as tolerated. Further review revealed, Resident #1 required ADL assistance due to amputation, with transfers, bed mobility, bathing, and dressing. The intervention included assistance from staff and encourage the resident to use bell to call for assistance. <BR/>Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 06/01/23 at 9:42 AM which reflected Resident sent to ER for Eval/TX (evaluation/treatment) r/t (related to) AMS (altered mental status), fall, and critical high lab values at this time. Transferred via stretcher by paramedics X2 (2 assistants) being transported by [EMS]. Resident is alert and oriented 1-2 with confusion noted. No distress noted. Resident in stable condition. <BR/>In an interview on 06/28/23 at 1:11 PM, Resident #1 stated he pressed the call light and wanted his PRN pain medication. He stated when he did not receive his pain medication , he felt dizzy from the pain. He stated LVN A went to his room but would not provide the medication. Resident #1 stated he started screaming he needed his medication. He stated when no one responded he attempted to get in his wheelchair to go into the hall to find the nurse to ask for his pain medication. Resident #1 stated while trying to get in his wheelchair he fell on the floor. He stated he slide towards the door and screamed for help. Resident #1 stated he believed this was about 3-4 AM. He stated LVN A came into his room and told him he should not have attempted to get out of bed by himself and he would have sleep on the floor. Resident #1 stated LVN A closed the door. He stated he slept on the floor and then at about 6-7 AM, when the shift changed, morning shift nurses came to help him. Resident #1 stated he told RN C that LVN A left him on the floor after he fell. He stated he did not have injuries. Resident #1 stated he also told the DON that LVN A left him on the floor . He stated he did not understand how LVN A was still working at the facility and when she saw him, she would look at him with a smirk on her face.<BR/>In an interview on 06/28/23 at 1:32 PM, RN C stated she provided RN coverage on 06/01/23 and was called to Resident #1's room, by LVN B, because he was found on the floor . She stated LVN B was taking Resident #1's vitals and assessing him for injuries. RN C stated Resident #1 told her he had been on the floor for several hours. RN C stated Resident #1 told her LVN A knew he fell and refused to help him off the floor. She stated Resident #1 told her LVN A told him to sleep on the floor. RN C stated Resident #1 did not have injuries from the fall but was sent to the hospital because labs were high for white blood cell count. RN C stated Resident #1's allegations about LVN A's actions were considered abuse & neglect; so, she did report to the DON what Resident #1 said about LVN A leaving him on the floor. <BR/>In an interview on 06/28/23 at 2:18 PM, the DON stated she was aware that Resident #1 fell on [DATE]. She stated while RN C was assessing him, she did go into Resident #1's room. The DON stated Resident #1 was very confused and when she attempted to ask him what happened he was not providing a coherent statement. She stated Resident #1 did not tell her that he was left on the floor by LVN A. The DON stated all she remembered him saying about the incident was something about a big African woman and this shouldn't have happened. She stated she was not sure what these statements meant. The DON stated Resident #1 returned to the facility from the hospital the same day and was more oriented. She stated she did not follow up with Resident #1 about his comments of the big African woman and this shouldn't have happened. The DON stated she did not recall RN C telling her that Resident #1 alleged LVN A left him on the ground after he fell. She stated she was not saying RN C did not tell her, but that she just did not remember her saying it because it was so much going on. The DON stated this would be an allegation of abuse and neglect. She stated when there is an allegation of abuse and neglect, it was supposed to be investigated by the facility and reported to the state .<BR/>In a phone interview on 06/28/23 at 3:12 PM, LVN A stated Resident #1 did not fall on her shift. LVN A stated Resident #1 never requested PRN medications on the day he fell, and she never went into his room, after he went to bed. LVN A stated the CNAs complete rounds through the night and had not reported he fell or was on the floor. LVN A stated she was made aware of Resident #1's allegation by RN C, when she reported to work on 06/01/23 at 6:00 PM. She stated the allegations were not true. She stated the DON, nor the Administrator asked her about the allegations.