Ganado Nursing And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 24 (Residents #27, #29) residents reviewed for Activities in that: 1.Residents #29, and #27 stated the activity schedule was not followed and there was no back up, if the activity director did not work. 2.The facility failed to provide activities as posted. This failure could affect all residents and could result in no Activity program for residents. The Findings:1.Record review of the Activity schedule for February 2026 revealed:2/21/2026 - Saturday -no activity scheduled.2/22/2026 - Sunday- no activity on the Activity schedule. (day of entrance)2/23/2026 - Monday9:00 AM - coffee and chat9:30 AM - one to one10:00 AM - Dominoes11:00 AM - Appetizer hour2:30 PM - Bingo4:00 PM - pretty nails 2/24/2026 Tuesday9:00 AM - coffee and chat9:30 AM - one to one10:00 AM - Board games11:00 AM - Appetizer hour2:30 PM - Bingo 2/25/2026 Wednesday9:00 AM - coffee and chat9:30 AM - one to one10:00 AM - Penny hour11:00 AM - Appetizer hour2:00 PM - Bingo Observation on 2/22/2026 12:30 PM the activity calendar on the wall, close to nurse's station, large enough for residents to read, had no activities scheduled for weekends. Observations on 2/22/2026 from 1:00 PM to 4:00 PM revealed no activities were observed for residents. Observations on 2/23/2026 at 3:00 PM revealed no bingo or activities were observed for the day for residents. Observations on 2/24/2026 at 5:00 PM revealed staff were playing a game with a few residents in the front lobby, no other activities for the day. Observations on 2/25/2026 at 2:00 PM revealed a community volunteer was calling out numbers for Bingo in the dining room Record review of the December 2025 Resident Council minutes documented their favorite activity was bingo and they wanted more bingo. Record review Resident Council Minutes for January 2026 was documented their favorite activity was bingo and they wanted to play twice a week. Record review of February 2026 Resident Council minutes documented their favorite activity was Bingo. 2.Record review of Resident #27's admission Record dated 2/25/2026 documented she was admitted on [DATE], re-admitted on [DATE] with diagnoses of dementia, cognitive communication deficit, osteoarthritis of hip, difficulty walking, major depressive disorder, unsteadiness on feet and need assistance with personal care. Record review of Resident #27's Annual MDS dated [DATE] revealed her BIMs score was 12/15 (moderately cognitive impaired), Activities (f section) included very important things with groups of people, do favorite activity; somewhat imported was go outside to get fresh air, participate in religious services/practices, and she required a wheelchair to mobilize. Record review of Resident #27's care plan dated 1/31/2026 was documented for Activity, provide a program of activities that accommodate the resident abilities. Also, Resident #27 would benefit out of room social, spiritual, and stimulus activities and mental stimulation related to decrease interest in doing things due to diagnoses of depression. The Activity Director will encourage and remind the residents of current activities. Resident #27 will attend activities of her choice, watch television, read, and socialize with other residents at least 2 times weekly. Interview and observation on 2/24/2026 at 9:30 AM with Resident #27, while near the large Activity calendar for February 2026, near the nursing desk area. Resident #27 stated there was no Bingo yesterday, on 2/23/2026. Resident #27 stated there were no weekend activities, and nothing was planned, and the Activity Director had not worked for the last few days due to physical inability. 3.Record review of Resident #29's admission Record dated 2/25/2026 revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia, major depressive disorder, unsteadiness on feet, and need assistance with personal care. Record review of Resident #29's admission MDS dated [DATE] documented with BIMs score of 11/15 (moderate cognitive impairment), required a walker/wheelchair, and for Activities (f section) included very important was keep up with the news, do things with groups of people, do favorite activities, and go outside to get fresh air. Record review of Resident #29's care plan dated 1/27/2026 documented to encourage the residents to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Also, provide program of activities that accommodate the resident abilities. Interview on 2/25/2026 at 11:24 AM with Resident #29 stated they did not have pretty nails activity on 2/23/2026, Monday and no appetizer hour scheduled for today. Resident #29 stated they had activities this morning and did not have any all week, and no activities on weekends. Interview on 2/23/2026 at 10:00 AM with the ADM stated the Activity Director was not coming in today, Monday, 2/23/2026, due to physical ailments. ADM stated if Activity Director was not able to work, he would get staff together to ensure residents got the scheduled Activities. Interview on 2/24/2026 at 2:00 PM with the ADM stated the Activity Director was not coming in today, Monday, 2/23/2026, due to physical ailments. Interview on 2/25/2026 at 2:28 PM with the Activity Director stated she had been physically unable to go to work this week and does not work weekends. The Activity Director stated she comes in for resident activities once a month when she is the manager on duty. The Activity Director stated she did not have an assistant but had volunteers from community coming to visit and do different activities with residents. The Activity Director stated the one-to-one on the activity calendar; meant she meets with resident individually. The Activity Director stated the one-to-one notes were with her and not at the facility. The Activity Director stated she did not find out until later the volunteer bingo was cancelled. The Activity Director stated she was not aware the activities were not being held at the facility for residents. The Activity Director stated she did not have a back-up plan if she was not able to make it to work for the scheduled activities. The Activity Director stated on weekends she leaves board games and some volunteers for Bingo. The Activity Director stated church volunteers come in on Sundays. Activity Director usually gathers residents for activities and see if they wanted to come. Record review of policy Activity programming dated 2011, was documented The Activity Director and staff will provide for ongoing Activity program. 1. Recreation programs are based on the interest and needs of the resident expressed through the Activity assessment. 3. Activity program area based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. 5. Those who cannot participate in group settings are provided individual programming. inability to participate could include those who refuse to participate in activates, those who are in isolation, or physician orders bed rest. 6. Programming includes large groups, small groups, individual and independent opportunities. 7. Programs may take place in the mornings, afternoons, and /or evenings that span throughout the entire week.

