Health inspection·November 29, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 of 15 residents (Resident #3 and Resident #19) reviewed for Respiratory Care. Residents Affected - Few The facility failed to follow MD orders for initial and dating oxygen supplies for Resident #3 and Resident #19. This deficient practice has the potential to affect residents by placing them at an increased risk of respiratory compromise, infections, pneumonia, respiratory distress, and sepsis. Findings include: Resident #3 Record review of Resident #3's face sheet dated 11/29/23 revealed an [AGE] year-old female with an admission date of 07/18/05 with the following diagnoses: dementia (cognitive loss), diabetes (high blood sugar) and schizoaffective disorder (mental illness). Record review of Resident #3 quarterly MDS dated [DATE] Section O - Special Treatments, Procedures and Programs revealed Resident #3 used oxygen therapy while a resident. Record Review of Resident #3's Care Plan, dated 11/03/23, revealed Resident #3 had PRN oxygen therapy related to ineffective gas change. Interventions included change tubing, humidifier, and clean filter weekly with time, date and initial all supplies. Record Review of Resident #3's current Physician Orders dated 11/29/23 revealed an order dated 08/12/21 to change oxygen equipment and clean filters weekly. Initial and date all tubing when changed. (Every night shift, every Sunday). Physician Orders further revealed an order for Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank oreder dated 08/12/21. Record Review of Resident #3's Treatement Administration Record dated 11/29/23 revealed oxygen was administered 11/1/23 throught 11/28/23. Resident #19 Record review of Resident #19's face sheet dated 11/27/23 revealed a [AGE] year-old-male with an admission date of 10/15/19 with the following diagnoses: end stage renal (kidney) disease, diabetes Page 1 of 12 675842 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0695 (high blood sugar), hypertension (high blood pressure), acute and chronic respiratory failure. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #19's quarterly MDS dated [DATE] Section O - Special Treatments, Procedures and Programs revealed Resident #19 used oxygen therapy while a resident. Residents Affected - Few Record Review of Resident #19's Care Plan, dated 11/03/23, revealed Resident #19 used oxygen at 1-5 liters via cannula/mask by concentrator/tank. To initial when using oxygen. Record Review of Resident #19's current Physician Orders dated 11/27/23 revealed an order dated 08/05/21 to change oxygen equipment and clean filters weekly. Initial and date all tubing when changed. (Every night shift, every Sunday). Physician Orders further revealed an order for Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank oreder dated 08/05/21. Record Review of Resident #19's Treatement Administration Record dated 11/29/23 revealed oxygen was administered 11/1/23 throught 11/28/23. During an observation on 11/27/23 at 09:44 AM Resident #3 and Resident #19 had no date or initials on tubing or humidification bottle. During an observation on 11/28/23 at 02:13 PM Resident #3 and Resident #19 had no date or initials on tubing or humidification bottle. During an observation on 11/29/23 at 09:00 PM Resident #3 and Resident #19 had no date or initials on tubing or humidification bottle. During an interview on 11/29/23 at 09:19 AM with LVN C, he stated tubing was changed and dated every Sunday on the night shift. He stated the potential negative outcome could be infection. He stated if he replaced the oxygen tubing or humidification bottle it should be dated. During an interview on 11/29/23 at 09:26 AM with the ADON, she stated oxygen tubing and humidification bottles were change on Sunday by the night shift. She stated the reason the tubing and humidification bottles were not dated might be because they were using agency nurses for the night shift . She stated the potential negative out could be you don't know how long the tubing and humidification bottles have been there and the risk of infection. During an interview on 11/29/23 at 09:30 AM with the DON she stated she was not sure if the oxygen tubing and humidification bottles needed to be dated. She stated she would have to review the policy. She stated she was not aware of the physician order to date tubing and humidification bottle for Resident #3 or Resident #19. She stated she did not put the order in and would never put an order in like that. She stated she was not sure why the tubing and humidification bottles were not dated. She stated they were using agency on the night shift and that may be the reason. When asked about potential negative outcome she stated, I don't know. She stated staff have been trained to date tubing and humidification bottles. Record review facility policy titled Administration of Oxygen and Maintenance of Tubing and Equipment, dated 08/2010 revealed the following: Maintenance of Tubing and Equipment: . 