Health inspection·August 22, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents' self-esteem. In an interview on 08/22/25 at 11:10 AM with CNA A, she stated Resident #28 was wearing shorts because it was the request of the family. She stated she asked for staff to cover the resident's legs because she thought resident would be cold in the hallway with only shorts on. She stated Resident #28 did not communicate understandably, so he did not report being cold. CNA A stated nurses and CNAs were responsible for ensuring residents were dressed appropriately. She stated residents were to be dressed their best, and it could affect their dignity if their appearance was not maintained. In an interview on 08/22/25 at 11:27 AM with LVN C, she stated the CNAs were responsible for assisting residents with dressing and grooming. She stated the nurses, ADON, DON, and CNA A were responsible for monitoring residents' grooming and appearance daily in the shift. She stated she had a concern with Resident #28's appearance on 08/21/25, since Resident #28 was observed with unkempt hair. She stated this could affect the resident's self-esteem. In an interview on 08/22/25 at 12:02 PM with the DON, she stated Resident #28's family only provided the resident with clothing including shorts. She stated the family of Resident #28 tended to get hot, and that was the reason Resident #28 was wearing shorts. She stated she observed Resident #28 on 08/21/25 and agreed the resident appeared unkempt due to his hair not being groomed. She stated she notified CNA A of her concern that day. She stated CNA's were responsible for assisting residents with dressing and grooming. She stated CNA A monitored her CNA's daily, ensuring needs were met and residents look presentable. She stated the risks to residents not being groomed could negatively affect their dignity.Record Review of the facility's policy titled Resident Rights, with revised date 02/2021, read in part: Policy Statement- Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; be free from abuse, neglect, misappropriation of property, and exploitation. Event ID: Facility ID: 676457 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for three residents, (Residents #6, #33, and #44), of six residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #6, #33 and #44 to address residents prescribed insulin medication.These failures could affect residents prescribed insulin medication by placing them at risk for not receiving care and services to meet their needs.Findings Include:Resident# 6Record review of Resident #6's admission Record dated 08/19/2025 revealed an admission date of 07/21/2025.Record review of Resident #6's Health and Physical not dated, revealed to Continue insulin regimen and PO (oral) diabetic medication.Record review of Resident #6's 5-day MDS assessment revealed a BIMS score of 11 indicating moderate cognitive impairment.Record Review of Resident #6's care plan revealed no information regarding insulin medication.Record review of Resident #6's Administration Record revealed Insulin Glargine Subcutaneous solution 100 unit/ml inject 30 unit subcutaneously in the morning for diabetes mellitus. Insulin Lispro injection solution 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus.Resident# 33Record review of Resident #33's admission Record dated 08/22/2025 revealed that Resident #33 was admitted on [DATE]Record review of Resident #33's health and physical dated 08/01/2025 revealed a diagnosis of Diabetes Mellitus Type II. Plan explained Resident would be placed on sliding scale for management of hyperglycemia.Record review of Resident #'s 5-day MDS revealed a BIMS score of 13 indicating an intact cognitive function.Record Review of Residents #33's care plan revealed no information regarding insulin medication. Record review of Resident #33's Order Summary Report revealed Lantus SoloStar Subcutaneous Solution Pen injector 100 unit/ml inject 15 unit subcutaneously two times a day for diabetes mellitus. Insulin Lispro Subcutaneous Solution Cartridge 100 unit/ml inject 8 unit subcutaneously before meals for diabetes mellitus. Novolog pen fill subcutaneous solution cartridge 100 unit/ml inject 8 unit subcutaneously before meals for diabetes mellitus before meals for diabetes mellitus.Resident# 44Record review of Resident #44's admission Record dated 08/20/2025 revealed Resident #44 was admitted on [DATE]Record review of Resident #44's health and physical dated on 07/30/2025 revealed a diagnosis of diabetes with hyperglycemia (high blood sugar).Record review of Resident #44's 5-day MDS revealed a BIMS score of 15 indicating an intact cognitive function.Record Review of Resident #44's care plan revealed no information regarding insulin medication. Record review of Resident #44's Medication Administration Record revealed insulin Glargine subcutaneous solution 100 unit/ml inject 15 unit subcutaneous in the morning for diabetes mellitus type II.In an interview on 08/22/25 at 11:33 AM with LVN C, she stated the purpose of a care plan was for all staff to be aware of the residents' care and treatment plan. She stated the MDS nursing staff were responsible for ensuring care plans were updated. She stated nurses notified the MDS nurses of any changes of residents so the care plan could be updated. LVN C stated she was not aware how often they monitored care plans for accuracy. She stated the risk of care plans not being completed correctly included incorrect treatment of the resident. In an interview on 08/22/2025 at 12:16 PM with DON, she stated that the purpose of a care plan was to make sure that the residents were receiving the correct individualized treatment. She stated that the MDS nurses were responsible for creating and updating the Care Plan's. She stated that the floor nurses, DON and ADON were all in communication with the MDS nurses to notify of any updates needed on the care plan. She stated that insulin and diabetes diagnosis needed to be included in the care plan. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676457 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete stated that residents were at risk of not receiving the right treatment if treatment was not in care plan.In an interview on 08/22/2025 at 1:30 PM with MDS nurse, she stated that the purpose of a care plan was like a blueprint for resident care. She stated that the MDS nurses were responsible for keeping up with the changes that had to be made. She stated that insulin and diagnosis of diabetes had to be included in the care plan. She stated that floor nurses, DON and ADON communicate with MDS nurses to fill them in on any changes that residents have. She stated that when pertinent medications and diagnosis had not been care planned it could lead to an interruption in communication of care.Record Review of the facility's policy titled Care Plans, Comprehensive Person- Centered revised March 2022 read in part . The comprehensive, person-centered care plan includes measurable objectives and timeframes, Describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being . Event ID: Facility ID: 676457 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, 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:-The facility failed, on 8/19/25, to maintain the bottom of freezer # 1 clean and free of food crumbs and ice cream drippings. -The facility failed, on 8/19/25, to maintain the bottom of refrigerator # 2 clean and free of dry meat juices. -The facility failed, on 8/19/25, to seal a bag of lettuce and to close a box containing an open stick of butter in refrigerator # 3.These failures could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses.Findings included: In an observation on 8/19/25 at 8:45 AM during the initial kitchen tour in the facility's kitchen, revealed the following: Freezer # 1 at the bottom of the freezer, there were dried drippings of what appeared to be lemon ice cream and around it, there were crumbs of unknown food residues.Refrigerator #2 - at the bottom of the refrigerator, there were dried drippings of meat juices that were dark red and pink in color.Refrigerator #3 - there was a bag with two heads of lettuce that were not sealed. The lettuce looked yellow in color. An open box containing 11 bars of 1/4 lb. sticks of butter had an open stick of butter that was not sealed or covered.An interview on 8/19/25 at 8:54 AM with the Dietary Director revealed it was not acceptable for refrigerators to have food residues or dry drippings from food or meat juices. The Dietary Director stated that all food inside the refrigerators needed to be labeled, sealed, and closed. She explained that by having food drippings and open boxes and unsealed packages, there was a risk of cross contamination which could result in food borne illness which could make the resident sick to their stomach resulting in infection, vomiting or diarrhea. She stated that the expectation was that all equipment in the kitchen was cleaned and sanitized, all boxes and packaging were closed and sealed to prevent contamination, and that all staff from the kitchen were responsible for making sure these standards were met. An interview on 8/20/25 at 10:23 AM with the Head [NAME] revealed that all staff were responsible for making sure that all cooking utensils and kitchen equipment were clean and sanitized during and after meal preparation and at the end of each kitchen staff member's shift. He stated it was not acceptable that freezers of refrigerators were dirty with crumbs or food drippings and that all food inside the refrigerator and freezers needed to be labeled, sealed and closed. The Head [NAME] stated that by not covering or sealing the food and having food drippings, there was a risk for cross contamination which could make the residents sick to their stomach which could result in them getting sick from foodborne diseases. He stated there was a potential risk of residents getting sick with diarrhea or gastrointestinal (an adjective that refers to or involves the stomach and intestines) infections. In an interview on 8/21/25 at 11:05 AM with a Dietary Cook, she stated that all kitchen staff were responsible for ensuring the kitchen equipment and utensils were clean and free of food residues. She said that dry drippings of meat juice or crumbs left in the refrigerators could result in cross contamination for the residents' meals if they were not properly closed or sealed, which could make them sick to their stomach, and it could make their current health issues get worse. An interview on 8/21/25 at 11:13 AM with the DON revealed that she was the infection preventionist for the facility. She stated that it was not correct to leave things opened and unsealed food in the refrigerators or the freezers, she stated that the expectation was for the kitchen staff to clean kitchen freezers, fridges and utensils by the end of their shift. The DON stated that having crumbs, dry drippings, and opened bags could result in cross contamination for the food items. The DON said there was a risk of infections for gastrointestinal bacteria or intoxications which could result in residents getting sick from vomiting or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676457 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete diarrhea.In an interview on 8/22/25 at 10:21 AM with the Administrator, he stated the food inside the refrigerators should always be covered or sealed and there was a