Based on observation, interview, and record review, the facility to ensure the resident environment remains as free of accident hazards as is possible for residents for 1 of 4 shower rooms reviewed, in that: The shower room at the end of 300 hall contained an unlocked cabinet in which were approximately eight razors for shaving and a container of germicidal wipes labeled not a skin or baby wipe and keep out of reach of children. This deficient practice could result in residents living in an environment that is not safe, clean, and comfortable. The findings were: Observation on 02/22/2025 at 11:48 a.m. revealed the shower room at the end of 300 hall contained an unlocked cabinet in which were approximately eight razors for shaving and a container of germicidal wipes labeled not a skin or baby wipe and keep out of reach of children. Further observation revealed no residents were noted in the hallway near the shower room. During an interview with the Maintenance Director on 02/22/2025 at 11:50 a.m., the Maintenance Director confirmed that the cabinet containing razors and germicidal wipes should have been locked so that the items were out of reach of residents. Record review of the facility policy, Policy and Procedure: Maintenance of Physical Environment undated, revealed, The facility is committed to maintaining a safe, clean, and hazard-free physical environment for all residents, staff, and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Residents #37) reviewed for incontinent care and catheter care, in that: The facility failed to ensure that, while providing incontinent care for Resident #37, CNA A used a front to back motion to clean Resident #37. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #37's face sheet, dated 02/24/2026 , revealed an admission date of 09/04/2025 and, a readmission date of 10/17/2025, with diagnoses that included: Convulsions (involuntary movements of the body), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Dementia (decline in cognitive abilities), Hypertension (High blood pressure), Obstructive and reflux uropathy (urinary condition where blockages or backward urine flow can damage the kidneys if untreated). Record review of Resident #37's quarterly MDS, dated [DATE] , revealed a BIMS score of 2, which indicated the resident was severely impaired cognitively, and was indicated to always be incontinent of bowel and bladder. Record review of Resident #37's care plan, dated 09/25/2025, revealed a problem of The resident has bladder incontinence and, an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 02/24/2016 at 11:15 a.m. revealed while providing incontinent care for Resident #37, CNA A used a back and forth motion to wipe the resident instead of a front to back motion. During an interview on 02/24/2026 at 11:30 a.m. with CNA A, she stated she should have wiped front to back instead of using a back-and-forth motion and do multiple pass on the same area. During an interview with the DON on 02/24/2026 at 3:05 p.m., she stated that staff should not do back and forth motion with wipes during incontinent care. The staff should do a front to back pass with a wipe and change wipe before doing another pass to prevent fecal matter to enter the urinary tract and cause infection. She stated infection control training and incontinent care training were provided at least once a year and staff's skills were check once a year by the DON and ADON. Review of CNA proficiency audit for CNA A revealed she was passed proficiency on infection control and incontinent care on 10/15/2025. Record review of facility's policy titled Perineal care, dated 04/25/2022, revealed, Gently perform perineal care, wiping from clean urethral area to dirty, rectal area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary medication without adequate indication for its use, for 1 (Resident #11) of 15 residents reviewed for unnecessary medication, in that: Resident #11's prescription for Depakote did not have an associated diagnoses. This deficient practice could affect all residents who receive prescription medication. The findings were: Record review of Resident #11's face sheet, dated 02/24/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Adjustment Disorder with Mixed Anxiety and Depressed Mood, Generalized Anxiety Disorder, and Insomnia. Record review of Resident #11's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #11's care plan, initiated 07/26/2025, revealed, Adverse medication effect and behavior monitoring. Further review the resident's care plan revealed it did not address that the resident received Depakote. Record review of Resident #11's order for Depakote, dated 12/13/2025, revealed, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium). Give 1 capsule by mouth two times a day for mood stabilization. During an interview with the DON on 02/25/2026 at 10:59 a.m., the DON stated that Resident #11's Depakote order should have had an associated diagnoses, stated she did not know why it did not have one, and that it would be corrected. Record review of the facility policy, Unnecessary Medications, revised 02/12/2025, revealed, It is the policy of this facility each resident remains free of unnecessary medications. An unnecessary drug is any drug when used - . without adequate indications for its use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure menus reflected the needs of the resident population as well as input received from residents and resident groups for for 4 of 25 (Residents #29, #57, #22, and #17) residents reviewed for breakfast in that: 1. Resident #29 was bored of the same breakfast every morning and wanted variety.2. Resident #57 stated she was served the same breakfast every day and would rather have a variety of options. 3. Resident #22 stated she was served the same breakfast every day and would rather have a variety of options. 4. Resident # 17 stated he was served the same breakfast every day and would rather have a variety of options. This deficient practice could affect residents who consume breakfast and could result in psychosocial harm and/or weight loss. The findings were: 1. Record review of Resident #29's admission Record dated 2/25/2026 revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia, major depressive disorder, unsteadiness on feet, and need assistance with personal care.
Record review of Resident #29's consolidated orders for February 2026 documented Regular diet, Regular texture, and Regular consistency.
Record review of Resident #29's admission MDS dated [DATE] documented with BIMs score of 11/15 (moderate cognitive impairment), required a walker/wheelchair, was independent with eating and had not weight loss.
Record review of Resident #29's care plan dated 1/27/2026 documented potential risk for malnutrition, and intervention was updating food preferences as needed. Also, offer diet as ordered by the physician.
Record review of Resident #29's dietary profile dated 11/14/2026 documented she was on a regular diet, no allergies to foods, she likes breakfast, she was independent with eating, and some confusion/dementia was marked.
Record review of the Resident Council group meeting for February 2026 documented under Nutrition Services Review: Meal service compliments/concerns were, Variety on breakfast. Resident #29 was in attendance.
Observation on 2/23/2026 at 8:30 AM, 2/24/2026 at 8:15 AM and 2/25/2026 at 8:45 AM during breakfast revealed the meal served was: scrambled eggs, toast, sausage patties, bacon, gravy, and choice of cereal.
Interview on 2/23/2026 at 2:40 PM with Resident #29 stated the food was good, food comes out warm and stated she had the same breakfast every day. Resident #29 did report to ADM that breakfast was getting boring about 1 month ago
Interview on 02/25/2026 at 11:07 AM with Resident #29 said if they just had a little variety for breakfast and it would be nice. Resident #29 stated dietary staff had not asked for her preferences.
2. Record review of Resident #57's facesheet, dated 02/25/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Degenerative Disease of Basal Ganglia, Altered Mental Status, and Transient Cerebral Ischemic Attack.
Record review of Resident #57's admission MDS, dated [DATE], revealed a BIMS score of 12 which indicated Moderate cognitive impairment.
Record review of Resident #57's care plan, initiated 02/10/2026, revealed, The resident has an ADL Self Care Performance Deficit. Anticipate and meet the resident's needs.
Record review of Resident #57's order summary as of 02/25/2026, revealed, Regular diet Regular texture, Regular consistency.
During an interview with Resident #57 on 02/22/2026 at 10:32 a.m., the resident stated she had been served sausage and eggs every day since admission and though the food tasted good, she disliked having the same meal each morning and would rather have a variety of options.
3. Record review of Resident #22's facesheet, dated 02/25/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Atrial Fibrillation, Transient Cerebral Ischemic Attack, and Severe Protein Calorie Malnutrition.
Record review of Resident #22's quarterly MDS, dated [DATE], revealed a BIMS score of 9 which indicated moderate cognitive impairment.
Record review of Resident #22's care plan, initiated 12/19/2025, revealed, Determine food preferences and provide within dietary limitations.
Record review of Resident #22's order summary as of 02/25/2026, revealed, Regular diet Regular texture, Regular consistency.
During an interview with Resident #22 on 02/25/2026 at 8:26 a.m., the resident stated, I'm tired of the same thing every morning always eggs and sausage.
4. Record review of Resident #17's admission Record, dated 02/25/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Renal osteodystrophy, Pleural effusion, and Emphysema.
Record review of Resident #17's admission MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment.
Record review of Resident #17's care plan, initiated 02/04/2026, revealed, Determine food preferences and provide within dietary limitations.
Record review of Resident #17's order summary as of 02/25/2026, revealed, Renal diet Regular texture, Regular consistency, Large high protein portions.
During an interview with Resident #17 on 02/25/2026 at 8:31 a.m., the resident stated, Breakfast is always the same and I'm tired of eggs and sausage.
During an interview with the Dietary Manager on 02/25/2026 at 1:36 p.m., the Dietary Manager stated that the current menu has been in effect for a couple of month, and a few residents have told her that they are tired of having the same breakfast every day. The Dietary Manager stated that if the decision were hers to make, she would provide a variety, but that cooks must follow the menu. She stated that she had not discussed deviation to accommodate resident preference for variety with the consultant dietician.
Record review of the facility menus, dated 09/02/2025 and encompassing the time period of November 2, 2025 through May 30, 2026, revealed breakfast for each day was: choice of juice, hot or cold cereal, fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine, jelly, and whole milk.
Record review of the facility policy, Menu Approval and Honoring Residents Special Requests, and Food Brought to the Facility from Unapproved Sources, dated 2012, revealed, .Every attempt will be made to honor resident food preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure the food and drink that is palatable, attractive, and at a safe and appetizing temperature for 3 of 25 (#17, #25, and #57) residents reviewed for food temperature in that: 1.Resident #17 stated food temperature was cold. 2. Resident #25 stated food temperature was cold. 3. Resident #57 stated her meals were always served cold. This deficient practice could affect all residents who consume meals and/or snacks from the facility and could result in psychosocial harm and/or weight loss. The findings were:
1.Record review of Resident #17's admission Record dated 2/25/2026 documented he was admitted [DATE] with diagnoses of end stage renal disease, anxiety disorder and heart failure.