675842 Page 2 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0695 .2) Tubing will be dated and will be change weekly . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675842 Page 3 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 2 out of 30 days (11/25/23 and 11/26/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 11/25/23 and 11/26/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 11/30/23 revealed there were two RNs employed at the facility (DON and RN A). Record review of the DON time sheets dated 11/27/23 for the dates 10/29/23 - 11/11/23 and 11/12/23 11/27/23 reflected no coverage for 11/25/23 and 11/26/25. Record review of RN A time sheets dated 11/27/23 for the dates 10/16/23 - 10/31/23 and 11/01/23 11/15/23 reflected no coverage for 11/25/23 and 11/26/25. During an interview on 11/29/23 at 09:30 AM with the DON she stated RN coverage is the responsibility of the DON. The DON verified she did not have coverage for 11/25/23 and 11/26/23. She stated her normal hours was Monday through Friday 8am to 5pm. She stated RN A works in her place if she is not there. She stated she was aware there was no RN coverage for 11/25/23 and 11/26/23. She stated there we certain tasks an LVN cannot complete. She stated LVN cannot complete higher level assessments, assess a central line, or pronounce. She stated the purpose of having RN is coverage was to do the duties the LVN is unable to do. She stated she did attempt to find coverage by asking another RN, but she was not able to work. She stated the reason they did not have coverage on 11/25/23 or 11/26/23 was because they did not have a RN. She stated she was available by phone if needed. She stated they do have contracts with agency for LVN's only. When asked what the potential negative outcome could be she stated, I have no idea. She stated her expectations was to have RN coverage daily, but it is not always possible. Record review facility policy titled Staffing, undated reflected the following: Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all resident in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation . An RN is available for coverage 8 hours a day 7 days a week. 675842 Page 4 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 in 1 of 1 kitchen reviewed for dietary services 1)The facility failed to ensure foods were processed and pureed under sanitary conditions. 2) The facility failed to ensure foods were stored in a manner to prevent contamination. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made during a kitchen tour on 11/27/23 that began at 9:15 AM and concluded at 09:45 AM: The following spices stored on the shelf were found open: lemon pepper, garlic, onion, 2 boxes of salt, garlic herb, sage, and cumin. Bowls stored right side up on shelf. The following observations were made on 11/27/23 beginning at 11:00 AM during observation of puree meal preparation: After pureeing squash, [NAME] D took the processor bowl, lid, and blade to the 3 compartments sink and cleaned all 3 parts in the first sink with dish soap and a washcloth. She rinsed all 3 parts with running water and then placed the bowl right side up and the blade and lid on top of the bowl at the end of the sink. [NAME] D emptied water out of the bowl and placed it back on to the processor base and assembled it. The bowl had water on the sides and the lid was dripping water. [NAME] D prepared puree cornbread, took the processor bowl, lid, and blade back to the 3 compartment sink and placed them in the sink. No observation of sanitation used in the 3-compartment sink. During an interview on 11/28/23 at 02:30 PM with [NAME] D, she stated spices should be closed when not in use. She stated being left open the spices could get bugs or little ants in them. She stated bowls should be stored upside down. She stated the potential negative outcome could be bugs crawling in them and stuff falling in the bowl contaminating it. She stated the puree bowl should cleaned, rinsed, and sanitized. She stated she was in a rush and got nervous and forgot to do all the steps. She stated the puree bowl, lid and blade should be allowed to dry in between uses. She stated the potential negative outcome could be left over stuff going into the food. During an interview on 11/28/23 at 02:45 PM with the DM, she stated all spices should be closed. She verified spices on shelf were open. She stated leaving them open can cause them to spill, dry out and get bugs in them. She stated bowls should be stored upside down. She stated the bowl on the shelf that were stored right side up were the residents bowl they had washed and not returned to the residents. She stated storing bowls upside down could cause stuff to fall into them. She stated it was the responsibility of all staff to monitor food items