TRUMAN W SMITH CHILDREN'S CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #63) reviewed for resident rights. The facility failed to ensure RT C acknowledged Resident #63 while providing care on 11/16/25. This failure could place residents at an increased risk of anxiety and a diminished quality of life.The findings included: Record review of the order summary report, dated 11/18/25, reflected Resident #63 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of obstructive hydrocephalus (buildup of fluid in cavities called ventricles deep within the brain, which increases the size of the ventricles and puts pressure on the brain), neuromuscular scoliosis (sideways curvature of the spine), chronic respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body), anoxic brain injury (damage to the brain due to a loss of oxygen supply), spastic quadriplegic cerebral palsy (brain condition caused by damage or abnormal development of the brain before, during, or shortly after birth, which causes tight stiff muscles to all four limbs [arms and legs]), and obstructive sleep apnea (characterized by repeated interruptions in breathing during sleep due to a blockage in the airway). Record review of the annual MDS assessment, dated 10/20/25, reflected Resident #63 had no speech, was rarely/never understood, and was rarely/never to understand others. Resident #63 had poor long and short-term memory, no recall ability and had severely impaired decision making skills. The MDS reflected Resident #63 had no behavior or refusal of care and he liked to participate in his favorite activities. Resident #63 was totally dependent on staff for his ADLs. Record review of the comprehensive care plan, initiated on 11/13/23, reflected Resident #63 required total assist from the staff for meeting emotional, intellectual, physical, and social needs. The interventions included: all staff converse with resident while providing care. Record review of the comprehensive care plan, revised on 12/11/24, reflected Resident #63 had a tracheostomy. The interventions included: provide means of communication and procedural information, reassure that help is available immediately, provide paper and pencil if needed, work with resident to develop a communication system that will work in an emergency, and reassure resident to decrease anxiety. During an observation on 11/16/25 beginning at 10:46 AM, Resident #63's oxygen and heart rate monitor started beeping while a respiratory therapist was in the room with his roommate. The respiratory therapist yelled from the doorway for RT C's assistance. RT C entered the doorway and was looking at Resident #63's machine while she was putting on her isolation gown and gloves. RT C immediately walked to Resident #63's bed, swiftly lifted him up, shoved a pillow under his back, then laid him back down. RT C then proceeded to provide tracheal suctioning. RT C completed the tracheal suctioning, then rolled the suctioning tubing, placed it under Resident #63's pillow. Resident #63's oxygen and heart rate monitor returned to normal. RT C removed her PPE, left the room, then returned with a new pulse oximeter that attached to Resident #63 and replaced it. RT C did not speak or explain the care she was providing to Resident #63 during the observation. During an interview on 11/18/25 beginning at 9:48 AM, RT C interrupted an interview with the Respiratory Director. RT C stated generally upon going into a patient's room, the staff should knock, introduce themselves, and then explain the care that was going to be provided. RT C stated in an emergency situation, she did not always think about explaining what she was doing or talking to the resident. RT C explained Resident #63 was desaturating [his oxygen level was decreasing] and his pulse rate was elevated. RT C stated he was unable to cough so she had to perform the tracheal suctioning. RT C stated immediate action was needed to intervene and she said she just did not think about talking to him while providing care. During an interview on 11/18/25 at 10:23 AM, the DON stated facility staff should have knocked, introduced themselves, and talked to the residents while providing care. The DON stated talking to the residents while providing care was hard for the staff to remember because a lot of the kids were not able to respond back. The DON stated in-service education was provided regularly to the staff, specifically on dignity and making sure the staff was talking to the residents while providing care. She said it was important to ensure the staff were talking to the residents while providing care because it helped put them at ease. During an interview on 11/18/25 at 1:32 PM, the Administrator stated she expected staff to always acknowledge the residents while providing care. The Administrator stated she had not identified any issues with staff failing to acknowledge the residents' while providing care and did not have a system for monitoring. The Administrator stated it was important to ensure staff were acknowledging and talking to the residents while providing care to maintain dignity. During an interview on 11/18/25 at 2:18 PM, the Administrator stated she had gathered more evidence regarding Resident #63. The Administrator stated both Resident #63 and his roommate were crashing at the same time. The Administrator stated Resident #63 was relatively stable as he had an established airway, so RT C was trying to provide care quickly to help the other respiratory therapist with Resident #63's roommate. The Administrator stated RT C still should have communicated with Resident #63 while providing care, but it was more understandable why RT C did not provide Resident #63 with communication while she was providing care. Record review of the Resident Rights policy, revised 04/2017, reflected .Facility policies and procedures must be in compliance with these rights. Residents shall: . be treated as individuals in a manner that supports their dignity. The policy did not address communicating with the residents during care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 11 residents (Resident #18) reviewed for enteral nutrition. The facility failed to ensure Resident #18's head of the bed was elevated while receiving a tube feeding (delivers liquid nutrition through a flexible tube that goes directly into your stomach or small intestine) on 11/16/25. This failure could place residents with gastrostomy tube at risk for complications from feeding tube administration such as aspiration and pneumonia. The findings included: Record review of order summary report, dated 11/17/25, reflected Resident #18 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and gastrostomy status (surgical procedure that creates an artificial opening through the stomach wall and abdominal wall, allowing for the insertion of a gastrostomy tube that provides a conduit between the stomach and the outside of the body). The order summary report further reflected Resident #18 had an order, which started on 06/26/23, to elevate the head of the bed to 30 degrees every shift. Record review of the quarterly MDS assessment, dated 10/08/25, reflected Resident #18 had no speech and was rarely/never understood by others. Resident #18 had poor short and long-term memory, no recall ability, and severely impaired decision-making skills. He had no behaviors or refusal of care. The MDS reflected Resident #18 had a feeding tube and received 51 % or more of total calories through the feeding tube. Record review of the comprehensive care plan, revised 10/13/23, reflected Resident #18 required tube feeding. The interventions included: Resident #18 needed the head of the bed elevated 45 degrees during and thirty minutes after tube feeding. Record review of Resident #18's MAR, dated November 2025, reflected the nurses were signing off and checking Resident #18's head of the bed was elevated to 30 degrees every shift, including 11/16/25 for day and evening shift. During an observation on 11/16/25 at 10:27 AM, Resident #18 was lying flat on his mattress that was positioned on the floor. There were no wedges to lift the head of the bed observed under the mattress. He had a tube feeding that was going at 100 milliliters per hour from kangaroo pump. During an interview on 11/18/25 at 9:28 AM, RN D stated she had worked at the facility for 6 years. She stated residents who received feedings from a feeding tube should have the head of the bed, elevated at least 35 degrees. RN D stated elevating the head of the bed at least 35 degrees was the standard general rule unless the residents had issues where the head of the bed was unable to be elevated. RN D stated none of the residents on her side had issues that would prevent the head of the bed from being elevated. She stated if residents' mattresses were on the ground, the staff used wedge pillows under the bed to keep the head of the bed elevated. RN D stated Resident #18 would have kept the head of the elevated and did not move around much. She stated she was unsure why Resident #18 did not have the wedges under his mattress. RN D stated it was important to ensure the head of the bed was elevated while the residents received tube feedings to prevent aspiration. During an interview on 11/18/25 at 10:23 AM, the DON stated the head of the bed should have been elevated while residents received tube feedings. She stated the nurses were responsible for ensuring the head of the bed was elevated. The DON stated residents with mattresses on the ground should have wedges under the mattress to ensure the head of the bed was elevated. She stated she was unaware Resident #18 had no wedges under his mattress. The DON said she expected the staff to ensure wedges were utilized. The DON stated she did not know what the facility policy was on positioning residents during feeding, but she looked it up. She said the policy did not specifically address how residents with a feeding tube should have been positioned. The DON stated that residents who received tube feedings should not have been laid flat because it placed them at risk for aspiration. During an interview on 11/18/25 at 1:32 PM, the Administrator stated she expected staff to ensure the head of the bed was elevated while residents received tube feedings. The Administrator stated that any clinical staff were responsible for monitoring to ensure the head of the bed was elevated. The Administrator stated it was important to ensure the head of the bed remained elevated while residents received tube feedings to prevent aspiration. Record review of the Enteral Nutrition policy, reviewed 06/25/25, reflected Adequate nutritional support through enteral nutrition is provided to residents as ordered. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice. the provider will consider the need for supplemental orders, included: .head of bed elevation.Risk of aspiration may be affected by: . improper positioning of the resident during feeding. Record review of the Guidelines for Preventing Health-Care-Associated Pneumonia, 2003, accessed from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm reflected 2. Prevention of aspiration associated with enteral feeding a. In the absence of medical contraindication(s), elevate at an angle of 30 - 45 degrees of the head of the bed of a patient at high risk for aspiration (e.g. a person receiving mechanically assisted ventilation and/or who has an enteral tube in place) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 23 residents reviewed for environment. (Resident #48)<BR/>1. The facility failed to remove a green sputum filled suction canister over &frac34; full in the room of Resident #48 a timely manner. <BR/>This failure placed resident at risk of exposure to growing bacteria from another resident, living in an uncomfortable environment and a decrease in quality of life and self-worth.