Record review of Resident #17's consolidated orders documented he ordered a Renal diet regular texture/consistency and large portions.
Record review of Resident #17's Quarterly MDS dated [DATE] documented his BIMs score was 11/15 (moderately cognitive impairment) and was independent with eating with no weight loss.
Record review of Resident #17's care plan dated 2/14/2026 documented he was on a renal diet, regular texture, regular consistency with interventions of determined food preferences and provide within dietary limits.
Record review of Resident #17's dietary profile documented he was on a regular diet, favorite meal breakfast, he was alert and was independent in eating.
Observation on 2/23/2026 at 2:57 PM with Resident #17s room revealed it was located at the end of the hall.
Interview on 2/23/2026 at 2:58 PM with Resident #17 stated he ate in his room and the food was cold.
2.Record review of Resident #25's admission Record dated 2/25/2026 was admitted on [DATE], re-admitted on [DATE] documented with diagnosis of major depressive disorder, dementia, and anemia.
Record review of Resident #25's consolidated orders for February 2026 was documented an order for Regular diet, texture and consistency.
Record review of Resident #25's Quarterly MDS dated [DATE] was documented that he had a BIMs score of 11/15 (moderately cognitive impairment), he was independent with eating with no weight loss.
Record review of Resident #25's care plan was documented with regular diet and regular texture.
Record review of Resident #25's dietary profile dated 2/25/2026 was documented regular diet, regular texture, liked breakfast and eat in the dining room.
Interview on 2/22/2026 at 3:12 PM with Resident #25 stated her food cold and usually ate meals in the dining room.
3. Record review of Resident #57's facesheet, dated 02/25/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Degenerative Disease of Basal Ganglia, Altered Mental Status, and Transient Cerebral Ischemic Attack.
Record review of Resident #57's admission MDS, dated [DATE], revealed a BIMS score of 12 which indicated Moderate cognitive impairment.
Record review of Resident #57's care plan, initiated 02/10/2026, revealed, The resident has an ADL Self Care Performance Deficit. Anticipate and meet the resident's needs.
Record review of Resident #57's order summary as of 02/25/2026, revealed, Regular diet Regular texture, Regular consistency.
During an interview with Resident #57 on 02/22/2026 at 10:32 a.m., the resident stated that she always ate in her room and all three meals were served cold. Resident #57 stated she generally enjoyed the taste of the meals, but that receiving cold food made it unpalatable.
During an interview with the Dietary Manager on 02/25/2026 at 1:36 p.m., the Dietary Manager stated that no residents had informed her that meals were served cold.
Record review of the facility policy, Daily Food Temperature Control, dated 2012, revealed, We will assure that food is served at a safe temperature.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: A jar of marmalade, labeled refrigerate after opening was stored in a non-refrigerated dry goods pantry after being opened. This deficient practice could affect all residents who consume meals and/or snacks provided by the facility and result in food-borne illness. The findings were: Observation on 02/25/2026 at 7:16 a.m. revealed an eighteen-ounce jar of marmalade, labeled refrigerate after opening was stored in the dry good pantry. Further observation revealed the marmalade had been opened and partially consumed. During an interview with Dietary [NAME] F on 02/25/2026 at 7:18 a.m., Dietary [NAME] F confirmed the jar of marmalade, labeled refrigerate after opening was stored in a non-refrigerated dry goods pantry after being opened and should have been refrigerated. Dietary [NAME] F stated she did not know why the marmalade had not been properly stored. During an interview with the Dietary Manager on 02/25/2026 at 1:36 p.m., the Dietary Manager stated the jar of marmalade, labeled refrigerate after opening was stored in a non-refrigerated dry goods pantry after being opened and should have been refrigerated. Record review of the facility policy, Food Storage and Supplies, dated 2012, revealed, All facility storage areas will be maintained in and orderly manner that preserves the condition of food and supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Residents #6, #23, #37 and #48) reviewed for infection control, in that: 1.On 02/24/2026, the facility failed to ensure CNA B and CNA C sanitized between their fingers while providing incontinent care for Resident #6 2. On 02/24/2026, the facility failed to ensure CNA D changed gloves between soiled and clean brief, while providing incontinent care for Resident #23. 3. On 02/24/2026, the facility failed to ensure CNA A sanitized her hands between change of gloves and after touching the resident's environment, while providing incontinent care for Resident #37. 4. On 02/24/2026, the facility Failed to ensure Medication Aide E changed her gloves and sanitized her hands after touching medication cart and the resident's environment, while administering eye drop medication for Resident #48. These deficient practices could place residents at-risk for infection due to improper care practices.The findings include: 1.Record review of Resident #6's face sheet , dated 02/24/2026, revealed an admission date of 03/12/2025, with diagnoses that included: Epilepsy (brain condition that causes recurring seizures), Down syndrome ( genetic disorder associated with developmental delays and mild to moderate intellectual disability), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism (under active thyroid),, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #6's Quarterly MDS assessment, dated 01/29/2026, revealed the resident was rarely understood and her cognition was severely impaired. Resident #6 was dependent of the staff for care, had an indwelling catheter and was always incontinent of bowel. Record review of Resident #6's care plan dated 03/25/2025, revealed a problem of The resident has bowel incontinence and an intervention of Provide pericare after each incontinent episode. An observation on 02/24/2026 at 10:20 a.m., revealed while providing incontinent care for Resident #6, CNA B and CNA C, while sanitizing their hands during care, did not sanitize between their fingers. During an interview on 02/24/2026 at 11:03 a.m. CNA B and CNA C stated they should sanitize between their fingers when they used sanitizer just like they did when they use soap and water. They did not know why they did not sanitize between their fingers. They stated they received infection control within the year. During an interview with the DON on 02/24/2026 at 3:05 p.m., she stated that staff should sanitize all surfaces of their hands to ensure appropriate hand hygiene and prevention infection to the resident. She stated infection control training was provided and staff's skills were checked annually. Record review of the facility's policy titled Fundamentals of Infection Control Precautions , dated 03/2023, revealed, Recommended techniques for performing hand hygiene [ .] applying product to the palm of one hand and rubbing hands together, covering all surfaces of hands and fingers. 2.Record review of Resident #23's face sheet, dated 02/24/2026, revealed an admission date of 02/23/2016 and a readmission date of 07/12/2022, with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Chronic kidney disease (gradual loss of kidney function), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #23's Quarterly MDS assessment, dated 02/17/2026, revealed the resident had a BIMS score of 15, indicating she was intact cognitively. Resident #23 was dependent of staff for toileting hygiene; she had an indwelling catheter and was always incontinent of bowel. Record review of Resident #23's care plan dated 09/27/2023, revealed a problem of is incontinent ofbowel. She requires assistance for toileting tasks, incontinent care. and an intervention of Check on Resident #23 at routine intervals to assess needs and offer assist with Bowel incontinences x1 staff member. May include 2 staff members at times. An observation on 02/24/2026 at 3:25 p.m., revealed while providing incontinent care for Resident #23 CNA D touched a soiled brief to remove it from the resident and without changing her gloves and sanitizing her hands placed a clean brief on the resident. During an interview on 02/24/2026 at 3:38 p.m., CNA D stated she did not realize she had touched both brief with the same gloves but knew she should change her gloves between soiled and clean briefs. CNA D stated she received infection control training within the year. During an interview with the DON on 02/24/2026 at 3:40 p.m., she stated that staff should change gloves and sanitize their hands before touching clean briefs to ensure appropriate hand hygiene and prevention infection to the resident. She stated infection control training was provided and staff's skills were checked annually. Record review of the facility's policy titled Fundamentals of Infection Control Precautions , dated 03/2023, revealed, The following list is a list of some situations that require hand hygiene [ .] after handling soiled or used linens, dressing, bedpans, catheter and urinals. 