to make sure they were properly stored. She stated she is responsible for training and monitoring kitchen staff to ensure they follow proper 675842 Page 5 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many procedures. She stated the puree process should be washed and sanitized after each use. She stated it should be allowed to air dry. She stated they only have one bowl for the processor. She stated the potential negative outcome could be cross contamination. She stated all staff have been trained on proper storage of spices and bowls. She stated staff had been trained on how to properly clean the puree processor equipment. She stated her expectations were for all food to be properly closed and stored. She stated her expectations were for the puree processor to be properly cleaned, sanitized, and allowed to air dry. During an interview on 11/28/23 at 03:01 PM with the ADM, she stated all food items should be stored, closed and dated. She stated puree processing utensils was to be washed, rinsed, sanitized, and allowed to air dry between each use. She stated the DM, dietician, and ADM were responsible for making sure all items were properly stored and cleaned. She stated the potential negative outcome could be bacteria getting on it and cross contamination. Record review facility policy titled Food Preparation Area; revised date April 2006 revealed the following: Policy Statement: Our facility will maintain a clean, sanitary, and safe food preparation area/ Policy Interpretation and Implementation . 7. All machines and equipment that require cleaning shall be cleaned after use and covered with a washable cover between uses. Record review facility policy titled Sanitization: revised date October 2008 revealed the following: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation . 9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing: a. Scrape food particles and wash using hot water and detergent. b. Rinse with hot water to remove soap residue; and c. Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions may consist of: (1) Chlorine 50 ppm for 10 seconds. (2) Iodine 12.5 ppm for 30 seconds; or (3) Quaternary ammonium compound 150-200 ppm for time designated by the manufacturer. 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical . 675842 Page 6 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 4 of 5 residents (Residents #3, #13, #18, and #199) and 5 of 6 (RNA B, LVN C, LVN D, CNA E, and CNA F) staff reviewed for infection control. Residents Affected - Some 1. LVN D failed to perform hand hygiene between glove changes or use a clean field during wound care for Resident #199. 2. CNA E failed to perform hand hygiene or glove changes when providing incontinent care for Resident #18. 3. CNA F failed to perform hand hygiene between glove changes when providing incontinent care for Resident #13. 4. RNA B failed to perform hand hygiene when observed passing 4 residents meal trays during a dining observation. 5. LVN C failed to keep the oxygen tubing off the floor for Resident #3. These failures could place residents at risk for spread of infection and cross contamination. Findings include: During an observation on 11/27/23 at 12:10 PM RNA B passed 4 residents meal trays with no observation of hand washing or ABHR. During an interview on 11/27/23 at 02:59 PM with RNA B, she stated she should have washed hands or used ABHR between each resident when passing meal trays. She stated she just got caught up in the moment and forgot to wash hands or use ABHR. She stated she usually does not pass meal trays. She stated she is usually at lunch during this time. She stated the potential negative outcome of not washing hands or using ABHR could cause the spread of germs and puts the residents at risk of infection and sickness. Resident #18 A record review of Resident #18's face sheet, dated 11/28/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus (high blood sugar), covid-19 (lung infection), and urinary tract infection. Record review of Resident #18's comprehensive Minimum Data Set (MDS) assessment, dated 10/09/23, revealed Resident #18 was usually understood and had a BIMS score of 04 which indicated the resident's cognition was severely impaired. During an observation on 11/28/23 at 8:26 AM, CNA E performed incontinence care for Resident #18. CNA E washed her hands with soap and water and donned clean gloves. CNA E then removed Resident #18's brief and wiped the resident's groin, turned Resident #18 on her side and then wiped her buttocks 675842 Page 7 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with wipes. CNA E then removed the dirty brief and placed the clean brief under Resident #18. CNA E then fastened the brief, removed her gloves and washed her hands with soap and water. CNA E used dirty gloves to place a clean brief on Resident #18. During an interview on 11/28/23 at 11:25 AM with CNA E, she