<BR/>In an interview on 06/28/23 at 3:27 PM, the Administrator stated he was just made aware of Resident #1's allegations regarding LVN A. He stated these allegations would be considered abuse & neglect and should be investigated and reported to the state. The Administrator stated he was going to suspend LVN A, and the DON pending the investigation and file a report with the State. The Administrator stated he would start an in-service regarding abuse and neglect. He stated the risk to the residents would be a potential of reoccurring abuse and/or neglect.<BR/>In a phone interview on 06/29/23 at 12:21 PM, LVN B stated she was covering Resident #1's hall on 06/01/23. She stated she was an agency employee but had worked at the facility prior to returning as an agency employee, so she was familiar with Resident #1 and knew he was usually alert and oriented. LVN B stated she took Resident #1's breakfast tray to his room between 7:00 to 7:30 AM and found him on the floor near the door. LVN B stated Resident #1 was alert but was confused and was making random statements. She stated she asked Resident #1 what happened, and he kept saying he was on the floor for a long time, and no one would help him. LVN B stated she took his vitals and once she assessed him and he did not have injuries or fractures they got him off the floor. She stated while she was assessing him, RN C came to Resident #1's room. LVN B stated she left the room to get something and when she returned, she heard Resident #1 telling RN C that the overnight nurse knew he fell and left him on the floor. She stated RN C was his normal nurse and she believed he was more comfortable with her, so he told her what happened. LVN B stated RN C confirmed to her that Resident #1 stated LVN A knew he fell and left him on the floor. LVN B stated she was not sure if RN C reported the incident to the DON, but she heard the two of them talking about the incident in the hallway, so she assumed RN C told the DON. She stated when LVN A reported to work at 6:00 PM, RN C told her Resident #1's allegations asked LVN A about the situation. LVN B stated LVN A was very nonchalant about the situation and didn't say much other than denying the situation happened. She said she found it strange that LVN A did not seem shocked or asked for any additional information. LVN B stated she believed LVN A and Resident #1 had issues because 1-2 days before this incident she witnessed an incident between the two. LVN B stated she started her shift at 6 AM and Resident #1 asked her for pain medication. LVN B stated they were in the process of changing shifts and LVN A was sitting next to her at the nurse's station. LVN B stated Resident #1 said to her, in front of LVN A very loudly, that LVN A would not give him his pain pill and he was in pain all night. She stated LVN A did not deny it and just didn't respond at all. LVN B stated she knew LVN A heard him because she was sitting right next to her, and Resident #1 was loud and complaining. LVN B stated she checked the MAR and saw the medication had not provided, so she gave Resident #1 the pain medication . LVN B stated at the time she assumed there was a reason she didn't provide the medication and just chose not to interact with Resident #1 because he was upset. <BR/>A record review of the facility's policy titled Abuse Investigation and Reporting, undated, reflected All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 5 residents (Resident #2) reviewed for ADLs.<BR/>The facility failed to provide Resident #2 assistance with showers on a consistent basis.<BR/>This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status. <BR/>Findings include:<BR/>Record review of Resident #2's electronic face sheet, dated 06/28/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included unspecified dementia, unsteadiness on feet, muscle weakness, arthritis, and repeated falls. <BR/>Record review of Resident #2's Comprehensive MDS assessment, dated 04/20/23, revealed Resident #2 had a BIMS score of 12, which indicated his cognition was moderately impaired. Further review revealed section G0120. Bathing indicated code 4 (Total Dependency), which meant full staff performance every time during entire 7-day period. <BR/>Record review of Resident #2's care plan, dated 04/25/23, revealed Resident #2 required assistance from staff with ADLs. Requires assist from staff . transfers; . bathing . The intervention included Staff will assist with bathing and will encourage Resident to participate as able. <BR/>A record review of