3.Record review of Resident #37's face sheet, dated 02/24/2026 , revealed an admission date of 09/04/2025 and, a readmission date of 10/17/2025, with diagnoses that included: Convulsions (involuntary movements of the body), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Dementia (decline in cognitive abilities), Hypertension (High blood pressure), Obstructive and reflux uropathy (urinary condition where blockages or backward urine flow can damage the kidneys if untreated). Record review of Resident #37's quarterly MDS, dated [DATE] , revealed a BIMS score of 2, which indicated the resident was severely impaired cognitively, and was indicated to always be incontinent of bowel and bladder. Record review of Resident #37's care plan, dated 09/25/2025, revealed a problem of The resident has bladder incontinence and, an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. An observation on 02/24/2026 at 11:15 a.m., revealed while providing incontinent care for Resident #37, CNA A, after washing her hands and donning gloves, touched the bed remote to move up the bed. She did not change her gloves and sanitize her hands and started providing care. While providing care, CNA A did not sanitize her hands between change of gloves. During an interview on 02/24/2026 at 11:30 a.m., CNA A stated she knew she needed to use sanitizer in between change of gloves but did not have sanitizer with her. She stated she forgot to change her gloves after touching the bed remote but knew the bed remote was considered dirty. She stated she received infection control training within the year. During an interview with the DON on 02/24/2026 at 3:05 p.m., she stated that staff should change gloves and sanitize their hands after touching anything in the resident's environment and sanitize their hands between change of gloves to ensure appropriate hand hygiene and prevention of infection to the resident. She stated infection control training was provided and staff's skills were checked annually. Record review of the facility's policy titled Fundamentals of Infection Control Precautions , dated 03/2023, revealed, The following list is a list of some situations that require hand hygiene [ .] after handling soiled or used linens, dressing, bedpans, catheter and urinals [ .] after removing gloves[ .]. 4.Record review of Resident #48's face sheet, dated 02/24/2026 , revealed an admission date of 06/23/2023, with diagnoses that included: Hemiplegia (Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), Dementia (decline in cognitive abilities). Record review of Resident #48's annual MDS, dated [DATE], revealed a BIMS score of 7, which indicated the resident was severely impaired cognitively. Resident #48 required extensive assistance to total care for his activities of daily living. Record review of Resident #48's care plan, dated 10/28/2025, revealed a problem of has (L) side Hemiplegia/Hemiparesis r/t CVAHigh Spasticity to Left side and, an intervention of Give medications as ordered. Monitor/document for side effects and effectiveness. An observation on 02/24/2026 at 8:30 a.m., revealed while administering eye drops to Resident #48, Medication Aide E touched her medication cart key, medication cart, Resident's side table and Resident's bed remote with her gloved hand. She did not change gloves or sanitize her hands before touching Resident #48's face and administering the eye drops. During an interview on 02/24/2026 at 8:55 a.m. Medication Aide E stated the key, medication cart, side table and bed remote were considered dirty or contaminated and she should have change her gloves and sanitize her hands before touching the resident and administering the drops. She stated she received infection control training with the year During an interview with the DON on 02/24/2026 at 8:58 a.m., the DON stated the staff should have changed her gloves and sanitize her hands before touching the resident and provide care. She stated the staff had received infection control training within the year. Record review of the facility's policy titled Eye Ointment Administration , dated 2025, revealed, Identify the resident before administering medication [ .] wash hands, don gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision.
The facility failed to supervise Resident #1 who eloped from the facility on 03/30/2025 when he exited through an unlocked sliding door at the end of hallway 200 and was found outside in the driveway.
The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/30/2025 and ended on 04/28/25. The facility had corrected the non-compliance before the survey began on 05/13/2025.
This deficient practice could place residents at risk of harm, serious injury, or death.
The findings included:
Record review of Resident #1's face sheet revealed the resident had diagnoses including unspecified Parkinsonism (a neurological condition that effect movement), Dementia (decline in cognitive abilities),Osteoarthritis (a joint disease resulting in breakdown of bone cartilage), Dystonia (movement disorder), Dysphagia (difficulty swallowing), Psychosis (a condition that causes disassociation from reality), Major Depression Disorder.
Record review of Resident #1's Quarterly MDS assessment, dated 3/17/25, revealed Resident #1 had a BIMS score of 3, indicating severe cognitive impairment. Further review of MDS assessment did not indicate a history of wandering behavior.
Record review of Resident #1's Care plan revealed resident had no prior history of elopement and the Care Plan was updated on 3/30/25 to reflect actual elopement and as risk for elopement with interventions of providing structured activities, distraction with diversions to include food, conversation, television, books, determine need for exercise, compliance rounds and supervision. Resident required no special supervision prior to this elopement.
Record review of Form 3613-A Self-Report Incident, dated 4/4/25, revealed facility identified and reported an elopement incident that occurred when Resident #1 eloped from the facility on 3/30/25 at 4:00 p.m. in accordance with state guidelines and completed internal investigation, in-services and monitoring. Further review revealed Resident #1 was found outside the facility near the laundry room by another resident who then brought Resident #1 to the 200 Hall door and informed staff.
In an interview with the Administrator on 5/13/25 at 10:20 a.m., the Administrator stated Resident #1 was found within 10 minutes of the last time he was seen by staff on 3/30/25. The Administrator stated Resident #1 had self-propelled to his room on 200 Hall (room [ROOM NUMBER]) from common area and self-propelled out the end of the hallway door. The Administrator stated the door was normally locked and required a keypad code to enter and exit, but it was unlocked on 3/30/2025 when Resident #1 eloped from facility. The Administrator stated the facility was unable to state for certain what caused the door alarm to malfunction, but believed the keypad was affected by the weather or storm on that day. The Administrator stated the affected entry way was and remained a high traffic area as that was the entry and exit way staff used for laundry and trash barrels 24-hours a day.
Observation from 5/13/25-5/15/25 between hours of 8:00 a.m. and 4:00 p.m. each day revealed all of the resident corridor hallway door alarms were in working order.
During an interview with the Administrator on 5/13/25 at 10:20 a.m., The Administrator stated that all of the active staff working in the facility at the time of the incident on 3/30/25 were in-serviced on resident elopement protocol.
Record review of additional in-service training revealed live elopement drills were completed for all three shifts beginning 3/30/25 and continued thru 4/25/25.
Record review of the facility's staff roster revealed there were 76 active current employees and all employees received elopement protocol In-service to include Elopement prevention & response, how to monitor electric sliding keypad doors to include re-setting door lock and guidance to notify Administrator immediately if door lock is not able to be re-set and to utilize door monitor at all times until door lock is repaired, elopement protocol and Abuse & Neglect.
Record review of in-service training records dated 3/30/25 revealed 24 licensed nursing staff received in-service training on 3/30/25 to include how to identify residents who were elopement risk and how to locate risk Assessment, BIMS assessment and elopement care plan in EMR (Electronic Medical Record) and complete accurately.
Record review of in-service training records dated 3/30/25 revealed 27 nurse aides / certified medication aids received in-service training on 3/30/25 on how to locate and identify residents who are an elopement risk.
Record review of in-service training records dated 3/30/25 revealed 24 non-licensed employees received in-service on 3/30/25 on how to identify and recognize residents who may be a risk for elopement.
Record review of active employee roster dated 5/13/25 revealed all employees had received elopement protocol training.