<BR/>Findings included:<BR/>1. Record review of the face sheet 01/14/25 indicated Resident #48 was a [AGE] years old male and was admitted on [DATE] with diagnoses including disease of upper respiratory tract ( a common viral infection that affects the nose, throat and airways), major depressive disorder (a mental illness that causes a persistent low mood and loss of interest in activities) and other specified disorders of white blood cells (a category of blood conditions that affect white blood cell function). <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #48 was usually understood and usually understood others. The MDS indicated a BIMS score of 14 indicating Resident #48's cognition was intact. The MDS indicated Resident #48 was dependent on staff for ADL's.<BR/>During an observation on 01/12/25 at 10:04 A.M., near bed A on entrance of room revealed a suction canister filled with a green sputum substance dated 1/3/25. Further observations revealed on 01/13/25 at 8:14 A.M., near bed A at the entrance of the room was a suction canister filled with a green sputum substance dated 1/3/25. On 01/13/25 at 10:24 A.M., near bed A at the entrance of the room was a suction canister filled with a green sputum substance dated 1/3/25. On 01/14/25 at 8:43 A.M., near bed A at the entrance of the room was a suction canister filled with a green sputum substance dated 1/3/25.<BR/>During observation and interview on 01/12/25 at 12:06 P.M., revealed Resident #48 returned to the facility via ambulance on droplet precautions due mycoplasma pneumonia (bacteria cause respiratory tract infections) stated by LVN I. <BR/>During an interview on 01/12/25 at 2:03 P.M., Resident #48 said he did not notice the sputum in suction container at the entrance of the room.<BR/>During an interview on 01/14/25 at 9:00 A.M., LVN I said respiratory staff was responsible for removing and replacing the dirty suction canisters. She said the canister belonged to a discharged Resident #69 that went to the hospital. She said the suction canister in Resident #48's room looked nasty. She said she thought the canister should have been removed when the previous resident went to the hospital. She said the resident had been gone for 6 days and it looked nasty. LVN I clarified the previous resident was admitted to the hospital on [DATE].<BR/>During an interview on 01/14/25 at 9:05 A.M., LVN H said respiratory staff was responsible for removing and replacing the suction canisters by putting them in a biohazard bag and placing them in the biohazard room and as needed, but since it had been several days since the Resident #69 was admitted to the hospital the suction canister should have been removed. She said she was not sure on the number of days the canister was to be removed after a resident had left. She said but if a resident was in the room, when the canister got up to 1100ml they were supposed to remove the canister. She said some of the negative effects of the canister in the room was it was nasty to look at and it could have a potential to grow mold.<BR/>During an interview on 01/14/25 at 9:46 A.M., RN J said respiratory staff was responsible for ensuring that the suction canisters were changed when they were dirty. She said she felt like if a resident was sent to the hospital and admitted the canister should have been removed. She said the suction canister could start to stink and grow bacteria since the resident had been gone for 6 days. She said the suction canister with green sputum was not nice to look at.<BR/>During an interview on 01/14/25 at 9:55 A.M., RT K said respiratory staff were responsible for making sure suction canisters were changed out. He said normally they changed the suction canisters out when they were &frac34;'s full, 1200ml or at least once a month. He said the suction canister could grow mold in it. He said it was nasty to look at and it would not have been a bad idea to have removed the canister. He said he would not like to look at the green sputum filled canister in his home if it was not in use.<BR/>During an interview on 1/14/25 at 12:48 P.M., RN N said respiratory staff were responsible for changing out the suction canisters. She said she thought the canister should have been changed and removed. She said she felt like when the resident came back to the facility the canister would have been changed. She said there was bacteria in secretions, and they were growing and sitting in the suction canister. She said she would not want that green sputum filled canister sitting in her house. <BR/>During an interview on 1/14/25 at 1:15 P.M., the DON said respiratory staff were responsible for making sure the suction canisters were changed. She said she felt like if a resident had been gone for 6 days and had a suction canister was filled with green substance, it should have been removed. She said she would not want to look at that in her home if it was not in use.<BR/>During an interview on 1/14/25 at 3:37 P.M., the ADM said she could definitely see the suction canister with a green substance of a resident had been gone for 6 days a homelike environment issue. She said respiratory staff were responsible in changing the suction canisters and the suction canister should have been removed immediately after the resident left the facility. She said the canister was filled to the point that it should have been deposed of. She said she would not want to look at that in her home and there was a stigma attached to [NAME] and sputum, no one wanted to look at that. She said if Resident #48 had visitors they probably would not want to look at the dirty suction canister upon entrance of the resident's room.<BR/>Record review of a facility policy revision date of February 2021 and titled, Homelike Environment Indicated that, Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible . <BR/>Record review of a facility policy dated of 12/07/23, Policy and Procedure Manual, Titled, Change-Out Supplies, Indicated that, Suction canisters will be changed out every month or when &frac34; full. New canisters will be labeled with the date of change out. Used canisters will be placed in a red biohazard bag disposed of properly in the biohazard room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinent care infection control practices (Resident #79), and 3 of 3 residents observed for medication administration control practices. (Resident #'s 27, 91, 71).<BR/>1.CNA A did not change her gloves or sanitize her hands after performing incontinent care on the front perineal area for Resident #79 and touched clean areas. <BR/>2. The facility failed to ensure RN G performed hand hygiene before and after administering medications to 3 different residents. <BR/>These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.<BR/>Findings included:<BR/>1.Record review of the undated face sheet indicated Resident #79 was a [AGE] year-old female that admitted [DATE]. <BR/>Record review of the physician's orders dated 1/14/25 indicated Resident #79 had diagnoses that included: Seizures (uncontrolled jerking, blank stares, loss of consciousness caused by abnormal electrical activity in the brain), failure to thrive (not growing as expected), Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development before birth), and gastrostomy (tube inserted into the abdomen and stomach to provide a route for feeding).<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #79 had no speech, rarely or never understood others, and was rarely or never understood by others. She had short- and long-term memory problems. The MDS indicated Resident #79 was dependent for toileting hygiene. <BR/>Record review of the undated care plan indicated Resident #79 was totally dependent on one staff for incontinent care due to Cerebral Palsy. The care plan indicated she had impaired cognitive function and required tube feeding. <BR/>During an observation on 1/14/25 at 9:06 AM, revealed CNA A and CNA B provided incontinent care to Resident #79. They sanitized their hands and donned (put on) PPE for EBP. CNA A cleaned Resident #79's front perineal area and did not change her gloves or sanitize her hands before rolling the resident to her side and touching Resident #79's shoulder, bed pad, and bed. She then cleaned the resident's back side before changing her gloves and sanitizing her hands. <BR/>During an interview on 1/14/25 09:17 AM, CNA A said she was nervous and forgot to change her gloves after cleaning Resident #79's front before cleaning her backside. She said she did not realize she touched the resident's shoulder, bed, and bed pad with her dirty gloves. She said that could cause cross-contamination and spread infection. She said she was taught to always change her gloves and wash her hands after a dirty procedure and she should have changed them.<BR/>During an interview on 1/14/25 at 9:18 AM, CNA B said she did not realize CNA A had not changed her gloves after cleaning Resident #79's front area, before going to her backside. She said they were taught to change their gloves and clean their hands when going from a dirty procedure to a clean area. She said CNA A should have changed her gloves. <BR/>During an interview on 1/14/25 at 9:49 AM, LVN F said she was the Staff Coordinator/Trainer and she signed off that CNA A and CNA B had met the requirements for Pericare-Incontinent Care. She said they were taught to change gloves when going from dirty to clean. She said after CNA A cleaned Resident #79's front area, she should have changed her gloves and cleaned her hands before she cleaned her back side and before touching anything clean. She said not doing that was a risk of infection to staff and the residents, that could make staff and resident's sick. She said she would be reteaching both CNAs. <BR/>During an interview on 1/14/25 10:32 AM, CNA C said during incontinent care, he always changed his gloves and cleaned his hands when going from dirty to clean. He said after cleaning a resident's front part staff would need to clean their hands and change their gloves because their gloves would be dirty. He said not changing gloves from a dirty procedure to a clean one could cause infections to staff and residents. <BR/>During an interview on 1/14/25 at 1:28 PM, LVN D said staff should always change their gloves and clean their hands when going from dirty to clean. She said during incontinent care, after cleaning the front of a resident, staff should change their gloves and clean their hands before touching anything clean including the resident. She said if they did not change their gloves, it was a cross-contamination issue that could cause infection to residents and staff. <BR/>During an interview on 1/14/25 at 1:31 PM, ADON E said staff must always change their gloves and clean their hands when they go from dirty to clean. She said during incontinent care staff should change their gloves and clean their hands after cleaning the front perineal area and before going to the back because their gloves would be dirty. She said if staff touched clean areas with dirty gloves that was cross -contamination which could cause infection to residents and staff. <BR/>During an interview 01/14/25 2:19 PM, the DON said staff should always change their gloves and sanitize their hands when going from dirty to clean. She said when staff were performing incontinent care they should change their gloves and clean their hands after cleaning the front perineal area and before touching anything clean, or going to the back area. She said if they did not change their gloves or clean their hands, they were risking cross-contamination and infections to residents and staff. <BR/>During an interview on 1/14/25 at 2:48 PM, the ADM said staff should change their gloves anytime they were moving from dirty to clean. She said during incontinent care staff should change their gloves after cleaning the front perineal area and before touching anything clean. She said touching anything clean with dirty gloves was cross-contamination and had the potential to cause infection to residents and staff. <BR/>Record review of a Pericare-Incontinent Care competency dated 10/2/24 indicated CNA A had met the requirements. The competency was signed by evaluator, LVN F.