Resident #2's bathing ADLs in her electronic clinical record revealed Resident #2's revealed from 05/31/23 to 06/28/23 staff aided with a bath on 06/08/23, 06/14/23, 06/16/23, and 06/21/23. Further review of the bathing ADL chart revealed Resident #2 only refused a bath on 06/09/23. <BR/>A record review of Resident #2's electronic Progress Notes, from 05/31/23 to 06/28/23, revealed no documentation which reflected the resident refused baths. <BR/>In an interview on 06/27/23 at 12:34 PM with Resident #2 and Resident #2's Family Member (FM), the FM stated Resident #2 was supposed to receive baths 3 days per week and she was not getting them. The FM stated Resident #2 usually received 1 bath a week and that's only when CNA D worked. Resident #2 stated her last bath was either Tuesday (06/20/23) or Wednesday (06/21/23) of last week. Resident #2 stated she was supposed to receive a bath this morning, but CNA D was not at work, so she knew she was not going to get one. Resident #2 stated she received baths about once a week. She stated she had not been refusing baths and the CNAs were just not coming to give them to her. The FM stated CNA D is off today (06/27/23) and she did not know who was the CNA for Resident #2's hall. The FM stated she had been at the facility since about 9:30/10:00 AM and not one CNA had come to Resident #2's room, so she knew she was not going to get a bath today. The FM stated she was going to give Resident #2 a bath today because it had been a week since she last received one and she really needed it. The FM stated she brought this concern to the DON's attention about 1 month ago. The FM stated the DON said she would take care of it, but nothing ever changed. The FM said this DON was no longer working at the facility and she had not said anything to the new DON because she felt they did not do anything about it the first time, so she believe nothing would change this time as well. <BR/>In an interview on 06/28/23 at 12:50 PM, LVN E stated she did not receive any complaints from Resident #2 that she was not receiving baths. She stated none of the CNAs had ever told her Resident #2 was refusing baths. LVN E stated after the CNAs gave resident's baths, they were supposed to document it in their electronic clinical record. She stated if a resident refused, then the CNAs were supposed check off in their electronic chart that they refused and to notify her. LVN E stated if they confirmed they refused, then she was supposed to verify and document it in the resident's clinical record. <BR/>In an interview on 06/28/23 at 12:59 PM, CNA D stated her scheduled changed each week but on her scheduled days, she mainly worked on Resident #2's hall. She stated Resident #2 and her FM had complained to her that other CNAs were not giving her baths. CNA D stated the days she worked, she always gave Resident #2 a bath and she had never refused. CNA D stated after they gave resident's a bath, they were supposed to document it in their electronic clinical record. She stated if a resident refused, there is an area in the electronic record that says refused, which they were supposed to check off and they were supposed to notify the nurse. CNA D stated she could tell Resident #2 was not receiving baths when she didn't work because the resident would tell her and when she provided her a bath she would smell like urine, and she was visibly not clean. She stated she did not report this to the nurse or management because she did not want to get other CNAs in trouble .<BR/>In an interview on 06/28/23 at 3:27 PM, the Administrator stated he was not aware there was an issue with residents receiving baths. He stated CNAs were supposed to document if baths were received or refused in the resident's electronic clinical record. He stated he would conduct an in-service regarding this issues and he was going to add to the process in which CNAs would have to fill out a sheet if resident refused and the nurse would have to sign off and document in the resident's electronic clinical record. The Administrator stated he was not a nurse, so he did not know the medical effects of resident's not being bathed, but he did know resident's not receiving baths was a concerns of the resident's dignity not being upheld. <BR/>A record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, undated, reflected Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with eh plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure residents had a safe, clean, comfortable, and homelike environment for 5 of 5 residents (Resident #6, Resident #24, Resident #29, Resident #35, and Resident #53) reviewed for environment.