Interviews with 27 staff on 5/13/25 from 10:00 a.m. to 4:07 p.m. revealed the 27 staff (Administrator, DON, Activity Director, BOM, Medical Records, HR Director, FSS, Dietary I, Dietary J, Dietary K, Dietary L, Housekeeper M, Floor Maintenance N, Housekeeper O, Laundry Aide P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, Hospitality Aide W, CNA X, Director of Rehab, COTA AA, PTA, BB, and OT CC) revealed they had received in-service trainings for elopement protocols, and staff were able to verbalize an understanding of the facility's elopement protocols.
Record review of door monitoring dated 4/1/25-4/28/25 revealed all corridor doors, front door and dining room doors were checked every 15 minutes for security.
Record review of elopement monitoring of Resident #1 was completed 3/31/25-4/28/25 with no attempts at elopement.
Record review of elopement assessments were completed 5x/week for 4 weeks for all residents at risk for elopement.
Record review of the facility Post Elopement Drill / Actual Elopement Guide revealed facility would verify elopement, notify staff and family, and complete post event documentation for elopement protocol.
A request was made for a Policy for Elopement on 5/15/25, not received prior to exit.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 3 spa/shower rooms reviewed, in that:
The toilet in the spa/shower room on 200 hallway was loosely affixed to the floor and was able to be moved approximately two inches to the side.
This deficient practice could place residents, staff, and the public at risk of living, working, and visiting within an environment which was unsafe and not functional.
The findings were:
Observation on 11/12/2024 at 11:10 a.m. revealed the toilet in the spa/shower room on 200 hallway was loosely affixed to the floor and was able to be moved approximately two inches to the side.
During an interview with the Administrator on 11/12/2024 at 11:12 a.m., the Administrator confirmed the toilet in the spa/shower room on 200 hallway was loosely affixed to the floor and was able to be moved approximately two inches to the side. The Administrator further confirmed that anyone who attempted to utilize the toilet could possibly fall and sustain an injury. The Administrator directed staff to close the spa/shower room until the toilet was repaired.
Record review of the facility's Preventive Maintenance Policy dated 2003 revealed, Preventative maintenance is an undeniably critical component to any maintenance strategy .It is key to lowering maintenance costs, reducing equipment downtime improving asset lifespan, efficiency and increasing environmental safety .Maintenance employee will take the necessary precautions and actions to reduce equipment failures from occurring before they happen. For example, performing regular business and equipment inspections, cleaning and lubricating essential equipment, tidying the facility grounds .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 14 residents (Resident #30) reviewed for advanced directives, in that:
The facility failed to ensure Resident #40's Out-of-Hospital Do Not Resuscitate (OOH DNR) was signed by two witnesses, which made the document invalid.
This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.
The findings included:
Record review of Resident #30's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage without loss of consciousness (a brain injury that occurs when blood pools under the dura mater, usually due to a head injury), chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe), and chronic systolic (congestive) heart failure (a serious condition that occurs when the heart can't pump enough blood to the body). Further review of Resident #30's face sheet revealed the resident was identified as DNR status.
Record review of Resident #30's 5-day scheduled assessment MDS assessment, dated [DATE], revealed the resident had a BIMS of 8, indicating moderately impaired cognition.
Record review of Resident #30's comprehensive care plan, updated [DATE] revealed the resident was DNR status with interventions which included in absence of b/p, pulse, and respiration, CPR will not be initiated.
Record review of Resident #30's Order Summary Report, dated [DATE], revealed the following:
- DNR (Do Not Resuscitate), with an order date of [DATE] and no end date.
Record review of Resident #30's OOH DNR, dated [DATE], revealed it was signed by Resident #30 and the resident's physician on that date. The area for two witnesses was blank.
During an interview on [DATE] at 12:30 PM, the Regional Compliance RN stated Resident #30's OOH-DNR form was missing two signatures, rendering the form invalid. This meant the resident would receive CPR if she went into cardiac arrest.
During an interview on [DATE] at 12:55 PM, the DON stated there were no witness signatures on Resident #30's OOH-DNR form, which made the form invalid. The consequence of this failure was in the event the resident goes into cardiac arrest, she would be administered CPR, which would be against her wishes.
Record review of the facility policy EL 03-4.0 Do Not Resuscitate Order, revised [DATE], revealed: Procedure: 1. Any resident may initiate an Out of Hospital DNR Order. The resident's attending physician will document the presence of the terminal condition in the resident's permanent record. 2. If the resident is capable of providing informed consent for the order, he/she will sign and date the DNR order on the front of the official DNR form .5. In all cases the form must be signed and dated by two witnesses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 residents (Resident #37) reviewed for pharmacy services, in that:
The Narcotics refrigerator in the main medication storage room, contained an opened and expired medication, Lorazepam for Resident #37.
This failure could affect residents whose medications were stored in the medication storage room and place residents at risk of receiving expired medications.
The findings were:
Observation on 11/13/2024 at 4:17 p.m. of the facility medication storage room with the ADON present, revealed one expired medication, Lorazepam 2 mg/ml for Resident #37, found in the locked Narcotics refrigerator. The Pharmacy Label on the outside of the box read, discard 3/12/2024. The expiration date on the bottle itself was, 31 [DATE].
During an interview with the ADON on 11/13/2024 at 4:20 p.m., the ADON stated Resident #37's Lorazepam was expired and should have been discarded by the pharmacy expiration date on the label of 3/12/2024. The ADON stated that expired or discontinued medications should be removed from medication carts or storage room by each respective Nurse or Medication Aide as they conduct their medication cart checks, and that the Supply Nurse and DON, should check and dispose of any expired medications in the medication storage room during re-supply. The ADON stated that for expired controlled medications like the Lorazepam, they should be removed and placed in the locked storage inside the DON's office until the Pharmacist comes and conducts expired medication disposal. The ADON stated that keeping the expired Lorazepam stored with current medications could increase the risk of an expired medication being given, since Resident #37 was still in the facility, and noted that medication that was expired might be less effective.
Record review of the Pharmacist's Monthly Medication Review for October 2024, included a Medication Cart Audit dated 9/17/2024 which revealed, Medications that have been discontinued or meds for patients that have discharged - They should be pulled from the carts/med room same day and 3. I recommend pulling expiration dates 2-3 months in advance to avoid expired administration.
Record review of facility policy titled Storage of Controlled Substance undated but is part of the facility Pharmacy Policy & Procedure Manual 2003, revealed, Drugs shall not be kept on hand after the expiration date on the label, and no contaminated or deteriorated drugs shall be available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 1 narcotics refrigerator in main medication room, and for 1 of 2 medication carts (Hall 200 Medication Cart) reviewed for storage, in that:
1. During medication administration for Resident #34, MA- A left Hall 200 Medication cart unlocked outside the resident's room, out of sight of MA-A.
2. During medication administration for Resident #20, MA-B left 8 blister packages of medication unattended and unsecured on top of the 200 Hall medication cart.
These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards and not receiving therapeutic effects.
1. Observation on [DATE] at 7:56 a.m. revealed MA-A entering Resident #34's room carrying a wrist blood pressure cuff and shutting the curtains to doorway behind her. While she was inside the resident's room checking Resident #34's blood pressure, the medication cart was left unlocked outside the room and out of sight of MA-A. Inside the unlocked cart were medication blister packs, bottles and vials of medications for the residents on Hall 200.
During an interview with MA-A on [DATE] at 8:22 a.m., MA-A stated the medication cart was left unlocked while she was administering medications to Resident #34 inside the resident's room and out of view of the medication cart. MA-A stated she knew she was supposed to keep the medication cart locked when she was away from the cart but had forgotten to lock it. She stated that leaving the cart unlocked could result in medications being accessed by other residents or staff.
During an interview on [DATE] at 11:10 a.m., the RCN stated that the medication carts need to be kept locked at all times when not being directly accessed by Nurse or Medication Aide.