stated she did not know she did not change her gloves when going from dirty to clean during incontinence care for Resident #18. CNA E stated they are trained to change their gloves and perform hand hygiene when going from dirty to clean, she just forgot. CNA E stated the residents are at risk for infection due to it not being sanitary. Resident #13 Record review of face sheet for Resident #13, dated 11/28/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses to include type 2 diabetes (high blood sugar), cerebral infarction (stroke), and dysphagia (difficulty swallowing). Record review of Resident #13's comprehensive MDS, dated [DATE] revealed Resident #13 was usually understood and had a BIMS score of 03 which indicated the resident's cognition was severely impaired. During an observation on 11/28/23 at 9:05 AM, CNA F performed incontinence care for Resident #13. CNA F performed hand hygiene and donned clean gloves, then unfastened the brief for Resident #13. CNA F then wiped her groin and removed his gloves. CNA F donned clean gloves, turned Resident #13 on her side and wiped BM from her buttocks and removed the dirty brief. CNA F then removed his gloves and donned a pair of clean gloves. CNA F then placed a clean brief under Resident #13, removed his gloves and washed his hands with soap and water. CNA F did not perform hand hygiene between any of the glove changes. During an interview on 11/28/23 at 11:48 AM with CNA F, he stated he has been trained to perform hand hygiene between glove changes. CNA F stated he forgot to take ABHR into the room with him, and that is why he did not perform hand hygiene between glove changes. CNA F stated the residents had a risk for infection due to the lack of hand hygiene between glove changes. Resident #199 Record review of face sheet for Resident #199, dated 11/28/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses to include gram-negative sepsis (blood infection), pancytopenia (low red and white blood cells and low platelets), and hypokalemia (low potassium). Record review of Resident #199's comprehensive MDS, dated [DATE] revealed it was still in progress and had not been completed. Record review of Resident #199's physician orders, dated 11/28/23, revealed an order Clean wound to coccyx with sterile water. Apply appropriate size of silver alginate, apply foam dressing one time a day for Stage 2 decubitus (pressure ulcer) with a start date of 11/24/23. During an observation on 11/28/23 at 10:08 AM, LVN D provided wound care to Resident #199's coccyx wound. LVN D did not wipe down the bedside table or use a barrier for wound care supplies. LVN D washed her hands with soap and water and donned clean gloves. The old dressing was removed and LVN D 675842 Page 8 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0880 Level of Harm - Minimal harm or potential for actual harm removed her gloves. LVN D donned a pair of clean gloves and cleaned the wound with sterile water and gauze, then patted dry. LVN D then removed her gloves and donned a pair of clean gloves. LVN D then placed silver alginate on the wound bed and covered it with a foam adhesive bandage. LVN D then removed her gloves and washed her hands with soap and water. LVN D did not perform hand hygiene between glove changes during wound care. Residents Affected - Some During an interview on 11/28/23 at 11:20 AM with LVN D, she stated she has been trained to perform hand hygiene between glove changes. LVN D stated she has been trained to clean the beside table and use a barrier for her wound care supplies. LVN D stated she was nervous and forgot. LVN D stated the lack of barrier for her wound care supplies and not performing hand hygiene between glove changes has a risk for infection for the residents. Resident #3 Record review of Resident #3's face sheet dated 11/29/23 revealed an [AGE] year-old female with an admission date of 07/18/05 with the following diagnosis: dementia (cognitive loss), diabetes (high blood sugar) and schizoaffective disorder (mental illness). Record review of Resident #3 quarterly MDS dated [DATE] revealed Resident 33 had a BIMS score of 3 which indicated Resident #3 cognition was severely impaired. Section O - Special Treatments, Procedures and Programs revealed Resident #3 used oxygen therapy while a resident. Record Review of Resident #3's Care Plan, dated 11/03/23, revealed Resident #3 had PRN oxygen therapy related to ineffective gas change. Record Review of Resident #3's current Physician Orders dated 11/29/23 revealed an order for Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank oreder dated 08/12/21. During an observation on 11/29/23 at 09:44 AM Resident #3 oxygen tubing was laying on floor beside the bed. During an interview on 11/29/23 at 09:19 AM with LVN C, he stated oxygen tubing is to be kept in a bag not the floor. He stated some resident refuse to put tubing in their