<BR/>1. <BR/>The facility failed to ensure Resident #6, Resident #24, and Resident #53 had clean floors, free of dirt, dust, debris, and sticky sediment accumulation. <BR/>2. <BR/>The facility failed to ensure Resident #29's room remained free of pests, including a large cockroach. <BR/>3. <BR/>The facility failed to ensure Resident #35 had a footboard on her bed free from damage. <BR/>These failures could place residents at risk of not receiving a safe, clean, comfortable, and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings Included:<BR/>Record review of facility roster, Midnight Census Report, dated 04/17/2023 revealed:<BR/>Resident #6 resided in room [ROOM NUMBER]B in Hall D.<BR/>Resident #24 resided in room [ROOM NUMBER]A in Hall D.<BR/>Resident #29 resided in room [ROOM NUMBER]B in Hall D.<BR/>Resident #35 resided in room [ROOM NUMBER]A in Hall E.<BR/>Resident #53 resided in room [ROOM NUMBER]B in Hall D.<BR/>Review of the most recent pest control visit dated 04/11/2023 from , titled Service Report, revealed Pests . Ants . Cockroaches . Other Notes: Regular service was done today in hallway D & E .<BR/>Review of the facility's Pest Service Agreement, dated 05/25/2020 revealed a current contract <BR/>Resident #6<BR/>In observation on 04/18/2023 at 11:41am revealed Resident #6 resting in bed in room [ROOM NUMBER]. Resident's floor was noticeably sticky. A significant amount of white powdery substance was observed along the perimeter of the wall. Drywall damage was present above white powdery substance. There were dirt, dust, debris, and sticky sediment accumulated on the flooring.<BR/>In observation and interview with Resident #6 on 04/19/2023 at 11:11am revealed her resting in bed. Resident floor was noticeably sticky. A significant amount of white powdery substance was observed along the perimeter of the wall. Drywall damage was present above white powdery substance. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. Resident #6 stated that housekeeping does mop in her room, but she thought they could do a lot better. She stated she would be happier if her floors were more clean. <BR/>In observation and interview with ADON on 04/19/2023 at 11:11am he stated that he believed the white powdery substance in Resident #6's room was drywall. He stated that maintenance recently performed repairs, but he was not sure when or what was repaired specifically. He stated that the substance should not be on the floor and it was the maintenance departments responsibility to always clean up after themselves to prevent any risk to the residents. <BR/>Resident #53<BR/>In observation on 04/18/2023 at 11:52am revealed Resident #53 resting in bed in room [ROOM NUMBER]. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. Resident was non-verbal and not able to be interviewed. <BR/>In observation on 04/19/2023 at 11:21am revealed Resident #53 resting in bed. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring.<BR/>In observation on 04/20/2023 at 12:30pm revealed Resident #53 resting in bed. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. A laminate tile was displaced due to the stickiness of the floor by surveyor's shoe. <BR/>Resident #24<BR/>In observation and interview with Resident #24 on 04/19/2023 at 9:11am revealed her resting in bed in room [ROOM NUMBER]. Resident floor was noticeably sticky. There were dirt, dust, debris, and sticky sediment accumulated on the flooring. She stated that her dirty room bothers her and she would be happier if her flooring was properly cleaned. <BR/>In observation and interview with MA A on 04/19/2023 at 9:11am, he stated that Resident #24's room was sticky most times, as she spills a lot of things. He further stated that he does not know the cleaning schedule of housekeeping, but they do not clean each room daily, and stated that they could do a lot better than they were doing currently. <BR/>Resident #29<BR/>In observation on 04/18/2023 at 12:09pm an approximately 3-4'', oval, dark brown to black, six-legged insect was observed walking down hall D and entered room [ROOM NUMBER], approximately 3' from where Resident #29 was sitting in her wheelchair watching television. <BR/>In observation and interview with CNA G at 12:13pm, she was informed by surveyor that there was a cockroach in room [ROOM NUMBER]. CNA G entered Resident #29's room and stepped on the pest and resulted in the cockroaches' demise. CNA G stated that she sometimes sees cockroaches on the hall. She stated when she sees pests, she reports it to the nurse and they put in in the bug book and then they will come