Record review of facility policy titled Medication Administration Procedures undated, revealed under #8. After the medication administration process is completed, the medication cart must be completely locked or otherwise secured, and included in #5 During the medication administration process the unlocked side of the cart must always be in full view of the nurse.
2. Observation on [DATE] at 8:39 a.m., revealed MA-B prepared Resident #20's medications by popping out his medications from blister packs into a medication cup, then leaving the medication blister packs on top of the medication cart, locked the medication cart, and entered Resident #20's room carrying the medication cup and water. While MA-B was inside Resident #20's room administering his medications, the medication blister packs for the following medications: Buspirone 10 mg, Rytary 48.75/195 mg, Lasix 20 mg, Losartan 50 mg, Venlafaxine 75 mg and Venlafaxine 150 mg, Tizanidine 2 mg and Potassium Chloride ER 20 meq were left unsecured and unsupervised on top of the medication cart that was located outside his room and out of sight from MA-B.
During an interview with MA-B on [DATE] at 8:48 a.m. MA-B stated she knew she was supposed to keep the medications locked inside the cart but stated she got nervous and forgot to lock them back up inside the cart when she went inside Resident #20's room to give him his medications. MA-B stated that leaving medications out on top of the cart unsecured and unattended could result in someone stealing the medications or accidentally taking them.
During an interview on [DATE] at 9:00 a.m., the RCN stated medications should always be secured inside the locked medication cart and stated that the Medication Aide had been trained in medication administration and keeping medications locked but was just nervous and off her normal routine while being monitored by the Surveyor.
Record review of the Pharmacist's Monthly Medication Review for [DATE], included a Medication Cart Audit dated [DATE] which revealed, Medications that have been discontinued or meds for patients that have discharged - They should be pulled from the carts/med room same day and 3. I recommend pulling expiration dates 2-3 months in advance to avoid expired administration.
Record review of facility policy titled Storage of Controlled Substance undated but is part of the facility Pharmacy Policy & Procedure Manual 2003, revealed, Drugs shall not be kept on hand after the expiration date on the label, and no contaminated or deteriorated drugs shall be available.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #24) reviewed for infection control, in that:
MA A did not sanitize the blood pressure cuffs (wrist and manual) and stethoscope between use with different residents.
This deficient practice could place residents at-risk for infection due to improper care practices.
The findings include:
During an observation on 11/13/2024 at 7:56 a.m. MA A was observed to take the blood pressure for Resident #34 using a wrist blood pressure (B/P) cuff at first, and then after repeated error messages, switched to using the manual B/P cuff with stethoscope to assess Resident #34's blood pressure. MA-A then placed the wrist cuff back on the medication cart and the manual blood pressure (B/P) cuff inside the medication cart along with stethoscope and proceeded with medication administration to Resident #34. Then without sanitizing either the wrist or manual B/P cuff and stethoscope proceeded to Resident #24 to take his blood pressure using both the same wrist and manual B/P cuffs and stethoscope.
During an interview with MA A on 11/13/2024 at 8:22 a.m., MA A stated she had taken blood pressures on two different residents using the same wrist and manual B/P cuffs and stethoscope and stated she did not sanitize the cuffs or stethoscope between the residents. She stated she just forgot, but knew she was supposed to sanitize the cuffs in between uses with different residents as not sanitizing could be a risk for infection for the residents. She confirmed receiving training for infection control within the year.
During an interview on 11/13/2024 at 11:10 a.m., the RCN stated the MA should have sanitized the blood pressure cuff and stethoscope in between use with the different residents to avoid cross contamination. The RCN revealed infection control training was provided to the staff annually and as needed with competency checks.
Review of facility policy, titled Fundamentals of Infection Control Precautions, updated 3/2023, revealed Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant and Under Surveillance section Ensures that reusable equipment is appropriately cleaned, disinfected or reprocessed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for the safe storage, preparation, distribution, and serving of food, in that:
The facility failed to discard an expired food item in the facility reach-in refrigerator.
This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for receiving expired food items.
Findings included:
During an observation on 10/18/2024 at 08:25 a.m. in the facility's reach-in refrigerator, there was a plastic container labeled pineapple, dated 10/07/2024, and Use by: 10/14/2024.
During an observation and interview on 10/18/2024 at 08:25 a.m., [NAME] A stated the kitchen staff were told to date leftover items for use by 7 days after having been opened and stored. [NAME] A stated all kitchen staff were responsible for pulling food items out that were past their use-by date. When questioned, [NAME] A was observed taking the container labeled pineapple with Use by: 10/14/2024 from the investigator and stated she would take care of the item. [NAME] A stated there was not a concern for the pineapple having been left in the refrigerator past its use-by date because it had not been served.
During an interview on 10/18/2024 at 11:45 a.m., the RCN stated she did not see an impact for an item having been in the refrigerator past it's use-by date if the item was not used.
Attempted interview of the RDN on 10/18/2024 at 03:24 p.m. was unsuccessful.
The DM and the ADMIN were unavailable for interview on 10/18/2024.
Record review of the facility policy titled Food Storage and Supplies, dated 2012, reflected .9 . Perishable items that are refrigerated are dated once opened and used within 7 days .
Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5°C (41°F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .Open and hold cold (B) . refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in § (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by date if the manufacture determined the use-by date based on food safety.

Based on observation, interview, and record review, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 days (10/15/2024 to 10/16/2024) of 2 days reviewed.
The facility did not post the required current nurse staffing information from 10/15/2024 to 10/16/2024.
This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.
Findings included:
During an observation on 10/17/2024 at 09:03 a.m., a document labeled [facility name] Daily Staffing of Nursing Personnel dated 10/14/2024, was posted in a vertical sign holder on the nurses' station. The census on the document was noted as 45.
During an observation and interview on 10/17/2024 at 09:05 a.m., the MDS Nurse stated she and the ADON were responsible for updating the daily census and nurse staffing document daily and tried to have it posted before 9 o'clock. The MDS Nurse stated she and the ADON covered the responsibility when the other was not available. The MDS Nurse stated she could not find the scheduling book on the morning of 10/17/2024 which was why it was posted after 09:00 a.m. The MDS Nurse stated she was not sure why the posted document said the 14th. The MDS Nurse was observed removing the posted document, labeled [facility name] Daily Staffing of Nursing Personnel and dated 10/14/2024, and replaced it with a document, labeled [facility name] Daily Staffing of Nursing Personnel and dated 10/17/2024, during the conversation. The census on the document dated 10/17/2024 was noted as 47.
During an interview on 10/17/2024 at 08:22 p.m., the RCN stated the facility did not have a policy on staffing but did have a checklist that was used for required postings in the facility.
During an interview on 10/18/2024 at 11:45 a.m., the RCN stated every facility she worked with was different and the nursing facility company did not have company wide requirement for who was responsible for posting the daily census and nurse staffing posting. The RCN stated she did not feel there would be an impact on the posting being late or missed because there was a sign-in sheet that the facility staff used, and it would let the staff know where their assignment was and identify the other staff scheduled to work.
During an interview on 10/18/2024 at 01:37 p.m., the ADON confirmed she was normally responsible for posting the daily census and nurse staffing document and stated she tried to get the MDS Nurse to cover for her when she was not available. The ADON stated she was not sure who her actual back-up was for this task. The ADON stated that the facility goal was to post the daily census and nurse staffing document by 09:00 a.m., after the morning meeting. The ADON stated because she came in late on Tuesday, 10/15/2024, and was doing medication administration on Wednesday and Thursday morning, 10/16/2024 and 10/17/2024; the posting was missed or late.
Record review of facility document, Mandatory Posting, undated, revealed Daily Staffing by shift of Licensed and Unlicensed Nursing Staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 Residents (Resident #34) whose MDS records were reviewed for accuracy in that:
Resident #34's quarterly MDS assessment dated [DATE] incorrectly documented the resident was treated with insulin.