<BR/>Record review of a Pericare-Incontinent Care competency dated 10/2/24 indicated CNA B had met the requirements. The competency was signed by evaluator, LVN F.<BR/>Record review of a Perineal Care Policy with a revised date of 4/16/24indicated: <BR/>Perineal Care<BR/>Purpose<BR/>The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. <BR/>2. Record review of Resident #27's face sheet, dated 01/14/25, indicated she was a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included dependence on respiratory (ventilator) status (breathing machine), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), Chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs cannot exchange oxygen and carbon dioxide properly), personal history of pneumonia (a medical record that indicates a person has had pneumonia in the past) and gastrostomy status (the presence of a surgical opening in the abdomen that allows for nutritional support or gastric decompression). <BR/>Record review of Resident #27's quarterly MDS assessment, dated 12/26/24, indicated she did not perform a BIMS assessment (a 15-point cognitive screening measure that evaluates memory and orientation and includes free and recall items), because she was rarely/never understood and rarely/never understood others.<BR/>Record review of Resident #27's care plan, dated 01/13/25, indicated eating and nutrition the resident needs total assistance with tube feeding and water flushes, see MD orders for current feeding orders. Check for tube placement and gastric contents/residual volume per facility protocol and record. The resident is totally dependent on one staff for nutrition via G-Tube. The resident is dependent with tube feeding and water flushes, see MD orders for current feeding orders. Interventions: review infection control techniques with resident such as frequent handwashing and use of hand sanitizer. Remind the resident and caregivers to refrain from physical contact. For example, practice social distances with no handshaking or hugging and remaining six feet apart when possible.<BR/>3. Record review of Resident #71's face sheet, dated 01/14/25, indicated she was a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pseudomonas (is a [NAME] of bacteria commonly found in wet environments like soil and water), acute respiratory distress (condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen) and cystic fibrosis (an inherited life-threatening disorder that damages the lungs and digestive system).<BR/>Record review of Resident #71's quarterly MDS assessment, dated 10/17/24, indicated she did not perform a BIMS assessment, because she was rarely/never understood and rarely/never understood others.<BR/>Record review of Resident #71's care plan, dated 04/17/24, indicated provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection.<BR/>4. Record review of Resident #91's face sheet, dated 01/14/25, indicated he was a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs cannot exchange oxygen and carbon dioxide properly), pseudomonas (is a [NAME] of bacteria commonly found in wet environments like soil and water) and encounter for attention to tracheostomy (a medical appointment specifically focused on managing and caring for a patient's tracheostomy).<BR/>Record review of Resident #91's quarterly MDS assessment, dated 12/25/24, indicated he did not perform a BIMS assessment, because he was rarely/never understood and rarely/never understood others.<BR/>Record review of Resident #91's care plan, dated 04/17/24, indicated his level of staff assistance during care during transfer assistance and feeding assistance. Interventions enhanced barrier precautions (EBP). Follow facility fall protocol. Seizure precautions: Do not leave residential one during a seizure, protect from injury, if resident is out of bed, help to the floor to prevent injury, remove or loosen tight clothing, do not attempt to restrain resident during a seizure as this could make the convulsions more.<BR/>During an observation on 01/13/25 at 7:29 A.M., revealed RN G did not wash or sanitize her hands before preparing medication for Resident #71. RN G did not wash or sanitizer her hands prior to administering Resident #71's meds and administered Resident #71's G-Tube feeding and did not wash or sanitizer hers hands afterwards. <BR/>During an observation on 01/13/25 at 7:49 A.M. revealed RN G did not wash or sanitize her hands before preparing medication for Resident #27. RN G did not wash or sanitizer her hands prior to administering Resident #27's meds and did not wash or sanitizer hers hands afterwards. <BR/>During an observation on 01/13/25 at 8:04 A.M. revealed RN G did not wash or sanitize her hands before preparing medication for Resident #91. RN G did not wash or sanitizer her hands prior to administering Resident #91's eyedrops.<BR/>During an interview on 01/13/25 at 8:06 A.M., RN G said it was normally a habit for her to wash or sanitize her hands during med pass and between residents. She said she was nervous, so she forgot to sanitize her hands. She said staff should sanitize their hands between residents unless their hands were soiled, then they should wash their hands with soap and water. She said she should have sanitized her hands before giving meds and after she gave the meds to reduce the spread of infection rate.<BR/>During an interview on 01/13/25 at 10:43 A.M., LVN M said before a nurse started giving a medication, they should wash their hands. She said the nurse should wash their hands before and after administering meds. She said nurses' hands played a part to the chain of infection. She said not washing her hands could had made her and the residents more susceptible to infections.<BR/>During an interview on 01/14/25 at 9:00 A.M., LVN I said nurses should be washing their hands before and after a med pass to prevent cross contamination.<BR/>During an interview on 01/14/25 at 9:46 A.M., RN J said when a nurse administered medications, they should wash their hands before and after giving the medications. She said hand hygiene between residents should be performed. She said hand hygiene was the number one infection control prevention.<BR/>During an interview on 1/14/25 at 12:48 P.M., RN N said when a nurse administered meds they should wash their hands before a med pass, after the mad pass and before going to another resident. She said it was infection control and they could carry infections to another resident with their hands. She said nurses should always start fresh by washing their hands.<BR/>During an interview on 1/14/25 at 1:15 P.M., the DON said during med pass she expected the nurses to wash their hands. She said handwashing was for infection control measures. She said the nurses should wash their hands during med pass and between each resident. She said a negative effect of improper hand hygiene was the spread of infection.<BR/>During an interview on 1/14/25 at 3:17 P.M., the ADM said she excepted the nurses to wash their hands during med pass and between residents. She said a negative effect of improper hand hygiene was the risk of infection.<BR/>Record review of RN G Nurses: GT Med/Feeding administration check-off sheet dated 12/2/24 indicated RN G had met the requirements. The competency was signed by evaluator, RN N.<BR/>Record review of the facility's Handwashing/ Hand Hygiene Residents policy, last revised 1/25/23, indicated: this facility considers hand hygiene the primary means to prevent the spread of infections . <BR/>2. Residents may be trained and encouraged on the importance of hand hygiene in preventing the transmission of infections . 4. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, wipes etc.) shall be readily accessible and convenient for resident use to encourage compliance with hand hygiene policies .<BR/>Record review of the facility's Infection Prevention and Control Program policy. Last revised 01/01/24, indicated: an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable disease and infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 4 of 23 residents reviewed for range of motion. (Resident #6, Resident #21, Resident #67, and Resident #68) <BR/>The facility failed to provide restorative therapy for contractures or contracture prevention for Resident #6, Resident #21, Resident #67, and Resident #68.<BR/>This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 12/06/23 revealed Resident #6 was a [AGE] year-old male that admitted to the facility on [DATE]. Resident #6 had diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), cerebral vascular accident (stroke happens when there is a loss of blood flow to part of the brain), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease).<BR/>Record review of a MDS dated [DATE] revealed Resident #6 was rarely/never understood and had a BIMS of 99, which indicated severe cognitive impairment. Resident #6 required continuous oxygen administration, required tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care, and required mechanical ventilation (a type of therapy that helps you breathe or breathes for you when you can't breathe on your own). Resident #6 was dependent for all ADLs and was receiving restorative therapy for passive range of motion for at least 15 minutes 7 days per week.<BR/>Record review of a care plan last updated 10/27/23 revealed Resident #6 had limited physical mobility related to cerebral palsy and required a daily restorative passive range of motion program to promote joint mobility and decrease pain.<BR/>Record review of consolidated physician's orders dated 12/2023 revealed Resident #6 had an order dated 10/11/23 for bilateral lower extremity ROM for 15 reps an each joint daily. Resident #6 had a physician's order dated 1/23/2023 for bilateral upper extremity ROM for 15 reps on each joint daily.<BR/>Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #6 had not received passive range of motion exercises as prescribed on 11/08/23, 11/21/23, 11/25/23, 11/26/23, 11/27/23, 12/01/23, 12/02/23, nor 12/02/23.<BR/>2. Record review of a face sheet dated 12/06/23 revealed Resident #21 was a [AGE] year-old male that admitted to the facility on [DATE]. Resident #21 had diagnoses of quadriplegia (paralysis of all four limbs), hypertension (high blood pressure), and seizure disorder.<BR/>Record review of a MDS dated [DATE] revealed Resident #21 was rarely/never understood and had a BIMS of 99, which indicated severe cognitive impairment. Resident #21 required continuous oxygen administration and required tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. Resident #6 was dependent for all ADLs and was receiving restorative therapy for passive range of motion for at least 15 minutes 7 days per week.