and spray. <BR/>In interview with Resident #29 on 04/18/2023 at 12:13pm, she stated they will occasionally see large cockroaches but it was not frequent. She stated she would rather not have any pests in her room. <BR/>Resident #35 <BR/>In observation and interview on 04/20/2023 at 9:05am revealed Resident #35 resting in bed in room [ROOM NUMBER]A. Resident #35's bed was positioned against the wall with the resident's left side of the bed positioned towards the open area of the room. Resident #35's foot board had significant amount of damage on the left side, with jagged particle board exposed. The resident stated the bed being broken bothers her and when asked if she would like it repaired, she stated yes. <BR/>In observation and interview with LVN H on 04/20/2023 at 9:30am, he stated that he was not sure how long Resident #35's bed has been broken. He stated she does get up in a wheelchair and stated it could pose a risk to the resident for a laceration or other injury. <BR/>In interview with MTSPVSR on 04/20/2023 at 2:21pm, he stated there was a work order system at the facility [Telis] and his expectations were for any staff to report maintenance or pest control issues. He stated that he was not aware of any pest sightings and denied any evidence of reports of insects this week. Additionally, he was not aware of any furniture concerns reported this week. He stated it was important for resident furniture to be in good, working condition for safety. <BR/>Record review of the facility [Telis] work order log dated from 04/17/2023 - 04/20/2023 provided by MTSPVSR on 04/20/2023 revealed no documentation of relevant concerns. <BR/>In interview with HKSPVSR on 04/20/2023 at 2:43pm, she stated there was a work order system at the facility [Telis] and her expectations were for any staff to report maintenance or pest control issues. She stated that the cause of the sticky flooring was that the natural wax on the floor had worn off and anything acidic makes the floor sticky. She stated the risk to the resident regarding not having a clean environment would be the resident would feel demeaned and have a cross-contamination risk for infection. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. He further stated there was a work order system at the facility [Telis] and his expectations were for any staff to report maintenance or pest control issues. He started he expected resident floors to be clean and free of dirt, dust, debris, and sticky sediment accumulation. He declined to answer further questions at this time. <BR/>Review of facility policy, Maintenance Service, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 1. The Maintenance Department is responsible for maintaining the . and equipment in a safe and operable manner at all times. 2 . b. Maintaining the building in good repair and free from hazards.<BR/>Review of facility policy, Homelike Environment, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 8 residents (Resident # 19) reviewed for quality of care. <BR/>The facility failed to ensure Resident #19 had his call light within his reach while he was laying in bed. <BR/>This failure could place residents at risk of not receiving immediate care if assistance was needed. <BR/>Findings Included:<BR/>Review of Resident #19's Face Sheet, dated 04/20/23, revealed he was a 76 -year-old male admitted on [DATE]. Relevant diagnoses included Cerebral Infarction (Brain Stroke), Neuromuscular Dysfunction of Bladder (bladder malfunction, and history of falling. <BR/>Review of Resident #19's MDS, dated [DATE] revealed he was not cognitively intact with a BIMS score of 0. He required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. <BR/>Record review of Resident #19's Comprehensive Care Plan, dated 02/03/2023 revealed the resident required a one person assist for transfers, bathing/showering, toilet use, dressing, eating, and personal hygiene. <BR/> Observation and interview on 04/18/23 at 12:01 PM revealed Resident #19 laying in his bed and his call light button was not observed near him. He was asked where his call light button was located, and he advised that he did not know. The call light button was observed on the floor, wrapped around an IV pole in the floor.<BR/>Observation and interview with the Corporate Nurse on 4/18/23 at 12:21 PM, revealed Resident #19 laying in his bed and his call light being wrapped around his IV pole. The Corporate Nurse took the call light button and placed it on the bed alongside the resident. She did not want to indicate any risk to the resident of the call light not being in reach, and she stated I know what you are wanting to hear but I am not going to say it.