bag. He stated the potential negative outcome could be infection. During an interview on 11/28/23 at 12:12 PM, the ADM and DON stated they were both responsible for ensuring staff adhered to infection prevention policies. The DON stated she expected staff to perform hand hygiene between glove changes. The DON stated she expected staff to change their gloves and perform hand hygiene when going from dirty to clean during resident care. The DON stated she does not remember when staff was trained last, but she will look up their skills competencies. The ADM and DON stated they did not know why staff did not perform hand hygiene between glove changes, use a barrier for wound care supplies or change gloves between dirty and clean during incontinence care. The ADM and DON stated the risks to the residents was infection concerns. During an interview on 11/29/23 at 09:26 AM with the ADON, she stated oxygen tubing not in use should be stored in a bag attached to the concentrator. She stated the potential negative outcome for oxygen tubing to be on the floor was risk for infection. She stated staff have been trained to store oxygen tubing in the bag attached to the concentrator. 675842 Page 9 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/23 at 09:30 AM with the DON, she stated oxygen tubing should be stored in a bag on the concentrator. She stated the potential negative outcome of not storing the tubing properly could be infection. She stated staff have been trained on where to store tubing. She stated she does not know why the tubing was not stored in a bag for Resident #3. She stated the DON and ADON were responsible for monitor nursing staff. Residents Affected - Some Record review of facility's Hand Hygiene Competency Validation for CNA E revealed she completed a hand hygiene competency on 10/21/23. Record review of facility's Hand Hygiene Competency Validation for LVN D revealed she completed a hand hygiene competency on 10/21/23. Record review of facility's Hand Hygiene Competency Validation for CNA F revealed she completed a hand hygiene competency on 10/17/23. Record review of the facility's policy, titled Infection Prevention and Control Program, with a revised date of October 2018 reflected the following: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections Record review of facility policy titled Handwashing/Hand Hygiene, revised date 8/2019 revealed the following: Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. after removing gloves p. Before and after assisting a resident with meals . Record review of the facility policy, titled Wound Care, with a revised date of October 2010 reflected the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field Record review facility policy titled Administration of Oxygen and Maintenance of Tubing and Equipment, dated 08/2010 revealed the following: . 675842 Page 10 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0880 Maintenance of Tubing and Equipment Level of Harm - Minimal harm or potential for actual harm 1) Tubing will be kept in a bag when not in use . Residents Affected - Some 675842 Page 11 of 12 675842 11/29/2023 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 10 (Rooms #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33) of 40 semi-private rooms reviewed for physical environment. The facility failed to ensure resident Rooms #s 1, 3, 5, 8, 27, 29, 30, 31, 32 and 33 met the required minimum of 80 square feet per resident. This failure could place residents at risk of crowding and cause difficulty in providing resident care. Findings include: Record review of CASPER 3 during preparation for survey revealed a waiver for room size requirements had been done yearly by the facility. Record review of Room Size Wavier for Facilities dated 09/22/22, during preparation for survey, revealed a wavier for rooms #s 1,3,8,27,29,30,31, 32 and 33. Location) dated 11/28/23 documented that rooms #'s 1, 3, 5, 8, 27, 29, 30, 31, 32 and 33 were listed as a Title 18/19 bed classification semi-private rooms for two residents. During an interview on 11/28/23 at 9:08 AM with the Administrator regarding the square footage for room #'s 1, 3, 5, 8, 27, 29, 30, 31, 32 and 33. When asked if she wanted to apply for the room size waiver she stated, Yes, I want to apply for the waiver. The ADM stated room #'s 1, 3, 5, 8, 27, 29, 30, 31, 32 and 33 had a waiver for years due to no change in floor plan. During an observation on 11/27/22 from 10:00 AM to 10:30 AM, observed the following rooms: Room #s 1 and 3 were an office. Room #'s 5, 27 and 31 had two beds. Room #'s 8, 29,30, 32 and 33 had two beds. During an interview on 11/28/23 at 9:30 AM with the Administrator, regarding the risk of residents not having the appropriate space, she stated it had not been a problem in the past . The Administrator stated there was no facility policy for a room size waiver. 675842 Page 12 of 12