<BR/>Record review of a care plan last updated 10/16/23 revealed Resident #21 had limited physical mobility related to anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation) and required a daily restorative passive range of motion program to promote joint mobility and decrease pain.<BR/>Record review of consolidated physician's orders dated 12/2023 revealed Resident #21 had an order dated 11/11/23 for bilateral upper extremity ROM for 15 reps an each joint daily. <BR/>Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #21 had not received passive range of motion exercises as prescribed on 11/13/23, 11/14/23, 11/15/23, 11/18/23, 11/20/23, 11/21/23, 11/25/23, 11/26/23, 11/27/23, 12/01/23, 12/02/23, nor 12/02/23.<BR/>3. Record review of a face sheet dated 12/06/23 revealed Resident #67 was [AGE] years old and was admitted on [DATE] with diagnoses including Arnold Chiari Syndrome with Spina Bifida (a malformation in the brain along with when the neural tube does not close all the way, the backbone that protects the spinal cord does not form and close as it should), unspecified joint contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and neuromuscular scoliosis (one of three main types of scoliosis that cause an irregular curvature of the spine). <BR/>Record review of a MDS dated [DATE] revealed Resident #67 was rarely/never understood. A BIMS was not conducted due to the resident was rarely/never understood. The MDS indicated Resident #67 had limited range of motion and was impaired on both sides of the upper and lower extremities. The MDS indicated Resident #67 was dependent on staff for all ADLs and received passive range of motion therapy as part of the Restorative Nursing Program. <BR/>Record review of a care plan last updated 11/09/23 revealed Resident #67 had spastic quadriplegic cerebral palsy (characterized by paralysis of both arms and both legs, with muscle stiffness) affecting mobility. There were interventions to use braces and splints as ordered. The care plan indicated Resident #67 had limited physical mobility and was part of the restorative therapy program. <BR/>Record review of consolidated physician's orders dated 12/05/23 revealed Resident #67 had an order dated 06/13/23 for bilateral upper extremity ROM for 15 repetitions at each joint every day related to contracture. There was an order dated 06/10/23 for bilateral lower extremity ROM for 15 repetitions every day.<BR/>Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #67 had not received passive range of motion exercises as prescribed on 11/17/23, 11/21/23, 11/25/23, 11/26/23, 11/28/23, 12/01/23, 12/02/23, and 12/03/23.<BR/>Record review of progress notes from 11/07/23 - 12/06/23 did not indicate Resident #67 did not tolerate therapy, was not available for therapy, or had refused therapy.<BR/>4. Record review of a face sheet dated 12/06/23 revealed Resident #68 was [AGE] years old and was admitted on [DATE] with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), unspecified joint contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and chronic pain. <BR/>Record review of a MDS dated [DATE] revealed Resident #68 was rarely/never understood. A BIMS was not conducted due to the resident was rarely/never understood. The MDS indicated Resident #68 had limited range of motion and was impaired on both sides of the upper and lower extremities. The MDS indicated Resident #68 was dependent on staff for all ADLs and received passive range of motion therapy as part of the Restorative Nursing Program. <BR/>Record review of a care plan last updated 11/01/23 revealed Resident #68 was dependent on staff for physical needs. The care plan indicated Resident #68 had limited mobility related to anoxic brain damage and the resident was part of the restorative nursing passive ROM program. <BR/>Record review of consolidated physician's orders dated 12/05/23 revealed Resident #68 had an order dated 07/06/23 for passive range of motion to left hip, knee, and ankle for 15 repetitions every day. There was an order dated 07/06/23 for passive range of motion to right knee and ankle, avoiding right hip, for 15 repetitions every day. There was an order dated 10/28/23 for gentle passive range of motion to bilateral lower extremities for 15 repetitions every day. There was an order dated 11/08/23 for passive range of motion to bilateral upper extremities for 15 repetitions every day. <BR/>Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #68 had not received passive range of motion exercises as prescribed on 11/13/23, 11/17/23, 11/21/23, 11/22/23, 11/25/23, 11/26/23, 11/27/23, 11/28/23, 11/29/23, 12/02/23, and 12/03/23.<BR/>Record review of progress notes from 11/07/23 - 12/06/23 did not indicate Resident #68 did not tolerate therapy, was not available for therapy, or had refused therapy . <BR/>Record review of a green splint binder kept on the restorative aides' cart revealed there was no documentation of any resident not tolerating restorative therapy.<BR/>During an interview on 12/04/2023 at 9:30 a.m., LVN C stated there were splint aides that did all of the range of motion and splint applications for the facility. LVN C stated the splint aides were aware of the time requirements of 15 minutes or more and the therapy needing to be done 7 days a week to be effective. LVN C stated the regular CNAs did some passive ROM for the children but were not specially trained like the splint aides were. LVN C stated not getting the prescribed ROM could lead to further contractures and joint pain.<BR/>During an interview on 12/05/23 at 1:11 p.m., the MDS Coordinator said she was responsible for the restorative therapy program. She said the split aides provided restorative therapy to the residents. She said according to the documentation residents had not received restorative therapy. She said the splint aide should document in progress notes any days the resident did not tolerate the restorative therapy. She said there was a binder that was kept at the wing that contained documentation. <BR/>During an interview on 12/06/23 at 9:03 a.m., the MDS Coordinator said she had not found any further documentation concerning restorative therapy. She said she felt the residents had received the ordered therapy and it just had not been documented. <BR/>During an interview on 12/06/23 at 9:17 a.m., Splint Aide H said restorative therapy was documented in the electronic medical record of each resident. She said each therapy session should be documented daily. She said there were days when she was working on the floor and could not do her restorative aide duties. She said those days were documented as a zero since the task was not done. She said if residents had refused, the refusal would be documented on a handwritten form and placed in the splint binder. <BR/>During an interview on 12/06/23 at 9:20 a.m., Splint Aide J said there were days the splint aides had to work the floor and may not apply splints to residents and/or provide range of motion exercises. She said on the days she had to work the floor she does try to provide range of motion exercises but may not be able to provide it to all residents. She said there were times when someone had called off and she had to work the floor by herself and could not provide therapy to every resident. She said if a resident could not tolerate the restorative therapy it would have been documented on a handwritten paper and placed in the splint binder. <BR/>During an interview on 12/06/23 at 10:04 a.m., the DON said the splint aides were responsible for providing restorative therapy to the residents. She said restorative therapy should be charted in the electronic medical record of each resident. She said she would expect the therapy to be provided unless the resident was out of the building or if something was going on with the resident, such as being out of the building. She said if the resident was out of the building she would expect it to be documented in the progress notes. She said the purpose of restorative therapy was to prevent contractures or to maintain mobility. She said should like for it to be documented so she would know the therapy had been done. She said the therapy was needed, it was ordered, and it should be done. She said if the aide was unable to do their duty they should have made the MDS Coordinator aware . <BR/>During an interview on 12/06/23 at 10:36 a.m., the Administrator said she felt as the residents were being gotten up they were receiving range of motion exercises. She said she felt it had just not been documented. She said she would expect all completed task to be documented in the resident electronic medical record. She said a resident not receiving restorative therapy could cause stiffing of the joints. <BR/>Review of a Restorative Nursing Services facility policy dated January 2023 indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence . <BR/>Review of an article titled Contractures and Splinting, https://www.advanced-healthcare.com/wp-content/uploads/2011/07/August-2014-Inservice.pdf, dated August 2014 indicated, . Contractures - Joint movement is similar to the hinge on a door. Regularly moving the door keeps it working properly, so the door opens and closes easily. When the door isn't moved regularly, the hinge may rust from lack of use, making the door harder to open and close. Similarly, the structures in and around the joints stretch, flex, and move all day long keeping them functional. If the joint is not moved, it shrinks, becomes stiff, and loses the ability to stretch and move. This causes changes in fluids that lubricate the inside of the joint. Movement squeezes and pushes the fluid around, lubricating the joint. When a joint stops moving, so does the fluid. Now both the outside and inside of the joint are immobile. Contractures are joint deformities caused by immobility. Keeping residents active and moving is the best way to prevent contractures .<BR/>Resident #6<BR/>FTag Initiation<BR/>Resident #21<BR/>FTag Initiation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 resident personal refrigerators reviewed for food safety (Resident # 51).<BR/>The facility failed to ensure the refrigerator for Resident # 51 did not contain expired foods.<BR/>This failure could place resident at risk for food borne illnesses.<BR/>Findings include:<BR/>Record review of a face sheet dated 09/30/2023 indicated Resident # 51 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue), Morbid Obesity (A disorder involving excessive body fat that increases the risk of health problems), Acute Embolism and Thrombosis (Thrombosis is a clot in a blood vessel. An embolism or thromboembolism is a clot that moves through your bloodstream).<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident # 51 understood others and made himself understood. The MDS indicated Resident #51 cognition was intact with a BIMS score of 15. The MDS indicated Resident #51 was totally dependent for transfer and bed mobility.