<BR/>Interview on 04/20/23 at 4:00 PM with the ADON revealed he was made aware of Resident #19's call light button not being in reach of the resident. He advised that Resident #19 did have a history of fall and was encouraged to use his call light button. He advised that he thinks one of the Aides had provided assistance to the resident and had forgotten to place the call light button back within reach of the resident. He stated leadership was required to conduct Angel rounds, which involves leadership being assigned rooms to check to ensure the resident needs have been met. The ADON stated that he completes his rounds and one of the things he checks for were call light buttons being in reach. He did not want to indicate the risk to the resident with the call light not being in reach. <BR/>Interview on 04/20/23 at 06:00 PM with the Interim Administrator revealed she was made aware of Resident #19 not having his call light button within reach. She stated that it was the right of all residents to receive quality care and the resident should always have his call light within reach just in case he needs assistance or if he was having an emergency. She advised staff should check for things like call light buttons being within reach of the residents whenever they complete resident observations, which occurs at least every two hours. She advised the nursing leadership was responsible for ensuring overseeing this effort. <BR/>Review of the facility's policy and procedure on Call Light dated June 14, 2006, revealed, Answer all call lights promptly whether you are assigned to the patient or not. When providing care to patients, be sure to position the call light conveniently for patient's use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #35) of two residents observed for infection control. <BR/>1. <BR/>The facility failed to ensure LVN H performed hand hygiene during a wound care treatment on 04/20/23. <BR/>This failure could place residents at risk of cross-contamination and infections.<BR/>Findings Included:<BR/>Review of Resident #35's Face Sheet, dated 04/20/23, revealed she was a [AGE] year-old female re-admitted on [DATE] from the hospital. Relevant diagnoses included mental illness, leg fracture, hip replacement, DTI (deep tissue injury) of the right heel, Alzheimer's (progressive disease that destroys memory and mental functions) and dementia (loss of memory, language, or problem-solving skills.). <BR/>Review of Resident #35's Quarterly MDS, dated [DATE] revealed she had both short and long-term memory problems, and that she was severely impaired regarding cognitive skills for daily decision making. Resident #35 required extensive assistance of one staff with bed mobility, toileting, and personal hygiene. Her MDS further stated she had unhealed pressure sores. Resident #35 had one stage III pressure sore upon assessment. <BR/>Record review of Resident #35's Comprehensive Care Plan dated 03/06/23 revealed, Focus, I have (Stage 3) pressure ulcer Right heel r/t decreased mobility with interventions that included to administer treatments as ordered and monitor for effectiveness. <BR/>Review of Resident #35's physician orders revealed:<BR/>Cleanse right heel with NS and 4x4 gauze, then apply anasept and collagen powder. Then cover with gauze island dressing every day . one time a day for DTI Right Heel with a start date of 01/07/2023.<BR/>During observation of LVN H performing wound care treatment on Resident #35 on 04/20/23 at 9:12am revealed the resident resting in bed. LVN H performed hand hygiene upon entering resident room and prior to resident care. LVN H then donned gloves, obtained Resident #35's right foot, and then cleansed her right heel with normal saline and gauze. LVN H then removed his gloves and applied new gloves. LVN H did not perform hand hygiene between glove changes and going from a dirty to clean intervention/care. LVN H then applied anasept and collagen powder, then covered up the heel with an island dressing. LVN H then removed his gloves and lowered resident's bed, further contaminating resident's bed remote. LVN H then performed hand hygiene after assisting resident in her bed, further contaminating her bed linens and pillow. <BR/>During interview with LVN H on 04/20/2023 at 9:30am, he stated that he failed to perform hand hygiene between glove changes because he was nervous. He stated there was an infection control risk to the resident if proper hand hygiene was not performed during resident care, especially wound care treatments. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. He stated that his expectations were for all staff to comply with proper hand hygiene practices, as it was the best way to prevent infection. He stated that LVN H was expected to perform hand hygiene moving from a dirty to a clean procedure, and in between glove changes. <BR/>Review of facility policy, Handwashing/Hand Hygiene, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. Use an alcohol-based hand rub; or alternatively, and water for the following situations: .g. before handling clean . dressings, gauze pads, etc. h. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 1 of 5 residents (Resident #35) observed for environment.<BR/>1. <BR/>The facility failed to ensure Resident #29's room remained free of pests during observation on 04/18/2023. <BR/>This failure could place residents at risk of not receiving a safe, clean, comfortable and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings Included:<BR/>Record review of facility roster, Census Report, dated 04/17/2023 revealed:<BR/>Resident #29 resided in room [ROOM NUMBER]B in Hall D.<BR/>Review of the most recent pest control visit 04/11/2023 titled Service Report, revealed Pests . Ants . Cockroaches . Other Notes: Regular service was done today in hallway D & E .<BR/>Review of facility Pest Service Agreement, dated 05/25/2020 revealed a current contract. <BR/>In observation on 04/18/2023 at 12:09pm an approximately 3-4'', oval, dark brown to black, six legged insect was observed walking down hall D and entered room [ROOM NUMBER], approximately 3' from where Resident #29 was sitting in her wheelchair watching television. <BR/>In observation and interview with CNA G at 12:13pm, she was informed by surveyor that there was a large insect in room [ROOM NUMBER]. CNA G entered Resident #29's room and stepped on the pest, resulting in the cockroaches' demise. CNA G stated that she sometimes sees cockroaches on the hall. She stated when she sees pests, she reports it to the nurse and they put in in the bug book and then they will come and spray. <BR/>In interview with Resident #29 on 04/18/2023 at 12:13pm she stated she will occasionally see large cockroaches in her room. She stated she would rather not have any pests in her room. <BR/>In interview with MTSPVSR on 04/20/2023 at 2:21pm, he stated there was a work order system at the facility [Telis] and his expectations were for any staff to report pest control sightings. He stated that he was not aware of any pest sightings and denied any evidence of reports of insects this week. He stated it was important for the facility to maintain a pest-free environment for safety and resident right purposes. <BR/>Record review of the facility [Telis] work order log dated from 04/17/2023 - 04/20/2023 provided by MTSPVSR on 04/20/2023 revealed no documentation of pest sightings at the facility. <BR/>In interview with HKSPVSR on 04/20/2023 at 2:43pm, she stated there was a work order system at the facility [Telis] and her expectations were for any staff to report pest control issues. She stated the risk to the resident regarding pests was not having a clean environment would be demeaning for the resident in addition to a cross-contamination risk for infection. <BR/>In interview with the ADON on 04/20/2023 at 3:15pm, he stated that at this time there was not a DON nor a permanent Administrator at the facility. He further stated there was a work order system at the facility [Telis] and his expectations were for any staff to report any pest control sightings. He declined to answer further questions at this time. <BR/>Review of facility policy, Pest Control, undated, provided by the facility on 04/20/2023 revealed Policy Statement . Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation . 1. This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents.<BR/>Review of facility policy, Homelike Environment, undated, provided by the facility on 04/20/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure food in the refrigerator and freezer were dated and labeled.<BR/>The facility failed to ensure expired foods were discarded upon expiration date.<BR/>The facility failed to ensure food stored in the refrigerator and freezer were properly sealed.<BR/>The facility failed to ensure facility kitchen staff wore the proper hair and face restraint while preparing food in the facility only kitchen.<BR/>The facility failed to clean one of the dual ovens in the facility's only kitchen.