This failure could place residents at risk for inadequate care due to inaccurate assessments.
The findings included:
Record review of Resident #34's face sheet, dated 9/27/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on 10/16 21 with diagnoses that included diabetes with diabetic neuropathy (a chronic, long-lasting condition that affects how your body turns food into energy with damage to nerves in your body including your feet, organs, and muscles), muscle weakness and need for assistance with personal care.
Record review of Resident #34's most recent quarterly MDS assessment, dated 9/4/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and for Section N - Medications, under Insulin, Resident #34 was identified as having received insulin injections 1 day during the last 7 days and had orders for insulin injections of any type were received during the last 7 days.
Record review of Resident #34's comprehensive care plan, revision date 5/8/23 revealed the resident had diabetes with interventions that included to check sugar levels as ordered and check all of body for breaks in skin and treat promptly as ordered by doctor.
Record review of Resident #34's Order Summary Report, dated 9/27/23 revealed the following non-insulin medicines:
-Bydureon BCise Subcutaneous Auto-injector 2 MG/0.85 ML, inject 1 dose subcutaneously one time a day every Friday related to type 2 diabetes mellitus with diabetic neuropathy with order date 4/20/23 and no end date
-Glipizide 5 mg tablet by mouth one time a day related to type 2 diabetes mellitus with diabetic neuropathy with order date 4/14/22 and no end date
-Metformin 500 mg tablet by mouth one time a day related to type 2 diabetes mellitus with diabetic neuropathy with order date 10/6/21 and no end date.
Further review of Resident #34's Order Summary Report revealed the resident was not treated with insulin.
During an interview on 9/28/23 at 11:52 a.m., the DON revealed the MDS, and the care plan were the responsibility of the MDS Coordinator. The DON stated Resident #34 had diabetes and was treated with metformin and glipizide. The DON further stated she was not certain if Bydureon was insulin but confirmed it was used to treat diabetes. The DON stated, if the MDS was incorrectly coded then it would be considered inaccurate and it would not reflect the resident correctly.
During an interview on 9/28/23 at 12:05 p.m., the MDS Coordinator revealed Resident #34 was a diabetic and had been treated with Bydureon injection she believed to be a form of insulin. The MDS Coordinator revealed she was not aware Bydureon injection was not an insulin and was marked in error on the MDS assessment. The MDS Coordinator stated the error on the MDS assessment did not truly reflect the resident and the MDS assessment was used for reimbursement and to tell the story of the resident. The MDS Coordinator stated the RAI manual was used to develop/complete the MDS.
Record review of the medication prescribing information for Bydureon injection, revision date 1/2012 revealed in part, .Bydureon is an extended-release formulation of exenatide, administered as an injection once every seven days (weekly) .Bydureon is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus in multiple clinical settings .Bydureon is not a substitute for insulin .
Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 13.16% percent with 38 medication administration opportunities observed with 5 errors for 2 of 3 residents (Residents #6 and #35) and 1 of 2 (Medication Aide A) reviewed for medication administration, in that:
Medication Aide A administered an expired medication to Resident #6 and administered medications to Resident #35 outside parameters as ordered by the physician.
These deficient practices could place residents at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order.
The findings included:
1. Record review of Resident #6's face sheet dated 9/28/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, hypertensive heart disease without heart failure, hypertension (high blood pressure) and need for assistance with personal care.
Record review of Resident #6's most recent quarterly MDS assessment, dated 8/24/23 revealed the resident was severely cognitively impaired for daily decision-making skills.
Record review of Resident #6's comprehensive care plan, revision date 5/8/23 revealed the resident had hypertension with interventions that included to give medications as ordered.
Record review of Resident #6's Order Summary Report, dated 9/28/23 revealed the following:
-Norvasc tablet 5 mg (amlodipine besylate) give 1 tablet by mouth one time a day for hypertension with order date 6/24/22 and no end date
Record review of Resident #6's MAR for September 2023 revealed the following:
- Norvasc tablet 5 mg (amlodipine besylate) give 1 tablet by mouth one time a day for hypertension scheduled for 7:30 a.m.
Observation on 9/28/23 at 7:52 a.m., during the medication pass revealed Medication Aide A administered 1 tablet of Norvasc tablet 5 mg (amlodipine besylate) with expiration date 6/2023 to Resident #6.
During an interview on 9/28/23 at 7:56 a.m., Medication Aide A revealed Resident #6's medications were provided to the facility by the family and were checked by the charge nurse or the ADON for expiration dates before they were placed in the medication cart. Medication Aide A confirmed the Norvasc tablet 5 mg (amlodipine besylate) medication was expired. Medication Aide A then revealed the medications in the medication cart should be checked for expired medications by the medication aide or whoever was using the medication cart. Medication Aide A revealed, expired medications could result in the loss of therapeutic effect if given past the expired date.
2. Record review of Resident #35's face sheet dated 9/28/23 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, pure hyperglyceridemia (high concentration of triglycerides, most abundant fatty molecule in most organisms, in the blood), anemia (condition in which the blood does not have enough healthy red blood cells), hyperlipidemia (high cholesterol), difficulty in walking, and need for assistance with personal care.
Record review of Resident #35's most recent quarterly MDS assessment, dated 8/21/23 revealed the resident was moderately cognitively impaired for daily decision-making skills.
Record review of Resident #35's comprehensive care plan, revision date 5/8/23 revealed the following:
-resident had congestive heart failure and hypertension with interventions that included to administer hypertensive medications as ordered, metoprolol
-resident had potential for weight loss due to anemia with interventions to administer medications as ordered, ferrous sulfate
-resident had hyperlipidemia/hypercholesterolemia with interventions that included to administer medication as ordered, fenofibrate
Record review of Resident #35's Order Summary Report, dated 9/28/23 revealed the following:
-Amantadine tablet 100 mg, give 1 tablet by mouth one time a day for mild motor symptoms with order date 3/1/21 and no end date
-Fenofibrate tablet 145 mg, give 1 tablet by mouth one time a day for elevated triglycerides with order date 6/10/21 and no end date
-Ferrous Sulfate tablet 325 mg, give 1 tablet by mouth one time a day related to anemia with order date 6/30/21 and no end date
-Metoprolol Succinate ER tablet extended release 24-hour 100 mg, give 1 tablet by mouth two times a day related to hypertensive heart disease with heart failure with order date 12/2/22 and no end date
Record review of Resident #35's MAR for September 2023 revealed the following:
-Amantadine tablet 100 mg, give 1 tablet by mouth one time a day for mild motor symptoms scheduled for 7:00 a.m.
-Fenofibrate tablet 145 mg, give 1 tablet by mouth one time a day for elevated triglycerides scheduled for 6:30 a.m.
-Ferrous Sulfate tablet 325 mg, give 1 tablet by mouth one time a day related to anemia scheduled for 7:00 a.m.
-Metoprolol Succinate ER tablet extended release 24-hour 100 mg, give 1 tablet by mouth two times a day related to hypertensive heart disease with heart failure scheduled for 7:00 a.m.
Observation on 9/28/23 at 8:33 a.m. during the medication pass revealed Medication Aide A administered Resident #35's Amantadine, Fenofibrate, Ferrous Sulfate and Metoprolol outside parameters as ordered by the physician.
During an interview on 9/28/23 at 8:47 a.m., Resident #35 revealed he had not received any medications on 9/28/23 prior to the medications administered by Medication Aide A. Resident #35 stated, I'll take my medications any time they give them to me. Doesn't matter if it's before or after breakfast.