<BR/>Record review of a care plan for Resident #51 dated 10/21/2023 revealed Resident # 51 has an ADL self-care performance deficit and requires assistance with staff for most activities of daily living. <BR/>During an observation and interview on 12/04/2023 at 10:17 a.m., Resident # 51 said he did not know if anyone cleans out his refrigerator. Resident #51 used his electric wheelchair to leave the room. It was observed that a pickled okra jar, labeled and dated 8/24/2020, was in his room on top of his personal refrigerator. The Okra inside the glass jar had been decomposing, turned black, and was now falling apart. Inside the refrigerator for Resident # 51 was an unknown food item in an undated and unlabeled zip lock bag. The unknown food appeared moldy, falling apart, and had black and blue spots on it. <BR/>During an interview on 12/06/2023 at 8:15 a.m., CNA F said Housekeeping was responsible for cleaning out personal refrigerators. She said that she, as a CNA, can prep food and pull food out of the refrigerator as well. She said if there was spoiled food that she found in a personal refrigerator she would tell the resident and then throw the food away. She said if she found a food that was not labeled or dated, she would also throw that food out. She said food in the personal refrigerators are supposed to be labeled and dated as this is how she was trained. She said she had not seen the decomposing Okra in Resident #51's room. She said she did not know there was expired cheese in the fridge as well. She said that residents are placed at risk of illness if they eat expired food. <BR/>During an interview on 12/06/2023 at 8:45 a.m., with the Director of Nurses she said it is the responsibility of all staff to ensure that resident's personal foods are checked to ensure there is no out of date or expired foods. She said residents could be placed at risk for foodborne illness if they eat expired foods. She said food that is decomposing or moldy should be discarded and not consumed. <BR/>During an interview on 12/06/2023 at 9:05 a.m., the Administrator said it is the responsibility of the Dietary Manager to ensure that resident's personal refrigerators are clean and free from expired foods or foods that are not labeled or dated. She said decomposing okra should have been thrown away by facility staff. She said the Dietary Supervisor is ultimately responsible to ensure this is completed . She said that residents are placed at risk of illness if they eat expired foods. She said she expects her staff to follow facility policy. <BR/>During an interview on 12/06/2023 at 9:38 a.m., the Dietary Manager said it is the dietary staff that are responsible to clean out the refrigerators in resident's rooms. She said expired food should be discarded and all foods should be labeled and dated. She said the okra that is decomposing should have been thrown away and not left in the room. She said residents are placed at risk of illness if they eat expired foods. <BR/>Record Review of facility policy titled, Personal Refrigerators Policy revised January 2023. The policy revealed, Residents of the facility may place a personal refrigerator in their room if space permits and under Life Safety Code regulations, that the resident room has an adequate electrical system, such as proper outlets, to allow the connection of a refrigerator without overloading the electrical system. The care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. It is also the responsibility of the resident and/or resident representative to properly store non-facility supplied foods that require refrigeration in their personal refrigerator. If food is expired or appears spoiled or moldy, the facility reserves the right to discard it. Housekeeping can assist the resident and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinent care infection control practices (Resident #79), and 3 of 3 residents observed for medication administration control practices. (Resident #'s 27, 91, 71).<BR/>1.CNA A did not change her gloves or sanitize her hands after performing incontinent care on the front perineal area for Resident #79 and touched clean areas. <BR/>2. The facility failed to ensure RN G performed hand hygiene before and after administering medications to 3 different residents. <BR/>These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.<BR/>Findings included:<BR/>1.Record review of the undated face sheet indicated Resident #79 was a [AGE] year-old female that admitted [DATE]. <BR/>Record review of the physician's orders dated 1/14/25 indicated Resident #79 had diagnoses that included: Seizures (uncontrolled jerking, blank stares, loss of consciousness caused by abnormal electrical activity in the brain), failure to thrive (not growing as expected), Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development before birth), and gastrostomy (tube inserted into the abdomen and stomach to provide a route for feeding).<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #79 had no speech, rarely or never understood others, and was rarely or never understood by others. She had short- and long-term memory problems. The MDS indicated Resident #79 was dependent for toileting hygiene. <BR/>Record review of the undated care plan indicated Resident #79 was totally dependent on one staff for incontinent care due to Cerebral Palsy. The care plan indicated she had impaired cognitive function and required tube feeding. <BR/>During an observation on 1/14/25 at 9:06 AM, revealed CNA A and CNA B provided incontinent care to Resident #79. They sanitized their hands and donned (put on) PPE for EBP. CNA A cleaned Resident #79's front perineal area and did not change her gloves or sanitize her hands before rolling the resident to her side and touching Resident #79's shoulder, bed pad, and bed. She then cleaned the resident's back side before changing her gloves and sanitizing her hands. <BR/>During an interview on 1/14/25 09:17 AM, CNA A said she was nervous and forgot to change her gloves after cleaning Resident #79's front before cleaning her backside. She said she did not realize she touched the resident's shoulder, bed, and bed pad with her dirty gloves. She said that could cause cross-contamination and spread infection. She said she was taught to always change her gloves and wash her hands after a dirty procedure and she should have changed them.<BR/>During an interview on 1/14/25 at 9:18 AM, CNA B said she did not realize CNA A had not changed her gloves after cleaning Resident #79's front area, before going to her backside. She said they were taught to change their gloves and clean their hands when going from a dirty procedure to a clean area. She said CNA A should have changed her gloves. <BR/>During an interview on 1/14/25 at 9:49 AM, LVN F said she was the Staff Coordinator/Trainer and she signed off that CNA A and CNA B had met the requirements for Pericare-Incontinent Care. She said they were taught to change gloves when going from dirty to clean. She said after CNA A cleaned Resident #79's front area, she should have changed her gloves and cleaned her hands before she cleaned her back side and before touching anything clean. She said not doing that was a risk of infection to staff and the residents, that could make staff and resident's sick. She said she would be reteaching both CNAs. <BR/>During an interview on 1/14/25 10:32 AM, CNA C said during incontinent care, he always changed his gloves and cleaned his hands when going from dirty to clean. He said after cleaning a resident's front part staff would need to clean their hands and change their gloves because their gloves would be dirty. He said not changing gloves from a dirty procedure to a clean one could cause infections to staff and residents. <BR/>During an interview on 1/14/25 at 1:28 PM, LVN D said staff should always change their gloves and clean their hands when going from dirty to clean. She said during incontinent care, after cleaning the front of a resident, staff should change their gloves and clean their hands before touching anything clean including the resident. She said if they did not change their gloves, it was a cross-contamination issue that could cause infection to residents and staff. <BR/>During an interview on 1/14/25 at 1:31 PM, ADON E said staff must always change their gloves and clean their hands when they go from dirty to clean. She said during incontinent care staff should change their gloves and clean their hands after cleaning the front perineal area and before going to the back because their gloves would be dirty. She said if staff touched clean areas with dirty gloves that was cross -contamination which could cause infection to residents and staff. <BR/>During an interview 01/14/25 2:19 PM, the DON said staff should always change their gloves and sanitize their hands when going from dirty to clean. She said when staff were performing incontinent care they should change their gloves and clean their hands after cleaning the front perineal area and before touching anything clean, or going to the back area. She said if they did not change their gloves or clean their hands, they were risking cross-contamination and infections to residents and staff. <BR/>During an interview on 1/14/25 at 2:48 PM, the ADM said staff should change their gloves anytime they were moving from dirty to clean. She said during incontinent care staff should change their gloves after cleaning the front perineal area and before touching anything clean. She said touching anything clean with dirty gloves was cross-contamination and had the potential to cause infection to residents and staff. <BR/>Record review of a Pericare-Incontinent Care competency dated 10/2/24 indicated CNA A had met the requirements. The competency was signed by evaluator, LVN F.<BR/>Record review of a Pericare-Incontinent Care competency dated 10/2/24 indicated CNA B had met the requirements. The competency was signed by evaluator, LVN F.<BR/>Record review of a Perineal Care Policy with a revised date of 4/16/24indicated: <BR/>Perineal Care<BR/>Purpose<BR/>The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. <BR/>2. Record review of Resident #27's face sheet, dated 01/14/25, indicated she was a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included dependence on respiratory (ventilator) status (breathing machine), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), Chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs cannot exchange oxygen and carbon dioxide properly), personal history of pneumonia (a medical record that indicates a person has had pneumonia in the past) and gastrostomy status (the presence of a surgical opening in the abdomen that allows for nutritional support or gastric decompression). <BR/>Record review of Resident #27's quarterly MDS assessment, dated 12/26/24, indicated she did not perform a BIMS assessment (a 15-point cognitive screening measure that evaluates memory and orientation and includes free and recall items), because she was rarely/never understood and rarely/never understood others.<BR/>Record review of Resident #27's care plan, dated 01/13/25, indicated eating and nutrition the resident needs total assistance with tube feeding and water flushes, see MD orders for current feeding orders. Check for tube placement and gastric contents/residual volume per facility protocol and record. The resident is totally dependent on one staff for nutrition via G-Tube. The resident is dependent with tube feeding and water flushes, see MD orders for current feeding orders. Interventions: review infection control techniques with resident such as frequent handwashing and use of hand sanitizer. Remind the resident and caregivers to refrain from physical contact. For example, practice social distances with no handshaking or hugging and remaining six feet apart when possible.<BR/>3. Record review of Resident #71's face sheet, dated 01/14/25, indicated she was a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pseudomonas (is a [NAME] of bacteria commonly found in wet environments like soil and water), acute respiratory distress (condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen) and cystic fibrosis (an inherited life-threatening disorder that damages the lungs and digestive system).<BR/>Record review of Resident #71's quarterly MDS assessment, dated 10/17/24, indicated she did not perform a BIMS assessment, because she was rarely/never understood and rarely/never understood others.