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings include:<BR/>Observation on 04/18/23 at 9:49 AM in the Facility's only kitchen, revealed Corporate Culinary Director being observed assisting staff in the kitchen getting trays out to the residents. He was observed wearing a baseball hat to cover his head; however, he had approximately 1/2 inches in length of hair exposed along the back hairline of his head. He was also observed to have approximately a 1/4 inches in length of facial hair uncovered.<BR/>Observations on 04/18/2023 at 9:50 AM in the facility's only kitchen in the refrigerator and freezer revealed the following: <BR/>One 10-pound (lb.) box of unsealed pork sausage patties <BR/>One 10.25 lb. unsealed box of Fully Cooked Turkey Sausage Links<BR/>Three undated 2.5 lb. bags of Oven Roasted Sliced Roast Beef Eye Round<BR/>One opened and unsealed 2.5 lb. bag of Oven Roasted Sliced Roast Beef Eye Round<BR/>One ten lb. tube of Provolone Cheese with Smoke Flavor with an expiration date of 10/17/22<BR/>One opened but sealed 5 lb. bag of undated shredded parmesan cheese with no visible expiration date.<BR/> One 10.50 lb. block of Sharp Cheddar Cheese with an expiration date of 10/12/22<BR/>One unsealed bag of frozen beef patties (approximately 20 patties). <BR/>One undated 4 lb. bag of frozen Mediterranean Vegetable Blend.<BR/>One unsealed bag of frozen Salisbury steaks (approximately 6 patties)<BR/>One unsealed 5 lb. bag frozen tater tots that were freezer burned<BR/>One undated 5lb. bag of frozen French fries<BR/>One open and unsealed 5lb. bag of frozen potatoes that were freezer burned<BR/>One unsealed and undated 5lb. bag of French fries<BR/>One opened and undated bag of freezer burned frozen biscuits that were falling out of the bag and some of the biscuits were observed to have fallen on the freezer floor. <BR/>Two bags of undated refrigerated pancakes (approximately 18 in each bag)<BR/>Two half-gallon containers of Hill Country Heavy Whipping Cream with an expiration date of 04/13/2023.<BR/>Observations on 04/18/2023 at 10:00 AM in the facility's only kitchen in the dry food storage area revealed the following:<BR/>One undated 6lb. can of Great Northern Beans<BR/>One undated Gallon of Honey Mustard Dressing<BR/>Three one-gallon jars of Nacho Slices Jalapeno peppers dated 08/19 and no other expiration dates were visible on any of the jars.<BR/>One gallon container of mayonnaise dated 12/13/22.<BR/>One updated 12-ounce container of House Recipe Sugar free Pancake and Waffle Syrup with no visible expiration date.<BR/>One 12-ounce container of Smucker's Sugar Free Breakfast Syrup with an expiration date of 02/01/2023. <BR/>One 2.5 lb. container of Soda Fountain Malted Milk Powder dated 08/16 and no other expiration date of visible.<BR/>Observation on 04/19/23 at 11:30 AM revealed a dual oven in the facility's only kitchen. The left oven was heavily soiled with dirt, grease, and spills. <BR/>Interview with the Dietary Manager on 04/20/23 at 01:54 PM revealed, she had been the DM for two weeks at the facility. She was advised of the findings of the kitchen and shown pictures of the foods that were left exposed, food that had expired dates, and foods not labeled and dated. She advised that no particular person was responsible for ensuring items stored were properly stored. She stated that she had already went into the freezer, refrigerator, and dry food area and corrected some of the concerns. She advised that she had spoken with the Corporate Culinary Director, and he had placed on the appropriate head and face coverings. She stated she was not really paying attention to his hair not being fully covered nor his failure to wear a face covering. She was advised of the condition of the oven, and she stated she was not sure when the last time it was cleaned, and she had been at the facility for two weeks and it had not been cleaned. She stated she had since assigned this task to her dishwasher to clean at least weekly. She stated the risk to the residents of the facility not following the proper food storage, head and face coverings, and cleaning guidelines could in residents getting sick from foodborne illness.<BR/>Interview with the Interim Administrator on 04/20/23 at 4:00 PM revealed she was made aware of the findings in the kitchen by the Dietary manager. She stated her expectation was for the kitchen staff to ensure that they were following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. <BR/>Record Review of facility's policy and procedures for Food Receiving and Storage (Undated), revealed Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>Record Review of facility's policy and procedures for Hair Restraints, dated 02/21/2017, revealed Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.