During an interview on 9/28/23 at 8:49 a.m., Medication Aide A revealed she started her shift at 6:00 a.m. and started her shift by checking the medication cart to ensure it was stocked, stocked a pitcher with ice water and then started medication pass. Medication Aide A revealed she had asked Resident #35 if he wanted his medications at the beginning of the shift but Resident #35 wanted to go to the dining room first. Medication Aide A stated, medications needed to be given as scheduled because physician's orders were supposed to be followed and if not given as scheduled the medication would not have the proper therapeutic effect.
During an interview on 9/28/23 at 9:16 a.m., the DON confirmed medications were scheduled per facility policy and could be administered up to one hour before and one hour after the scheduled time.
During a follow up interview on 9/28/23 at 11:41 a.m., the DON revealed there were some residents who preferred their medications after eating breakfast but Resident #35 was not one of them. The DON revealed, Resident #35 would have taken his medications whenever they were offered. The DON revealed, expired medications given to the residents could result in an adverse effect or the resident could get sick and it would not be effective if used past the expiration date. The DON revealed, medications not administered during their scheduled time could results in those medications negatively interacting with other medications and could also results in the medication not providing a therapeutic effect. The DON revealed medications not given per schedule was not following the physician's orders.
Record review of the Medication Aide Proficiency Audit for Medication Aide A, dated 12/23/22 revealed Medication Aide had satisfied the requirements for passing medications, including checking medications 3 times, observing the 6 rights of medication including Right Time and checking medications for expiration dates.
Record review of the facility policy and procedure titled, Medication Administration Procedures, revision date 10/25/17 revealed in part, .If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes .Defining the schedules for administering medications to: Maximize the effectiveness of the medication .The 10 rights of medication should always be adhered to .Right time .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:
1. There was a storage container of prepared food in the reach-in cooler that was not properly sealed.
2. There was an open container of cottage cheese in the reach-in cooler without a date indicating when it should be used or discarded.
3. There were three open containers of thickened liquids in the reach-in cooler without dates indicating when they should be used or discarded.
4. There was an open 25 lb. sack of whole milk powder in the dry storage room that was rolled down and not placed in a sealed container.
These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.
The findings included:
1. Observation on 09/26/2023 at 11:17 a.m. in the reach-in cooler revealed a clear, plastic 4-quart container filled with cooked black-eyed peas. The container had a red plastic lid that did not extend to the end of the container, resulting in a gap approximately ½ between the lid and the container and exposing the contents of the container to the ambient air in the cooler and potential contamination by pathogens and bacteria.
Interview on 09/26/2023 at 11:20 a.m. with the DM revealed the lid on the container did not fully cover the container, preventing the container from being tightly sealed and exposing the contents of the container to the ambient air in the cooler. The DM stated he was aware there were problems with the lids for the containers and the facility needed to procure new ones. The DM further stated all dietary employees were trained to label, date and completely seal all food stored in the coolers, and he provided training monthly.
2. Observation on 09/26/2023 at 11:30 a.m. in the reach-in cooler revealed a 5-lb. container of cottage cheese that had been opened. There was a typed label on the container with the date 09/06/2023 and written in marker was, Open 09/13/2023. There was no marking to indicate the date or day by which the cottage cheese should be used or discarded.
Interview with the DM on 09/26/2023 at 11:32 a.m. revealed he acknowledged the cottage cheese was opened over ten days prior, did not have use-by date indicated by the facility, and should have been discarded to ensure it was safe from spoilage.
3. Observation on 09/26/2023 at 11:35 a.m. in the reach-in cooler revealed a 46 oz. container of thickened orange juice, a 46-oz. container of thickened lemon-flavored water and a 46-oz. container of thickened sweetened tea. On the thickened orange juice was written in marker, 8/16/2023. On the thickened lemon water there was a typed label reading 9/13/2023. On the thickened sweet tea was a typed label reading 9/06/2023.
Interview with the DM on 09/26/2023 at 11:36 a.m. revealed he acknowledged the thickened liquids did not have use-by dates but did not believe thickened water, tea and juice were subject to spoilage.
4. Observation on 09/26/2023 at 11:40 a.m. in the dry storage room revealed a 25 lb. paper sack of powdered milk. The sack had been opened and was rolled down. It was not placed in a sealed container to prevent potential contamination from rodents or pests.
Interview on 09/26/2023 at 11:41 a.m. with the DM revealed he acknowledged the sack of powdered milk had been opened and not properly stored in sealed container. The DM stated not properly sealing the powdered milk made it subject to potential contamination from pests.
Interview on 09/29/2023 at 9:45 a.m. with the administrator revealed all foods stored in coolers needed to be properly covered to prevent contamination from bacteria. The container of cottage cheese had been in the cooler for over ten days and should have been discarded. All foods brought into the facility are labeled with the date they are received and are marked with the date they are opened. The labels on the three containers of thickened liquids indicated the dates they were received by the facility. The administrator acknowledged all three containers had been opened and there were no labels or dates indicating the dates they were opened, and once opened, they were subject to deterioration and could potentially cause foodborne illness. The sack of milk powder in the dry storage room not placed in a sealed container after it had been opened and should have been to prevent the risk of contamination by pests.
Record review of facility policy IC00-8.0 Food Storage and Supplies, Dietary Services Policy & Procedure Manual 2012, revealed: 3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. 9. Perishable items that are refrigerated are dated once opened and used within 7 days.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.
Review of product storage instructions from the manufacturer of the thickened orange juice, water and sweet tea revealed all three products had the same storage instructions: Refrigerate after opening and use within 7 days. https://lyonsreadycare.com/collections/dysphagia/products/thickened-orange-juice-cartons-nectar-level-2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #1) reviewed for infection control, in that:
While providing incontinent care for Resident #1 CNA B did not wash or sanitize her hands between change of gloves before touching the resident's clean brief and after cleaning the resident's buttocks' area. The soiled brief and draw sheet came in contact with the inside of the new brief.
These deficient practices could place residents at-risk for infection due to improper care practices.
The findings included:
Record review Resident #1's face sheet, dated 08/31/2023, revealed an admission date 12/17/2018 and, a readmission date of 06/09/2023 with diagnosis including: Dementia(decline in cognitive abilities), Chronic kidney disease(gradual loss of kidney function), Hypertension(High blood pressure), anemia(blood disorder in which the blood has a reduced ability to carry oxygen)
Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 0 indicating severe cognitive impairment. Resident #1 required extensive assistance, was always incontinent of bladder and bowel.
Observation on 08/31/23 at 11:30 a.m. while providing perineal care for Resident #1, CNA B, after cleaning the resident buttocks, changed her gloves but did not sanitize her hands. The resident had a loose bowel movement and the CNA had feces on her gloves.
While changing the soiled briefs and draw sheet, NA A and CNA B rolled the soiled items against the resident then placed the new briefs an draw sheet under the soiled sheet and brief. When they rolled the resident the dirty draw sheet, which was stained with feces, came in contact with the inside of the new brief.
During an interview with CNA B on 08/31/2023 at 11:47 a.m , she confirmed she should have sanitized or washed her hands between changing gloves and understood it could cause a risk of cross contamination. She forgot to use sanitizer. She confirmed she received training for infection control and hand hygiene. She did realize she was contaminating the new brief and thought she was using the proper way to change the linen and brief.
During an interview with the DON on 08/31/2023 at 11:55 a.m., the DON confirmed not sanitizing between change of gloves was a risk of infection for the resident. She confirmed the soiled draw sheet should have not gotten in contact with the inside of the new brief. She confirmed training for infection control was done at least annually and every time a concern with infection control occurred.
Record review of annual skills checklist revealed skills checks were not done for NA A and CNA B since they had not been employed at the facility for a year.
Record review of the facility's policy, titled, Perineal care, dated 05/11/2022, revealed, Always perform hand hygiene before and after glove use.