<BR/>Record review of Resident #71's care plan, dated 04/17/24, indicated provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection.<BR/>4. Record review of Resident #91's face sheet, dated 01/14/25, indicated he was a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs cannot exchange oxygen and carbon dioxide properly), pseudomonas (is a [NAME] of bacteria commonly found in wet environments like soil and water) and encounter for attention to tracheostomy (a medical appointment specifically focused on managing and caring for a patient's tracheostomy).<BR/>Record review of Resident #91's quarterly MDS assessment, dated 12/25/24, indicated he did not perform a BIMS assessment, because he was rarely/never understood and rarely/never understood others.<BR/>Record review of Resident #91's care plan, dated 04/17/24, indicated his level of staff assistance during care during transfer assistance and feeding assistance. Interventions enhanced barrier precautions (EBP). Follow facility fall protocol. Seizure precautions: Do not leave residential one during a seizure, protect from injury, if resident is out of bed, help to the floor to prevent injury, remove or loosen tight clothing, do not attempt to restrain resident during a seizure as this could make the convulsions more.<BR/>During an observation on 01/13/25 at 7:29 A.M., revealed RN G did not wash or sanitize her hands before preparing medication for Resident #71. RN G did not wash or sanitizer her hands prior to administering Resident #71's meds and administered Resident #71's G-Tube feeding and did not wash or sanitizer hers hands afterwards. <BR/>During an observation on 01/13/25 at 7:49 A.M. revealed RN G did not wash or sanitize her hands before preparing medication for Resident #27. RN G did not wash or sanitizer her hands prior to administering Resident #27's meds and did not wash or sanitizer hers hands afterwards. <BR/>During an observation on 01/13/25 at 8:04 A.M. revealed RN G did not wash or sanitize her hands before preparing medication for Resident #91. RN G did not wash or sanitizer her hands prior to administering Resident #91's eyedrops.<BR/>During an interview on 01/13/25 at 8:06 A.M., RN G said it was normally a habit for her to wash or sanitize her hands during med pass and between residents. She said she was nervous, so she forgot to sanitize her hands. She said staff should sanitize their hands between residents unless their hands were soiled, then they should wash their hands with soap and water. She said she should have sanitized her hands before giving meds and after she gave the meds to reduce the spread of infection rate.<BR/>During an interview on 01/13/25 at 10:43 A.M., LVN M said before a nurse started giving a medication, they should wash their hands. She said the nurse should wash their hands before and after administering meds. She said nurses' hands played a part to the chain of infection. She said not washing her hands could had made her and the residents more susceptible to infections.<BR/>During an interview on 01/14/25 at 9:00 A.M., LVN I said nurses should be washing their hands before and after a med pass to prevent cross contamination.<BR/>During an interview on 01/14/25 at 9:46 A.M., RN J said when a nurse administered medications, they should wash their hands before and after giving the medications. She said hand hygiene between residents should be performed. She said hand hygiene was the number one infection control prevention.<BR/>During an interview on 1/14/25 at 12:48 P.M., RN N said when a nurse administered meds they should wash their hands before a med pass, after the mad pass and before going to another resident. She said it was infection control and they could carry infections to another resident with their hands. She said nurses should always start fresh by washing their hands.<BR/>During an interview on 1/14/25 at 1:15 P.M., the DON said during med pass she expected the nurses to wash their hands. She said handwashing was for infection control measures. She said the nurses should wash their hands during med pass and between each resident. She said a negative effect of improper hand hygiene was the spread of infection.<BR/>During an interview on 1/14/25 at 3:17 P.M., the ADM said she excepted the nurses to wash their hands during med pass and between residents. She said a negative effect of improper hand hygiene was the risk of infection.<BR/>Record review of RN G Nurses: GT Med/Feeding administration check-off sheet dated 12/2/24 indicated RN G had met the requirements. The competency was signed by evaluator, RN N.<BR/>Record review of the facility's Handwashing/ Hand Hygiene Residents policy, last revised 1/25/23, indicated: this facility considers hand hygiene the primary means to prevent the spread of infections . <BR/>2. Residents may be trained and encouraged on the importance of hand hygiene in preventing the transmission of infections . 4. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, wipes etc.) shall be readily accessible and convenient for resident use to encourage compliance with hand hygiene policies .<BR/>Record review of the facility's Infection Prevention and Control Program policy. Last revised 01/01/24, indicated: an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable disease and infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Residents were free of accidents for 1 of 4 Residents reviewed for accidents. (Resident #1)<BR/>The facility did not ensure staff repositioned Resident #1 safely resulting in a fracture to Resident #1's left Femur. <BR/>This failure could place Residents at risk for injury. <BR/>Findings included:<BR/>A face sheet dated 01/09/23 showed Resident #1 was an [AGE] year-old admitted on [DATE] with diagnoses of Spastic Quadriplegic cerebral Palsy, (CP affecting all four limbs, the trunk, and the face), adult failure to thrive (A decline seen in adults - typically those with multiple chronic medical conditions), Intellectual disabilities, contracture, chronic pain, Subluxation (partial dislocation) of left hip, personal history of COVID19, Ileus (lack of the normal muscle contractions of the intestines), malnutrition, and cerebral palsy.<BR/>A MDS dated [DATE] showed Resident #1 was rarely or never able to make himself understood or understand others. required total dependence for all ADLs, required one person assistance for bed mobility and two-person assistance for transfers. He was always incontinent to bowel and bladder. Resident #1 had unclear speech, rarely or never understood or able to understand others. <BR/>A care plan dated 08/19/22 showed Resident #1 had potential for pain related to contractures and spastic quadriplegic cerebral palsy. Staff were to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Staff were to monitor/document for probable cause of each pain episode, remove/limit causes where possible. <BR/>A care plan dated 08/30/22 showed Resident #1 was totally dependent on one staff for bed mobility, turning and repositioning as needed. Resident is totally dependent on two staff for transferring.<BR/>A video surveillance tape dated 12/31/22 at 1:14 PM provided by the Administrator showed Resident #1 laying sideways with Resident #1's hips and legs on a mattress, foot against the wall and the upper torso on a mat and head on a pillow. There was a pillow between Resident #1's legs. The mattress and mat were directly on the floor in the lowest position possible. Resident #1 was alert with no signs of destress. Two staff identified by the administrator as RN-A and CNA-A entered the room. CNA-A spoke to Resident #1 in a pleasant tone of voice. CNA-A placed his left hand on Resident #1's left shoulder and with a twisting motion turned Resident #1 to the right. There was an audible pop. Resident #1 immediately started to cry out as if in pain. CNA-A turned Resident #1 on to left side and RN-A conducted some type of treatment to Resident #1 buttock. Resident #1 stopped crying while lying on the left side while the treatment was administered. Resident #1 started to cry again and had a grimacing expression. RN-A finished the treatment and left the room. CNA-A remained in the room kneeling beside Resident #1 when the video ended. <BR/>A patient report from local x-ray provider dated 01/01/23 at 12:41 AM showed an x-ray was conducted on 01/01/23 of Resident #1's left femur. Findings showed the bilateral acetabula are dysplastic (an abnormally shallow hip socket) and there are bilateral age-indeterminate superior dislocated femoral heads. An oblique fracture of the left proximal femoral shaft. (A fracture is a straight line that's angled across the width of your bone.)<BR/>Interview on 01/04/23 at 3:21 PM, RN-A said he was the nurse on duty 12/31/22 when Resident #1's leg was broken. RN-A said the CNA had notified him that Resident #1 had been scratching behind his scrotum and needed treatment. RN-A said he went to provide the treatment. RN said then CNA-A bent over to move Resident #1 over in the bed, he heard a pop. RN-A said he thought it was either CNA-A's back or a toy hitting the floor. RN-A said he had never heard a bone break and did not recognize the pop as a bone breaking. RN-A said he did not tell the oncoming nurse or contact the family, because he did not know Resident #1 leg was broken. He said he did not hear Resident #1 crying after he had calmed down.<BR/>Interview on 01/04/23 at 3:33 PM, CNA-A said he was the aide on duty 12/31/22, when Resident #1's leg broke. CNA-A said when he and RN-A went into the room, Resident #1 had slid off his mattress. CNA-A said he moved Resident #1 back on his mattress and heard a pop. CNA-A said RN-A asked him if that was his back or something. CNA-A said he told RN-A it was not him and they thought it was a toy that had fell to the floor. CNA-A said Resident #1 does not like to be touched or bothered so he thought Resident #1 was fussing because he did not want to be changed or repositioned. CNA-A said Resident #1 did not make much noise while being changed but became upset when he placed the pillows between Resident #1's legs. CNA-A said he did not know Resident #1's leg was broken.<BR/>Interview on 01/08/23 at 1:35 PM the Administrator said she was investigating the incident with Resident #1 fractured femur. Administrator said she had an emergency QUPI meeting on 01/02/23 to develop a plan of correction. The Administrator said RN A and CNA A were immediately suspended pending investigation. The Administrator said all nursing staff received training on bed mobility and transfer assistance, reporting abuse and neglect, and administering pain medications. The Administrator said all nursing staff were tested on skills for transfer mobility, and repositioning techniques, starting on 01/01/23 and completed on 01/08/23. The Administrator said an audit was conducted that included bed mobility and transfer needs for all residents. The Administrator said the DON/designee and Rehabilitation Director will monitor three times a week for four weeks, then two times a week for eight weeks and then weekly thereafter. The Administrator said the QAPI committee will provide oversight monthly for 3 months and every 6 months until resolved.<BR/>Interview on 01/09/23 at 10:18 AM, the DON said she had reviewed the video of the incident with Resident #1. The DON said CNA-A failed to use the proper technique when he repositioned Resident #1. The DON said because of the angel Resident #1 was lying in at the time, CNA-A should have asked RN-A to assist with repositioning Resident #1. The DON said because of the improper way Resident #1 was repositioned by CNA-A, Resident #1's left femur was fractured. The DON said both staff, CNA-A and RN-A were terminated for failing to assess Resident #1's condition and for failing to report an injury of a Resident to the Administrator and/or DON. The DON said on 01/01/23 at 3:00 AM the charge nurse notified the ADON that there was swelling to Resident #1's left leg and x-rays had been ordered. The DON said Resident #1 received pain medication on 12/31/22 at 2:00 PM and again on 01/01/22 after the swelling was discovered. The DON said it was hard to know how Resident #1 was feeling because he yelled out and makes a lot of noise when he is mad, happy, or just in general. <BR/>Interview on 01/09/23 at 10:47 AM, LVN A said she was working on 12/31/22 5:00 AM to 5:00 PM. LVN-A said that afternoon around 2:00 PM, LVN A went in to see Resident #1. LVN A said Resident #1 was crying, but that was not unusual. LVN A said she fed him some pudding with pain medication. LVN said after feeding him the pudding, she stayed with Resident #1 for about twenty minutes and left the room. LVN A Resident #1 had stopped crying. LVN A said later she saw Resident #1 on his way to get a shower. LVN A said he was not crying when she saw him.<BR/>Interview on 01/09/23 at 11:25 AM, CNA-B said he was working on the afternoon on 12/31/22. CNA-B said Resident #1 did not appear to be any more upset then normal. CNA-B said Resident #1 always yelled out during care and he did not notice Resident #1 yelling out more than normal and did not notice Resident #1 was having problems with his left leg. CNA-B said the shower was about the same as always with nothing unusual.<BR/>Interview on 01/08/23 CNA-B, CNA-C, LVN-A and RN-B said they had received training on abuse/neglect and transferring and repositioning residents. <BR/>Observations on 01/08/23 from 1:00 PM to 1:15 PM showed 3 residents being repositioned by staff. Staff used proper technique and provided appropriate support when repositioning residents in their beds.<BR/>Inservice record from 01/01/23 through 01/08/23 showed documentation that nursing staff had received training on Reporting Abuse and Neglect, Skills Assessments on transfer, and bed mobility/positioning techniques.<BR/>Facility policy revised 07/18/18 showed The QA Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. 1. A. Orientation & Training: Nursing staff will receive in-service training for the criteria used to assess for appropriate level of assistance required. Transfer training refers to the teaching techniques and use of equipment involving in moving patient/resident from one surface to another (e.g., bed to wheelchair) or the moving or repositioning of a patient/resident on one surface (e.g., bed, mat table) Bed Mobility/Repositioning .All motion is slow, specific, and methodical. More than one caregiver may be needed in the event the resident is dependent, bariatric, brittle, rigid, resistant, and so on. Great care should be taken to keep the body as a unit during rolling and repositioning and keeping arms and legs aligned and visible during the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Residents were free of accidents for 1 of 4 Residents reviewed for accidents. (Resident #1)<BR/>The facility did not ensure staff repositioned Resident #1 safely resulting in a fracture to Resident #1's left Femur. <BR/>This failure could place Residents at risk for injury. <BR/>Findings included:<BR/>A face sheet dated 01/09/23 showed Resident #1 was an [AGE] year-old admitted on [DATE] with diagnoses of Spastic Quadriplegic cerebral Palsy, (CP affecting all four limbs, the trunk, and the face), adult failure to thrive (A decline seen in adults - typically those with multiple chronic medical conditions), Intellectual disabilities, contracture, chronic pain, Subluxation (partial dislocation) of left hip, personal history of COVID19, Ileus (lack of the normal muscle contractions of the intestines), malnutrition, and cerebral palsy.<BR/>A MDS dated [DATE] showed Resident #1 was rarely or never able to make himself understood or understand others. required total dependence for all ADLs, required one person assistance for bed mobility and two-person assistance for transfers. He was always incontinent to bowel and bladder. Resident #1 had unclear speech, rarely or never understood or able to understand others. <BR/>A care plan dated 08/19/22 showed Resident #1 had potential for pain related to contractures and spastic quadriplegic cerebral palsy. Staff were to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Staff were to monitor/document for probable cause of each pain episode, remove/limit causes where possible. <BR/>A care plan dated 08/30/22 showed Resident #1 was totally dependent on one staff for bed mobility, turning and repositioning as needed. Resident is totally dependent on two staff for transferring.<BR/>A video surveillance tape dated 12/31/22 at 1:14 PM provided by the Administrator showed Resident #1 laying sideways with Resident #1's hips and legs on a mattress, foot against the wall and the upper torso on a mat and head on a pillow. There was a pillow between Resident #1's legs. The mattress and mat were directly on the floor in the lowest position possible. Resident #1 was alert with no signs of destress. Two staff identified by the administrator as RN-A and CNA-A entered the room. CNA-A spoke to Resident #1 in a pleasant tone of voice. CNA-A placed his left hand on Resident #1's left shoulder and with a twisting motion turned Resident #1 to the right. There was an audible pop. Resident #1 immediately started to cry out as if in pain. CNA-A turned Resident #1 on to left side and RN-A conducted some type of treatment to Resident #1 buttock. Resident #1 stopped crying while lying on the left side while the treatment was administered. Resident #1 started to cry again and had a grimacing expression. RN-A finished the treatment and left the room. CNA-A remained in the room kneeling beside Resident #1 when the video ended. <BR/>A patient report from local x-ray provider dated 01/01/23 at 12:41 AM showed an x-ray was conducted on 01/01/23 of Resident #1's left femur. Findings showed the bilateral acetabula are dysplastic (an abnormally shallow hip socket) and there are bilateral age-indeterminate superior dislocated femoral heads. An oblique fracture of the left proximal femoral shaft. (A fracture is a straight line that's angled across the width of your bone.)<BR/>Interview on 01/04/23 at 3:21 PM, RN-A said he was the nurse on duty 12/31/22 when Resident #1's leg was broken. RN-A said the CNA had notified him that Resident #1 had been scratching behind his scrotum and needed treatment. RN-A said he went to provide the treatment. RN said then CNA-A bent over to move Resident #1 over in the bed, he heard a pop. RN-A said he thought it was either CNA-A's back or a toy hitting the floor. RN-A said he had never heard a bone break and did not recognize the pop as a bone breaking. RN-A said he did not tell the oncoming nurse or contact the family, because he did not know Resident #1 leg was broken. He said he did not hear Resident #1 crying after he had calmed down.<BR/>Interview on 01/04/23 at 3:33 PM, CNA-A said he was the aide on duty 12/31/22, when Resident #1's leg broke. CNA-A said when he and RN-A went into the room, Resident #1 had slid off his mattress. CNA-A said he moved Resident #1 back on his mattress and heard a pop. CNA-A said RN-A asked him if that was his back or something. CNA-A said he told RN-A it was not him and they thought it was a toy that had fell to the floor. CNA-A said Resident #1 does not like to be touched or bothered so he thought Resident #1 was fussing because he did not want to be changed or repositioned. CNA-A said Resident #1 did not make much noise while being changed but became upset when he placed the pillows between Resident #1's legs. CNA-A said he did not know Resident #1's leg was broken.<BR/>Interview on 01/08/23 at 1:35 PM the Administrator said she was investigating the incident with Resident #1 fractured femur. Administrator said she had an emergency QUPI meeting on 01/02/23 to develop a plan of correction. The Administrator said RN A and CNA A were immediately suspended pending investigation. The Administrator said all nursing staff received training on bed mobility and transfer assistance, reporting abuse and neglect, and administering pain medications. The Administrator said all nursing staff were tested on skills for transfer mobility, and repositioning techniques, starting on 01/01/23 and completed on 01/08/23. The Administrator said an audit was conducted that included bed mobility and transfer needs for all residents. The Administrator said the DON/designee and Rehabilitation Director will monitor three times a week for four weeks, then two times a week for eight weeks and then weekly thereafter. The Administrator said the QAPI committee will provide oversight monthly for 3 months and every 6 months until resolved.<BR/>Interview on 01/09/23 at 10:18 AM, the DON said she had reviewed the video of the incident with Resident #1. The DON said CNA-A failed to use the proper technique when he repositioned Resident #1. The DON said because of the angel Resident #1 was lying in at the time, CNA-A should have asked RN-A to assist with repositioning Resident #1. The DON said because of the improper way Resident #1 was repositioned by CNA-A, Resident #1's left femur was fractured. The DON said both staff, CNA-A and RN-A were terminated for failing to assess Resident #1's condition and for failing to report an injury of a Resident to the Administrator and/or DON. The DON said on 01/01/23 at 3:00 AM the charge nurse notified the ADON that there was swelling to Resident #1's left leg and x-rays had been ordered. The DON said Resident #1 received pain medication on 12/31/22 at 2:00 PM and again on 01/01/22 after the swelling was discovered. The DON said it was hard to know how Resident #1 was feeling because he yelled out and makes a lot of noise when he is mad, happy, or just in general. <BR/>Interview on 01/09/23 at 10:47 AM, LVN A said she was working on 12/31/22 5:00 AM to 5:00 PM. LVN-A said that afternoon around 2:00 PM, LVN A went in to see Resident #1. LVN A said Resident #1 was crying, but that was not unusual. LVN A said she fed him some pudding with pain medication. LVN said after feeding him the pudding, she stayed with Resident #1 for about twenty minutes and left the room. LVN A Resident #1 had stopped crying. LVN A said later she saw Resident #1 on his way to get a shower. LVN A said he was not crying when she saw him.<BR/>Interview on 01/09/23 at 11:25 AM, CNA-B said he was working on the afternoon on 12/31/22. CNA-B said Resident #1 did not appear to be any more upset then normal. CNA-B said Resident #1 always yelled out during care and he did not notice Resident #1 yelling out more than normal and did not notice Resident #1 was having problems with his left leg. CNA-B said the shower was about the same as always with nothing unusual.<BR/>Interview on 01/08/23 CNA-B, CNA-C, LVN-A and RN-B said they had received training on abuse/neglect and transferring and repositioning residents. <BR/>Observations on 01/08/23 from 1:00 PM to 1:15 PM showed 3 residents being repositioned by staff. Staff used proper technique and provided appropriate support when repositioning residents in their beds.<BR/>Inservice record from 01/01/23 through 01/08/23 showed documentation that nursing staff had received training on Reporting Abuse and Neglect, Skills Assessments on transfer, and bed mobility/positioning techniques.<BR/>Facility policy revised 07/18/18 showed The QA Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. 1. A. Orientation & Training: Nursing staff will receive in-service training for the criteria used to assess for appropriate level of assistance required. Transfer training refers to the teaching techniques and use of equipment involving in moving patient/resident from one surface to another (e.g., bed to wheelchair) or the moving or repositioning of a patient/resident on one surface (e.g., bed, mat table) Bed Mobility/Repositioning .All motion is slow, specific, and methodical. More than one caregiver may be needed in the event the resident is dependent, bariatric, brittle, rigid, resistant, and so on. Great care should be taken to keep the body as a unit during rolling and repositioning and keeping arms and legs aligned and visible during the care.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 laundry room reviewed for environment. The facility failed to ensure the air filters in the laundry room were clean, the air filters were dirty with a thick dark gray substance. This failure could place the residents at risk of living and working in an unsafe, unsanitary and uncomfortable environment. Findings included: During an observation and interview on 11/17/25 at 2:24 P.M., the laundry room had dirty air filters on the ceiling on the dirty and clean side of laundry room. The air filters had a thick dark gray substance on them. Laundry Aide B said the facility kept the air filters clean. She said the air filters were usually changed once a week. She said the maintenance man usually changed the air filters; she said she thought he changed the air filters last Thursday. She said the air filters got dirty, because the staff opened and closed the doors all the time and the area she worked in had a lot of lint. During an interview on 11/18/25 at 12:34 P.M., with Laundry Aide B, said Maintenance Man A came once a week, brought a new air filter and pulled the old air filter down, then put a new air filter in vent. She said that Maintenance Man A changed the air filters yesterday. She said she thought Maintenance Man A was responsible for changing the air filters as far as she knew. She said a negative effect of the dirty air filters would be improper air flow throughout the building. During an interview on 11/18/25 at 12:43 P.M., Maintenance Man A said the air filters were changed in the laundry room every Thursday; unless the staff told him the air filters were getting clogged, then he would change them as needed. He said he changed the air filters by taking the dirty air filter down and cut the material off the roll to fit the bracket, then slid the filter back into place. He said he was the primary person responsible for changing the air filters. He said a negative effect of the dirty air filters was if they got too dirty or clogged it would cause the air conditioning unit to freeze. During an interview on 11/18/25 at 12:51 P.M., with the DON she said she does not know how often the air filters were changed in the laundry room. She said the air filters in the laundry room looked like they needed to be changed. She said she does not know the process of changing the air filters in the laundry room. She said her guess was the maintenance man or housekeeping were responsible for changing the air filters. She said a negative effect of the dirty air filters was it would make everything in the laundry room dusty. During an interview on 11/18/25 at 2:30 P.M., with the Administrator she said due to the amount of laundry the facility had to do there the air filters may look like they had not been changed in a while or not within a reasonable timeframe, because the amount of lint that was on the air filters. She said the air filters were changed once a week. She said she had not observed the air filters changed in the laundry room. She said Maintenance Man A was responsible for changing the air filters in the laundry room and throughout the facility, but the laundry aides or anyone should notify Maintenance Man A if the air filters were dirty. She said a negative effect of a dirty air filter had potential for clogging the air conditioner unit. Record review of Homelike Environment Policy dated February 2021 provided by the Administrator indicated: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .2.The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting . a. Clean, sanitary and orderly environment. e. clean bed and bath linens that are in good conditions.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation.<BR/>The facility failed to ensure all foods stored in the freezers, and dry pantry were not kept past their expiration dates and did not contain employee personal items.<BR/>These failures could place residents at risk of foodborne illness and food contamination.<BR/>Findings included:<BR/>During an observation of the freezer on 1/12/2025 at 9:20 AM, the following items were observed:<BR/>(1) <BR/>32-ounce bag of frozen hashbrowns that was opened with approximately 1/3 of the bag remaining, wrapped in a plastic shopping bag with no label or date opened.<BR/>During an observation of the dry pantry on 1/12/2025 at 9:20 AM, the following items were observed:<BR/>(1) <BR/>Gallon container of distilled white vinegar that was approximately half full with an open date of 12/26/2024 and an expiration date of 6/7/2022.<BR/>During an observation and interview on 1/12/2025 at 9:20 AM, the [NAME] said the open bag of hashbrowns in the refrigerator was her personal food. She took the bag out of the freezer and disposed of them. She said she should not have put them in the refrigerator, and she took responsibility for them. She said she knew she was not supposed to put personal food items in the refrigerators. She said she was supposed to keep personal food items in the employee refrigerator. <BR/>During an interview on 1/14/2025 at 9:15 AM, the Dietary Aide said the cooks were supposed to check the walk-in refrigerators and freezers for expired foods and the dietary aides were supposed to check the dry pantry area for expired foods on Wednesdays. She said she last checked the dry pantry area last week on Wednesday, but she was very busy that day and did not make it to the top shelf where the vinegar was, so she just missed it. She said the resident could get sick by a food borne illness by consuming expired foods.<BR/>During an interview on 1/14/2025 at 1:12 PM, the DM said that there was a cleaning schedule for both the cooks and the dietary aides. She said the cooks were responsible for checking the walk-in refrigerators and freezers for expired foods on Fridays of every week. She said the dietary aides were responsible for checking the dry pantry area on Wednesdays for expired foods. She said it was her responsibility to check behind them to make sure everyone is performing their job functions. She said the residents could get sick by a food borne illness by consuming expired foods.<BR/>During an interview on 1/14/2025 at 1:23 PM, the [NAME] said she was responsible for checking the refrigerators and walk in for expired food. She said the Dietary Aide was responsible for checking the dry pantry for expired foods. She said the DM was responsible for making sure that all the kitchen employees did their jobs. She said it could cause the residents to get sick by a food borne illness by consuming expired foods. <BR/>During an interview on 1/14/2025 at 2:25 PM, the Administrator said all foods should be used or disposed of by the use by date. She said food borne illness was a potential risk to the resident for consuming expired foods.<BR/>Record review of facility policy titled Dry Storage dated January 2023, indicated: 5. All expired foods must be removed from the store room .<BR/>Record review of facility policy titled Food Storage dated January 2023, indicated: Safe and sanitary conditions shall be maintained in storage, preparation, and distribution of food.Staff shall not store personal items within the food preparation and storage areas .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation.<BR/>The facility failed to ensure all foods stored in the freezers, and dry pantry were not kept past their expiration dates and did not contain employee personal items.<BR/>These failures could place residents at risk of foodborne illness and food contamination.<BR/>Findings included:<BR/>During an observation of the freezer on 1/12/2025 at 9:20 AM, the following items were observed:<BR/>(1) <BR/>32-ounce bag of frozen hashbrowns that was opened with approximately 1/3 of the bag remaining, wrapped in a plastic shopping bag with no label or date opened.<BR/>During an observation of the dry pantry on 1/12/2025 at 9:20 AM, the following items were observed:<BR/>(1) <BR/>Gallon container of distilled white vinegar that was approximately half full with an open date of 12/26/2024 and an expiration date of 6/7/2022.<BR/>During an observation and interview on 1/12/2025 at 9:20 AM, the [NAME] said the open bag of hashbrowns in the refrigerator was her personal food. She took the bag out of the freezer and disposed of them. She said she should not have put them in the refrigerator, and she took responsibility for them. She said she knew she was not supposed to put personal food items in the refrigerators. She said she was supposed to keep personal food items in the employee refrigerator. <BR/>During an interview on 1/14/2025 at 9:15 AM, the Dietary Aide said the cooks were supposed to check the walk-in refrigerators and freezers for expired foods and the dietary aides were supposed to check the dry pantry area for expired foods on Wednesdays. She said she last checked the dry pantry area last week on Wednesday, but she was very busy that day and did not make it to the top shelf where the vinegar was, so she just missed it. She said the resident could get sick by a food borne illness by consuming expired foods.<BR/>During an interview on 1/14/2025 at 1:12 PM, the DM said that there was a cleaning schedule for both the cooks and the dietary aides. She said the cooks were responsible for checking the walk-in refrigerators and freezers for expired foods on Fridays of every week. She said the dietary aides were responsible for checking the dry pantry area on Wednesdays for expired foods. She said it was her responsibility to check behind them to make sure everyone is performing their job functions. She said the residents could get sick by a food borne illness by consuming expired foods.<BR/>During an interview on 1/14/2025 at 1:23 PM, the [NAME] said she was responsible for checking the refrigerators and walk in for expired food. She said the Dietary Aide was responsible for checking the dry pantry for expired foods. She said the DM was responsible for making sure that all the kitchen employees did their jobs. She said it could cause the residents to get sick by a food borne illness by consuming expired foods. <BR/>During an interview on 1/14/2025 at 2:25 PM, the Administrator said all foods should be used or disposed of by the use by date. She said food borne illness was a potential risk to the resident for consuming expired foods.<BR/>Record review of facility policy titled Dry Storage dated January 2023, indicated: 5. All expired foods must be removed from the store room .<BR/>Record review of facility policy titled Food Storage dated January 2023, indicated: Safe and sanitary conditions shall be maintained in storage, preparation, and distribution of food.Staff shall not store personal items within the food preparation and storage areas .