risk of cross contamination or foodborne illness which could potentially make the residents sick with stomach infections which could result in vomiting or diarrhea and possible dehydration. He said that all kitchen equipment and utensils should be free of food residues and drippings because it could potentially lead to cross contamination which could also make the residents sick. Review of the FDA Food Code 2022 reflected Chapter 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings;. Record Review of the facility's policies and procedures revised in November 2022, titled Dietary Services-Food and Nutrition Services, stated in part: Food Receiving and Storage, Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. Refrigerated/Frozen Storage: All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Other opened containers are dated and sealed or covered during storage. Record Review of the facility's policies and procedures revised in July 2014, titled Preventing Foodborne Illness - Food Handling, stated in part: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. This facility recognizes that the critical factors implicated in foodborne illness are: contaminated equipment. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. Event ID: Facility ID: 676457 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #9) residents reviewed for infection control. CNA A failed, on 8/19/25, to properly serve a meal tray to Resident #9 by touching her cheeseburger with her bare hands. This deficient practice could place residents at risk for infection due to improper care practices.Findings included:During observation on 8/19/25 at 12:10 PM in the dining room, CNA A approached Resident #9 who was sitting at the table and had her lunch in front of her. CNA A took a quarter cut of (his/her) cheeseburger with her bare hands and handed it to the resident. Resident # 9 took the piece of cheeseburger with her hands and proceeded to eat it. CNA A was not wearing gloves and failed to provide the resident with her meal utilizing utensils.In an interview on 8/19/25 at 12:20 PM with the Director of Dietary, she stated that it was not acceptable to touch a resident's meal at any time after their meal left the kitchen. The Director of Dietary stated that if a Resident needed assistance, staff needed to wear gloves and use utensils for assistance such a fork, spoon or tongs. She stated the risk of touching the Resident's meal with bare hands could result in cross contamination or infection which could make the resident ill. In an interview on 8/19/25 at 12:25 PM with CNA A, she stated she should not have touched Resident # 9's meal with her bare hands because it could result in cross contamination and the possible outcome could be that the resident got sick from their stomach. CNA A stated she did not realize she had touched the resident's food with her hands, and the proper procedure was to assist the resident by using her utensils such a fork or spoon if necessary.In an interview on 8/21/25 at 11:05 AM with the Dietary [NAME] she stated when meals were served, staff was expected to use cooking utensils such as spoons, ladles, and tongs, and it was not acceptable for them to ever touch a resident's food with their bare hands. The Dietary [NAME] stated touching a resident's meal without gloves could result in cross contamination which could make the resident's sick from their stomach. In an interview on 8/21/25 at 11:13 AM with the DON, she stated CNAs were not supposed to touch the resident's meals with their bare hands. The DON said that if a resident required assistance from the staff, they needed to use the proper utensils for their meals such as spoons, forks or tongs. The DON said that CNA A touching Resident # 9's meal with her bare hands posed a risk of cross contamination and it was a concern with infection control. The DON said the result of not properly assisting the residents during mealtime could be for the residents to get sick from cross contamination resulting in vomiting or diarrhea or them getting a gastrointestinal infection. [SH1] In an interview on 8/22/25 at 11:05 AM with the Administrator, he stated it was not acceptable for staff to touch Resident # 9's meal with their bare hands and that staff should never touch a resident's meal once it left the kitchen. The Administrator said the expectation was for staff to use utensils such as spoons, forks or tongs if the resident required assistance. He stated that the possible outcome of a CNA touching a resident's meal with their bare hands could result in them getting sick due to cross contaminations which could make the resident sick from their stomach that could cause infections, vomit or diarrhea. Review of the U.S. FDA Food Code 2022 revealed Chapter 3-301.11 paragraph B .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment ., CNA A was not in compliance with the Food Code.U.S. FDA Food Code 2022 Chapter 3-301.11 paragraph B .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment ., CNA A was not in compliance with the Food Code by Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676457 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete touching the resident's meal with her bare hands.Record Review of the facility's policies and procedures revised in October 2017, titled Dietary Services-Meals, Snacks and Services, stated in part: Dining Room Audits: Our facility audits the food and nutrition services department regularly to ensure that resident needs are met and that dining is a safe and pleasant experience for residents. The dietitian, food and nutrition services manager and/or dietary supervisor will make scheduled daily meal rounds to every dining room at all meal times to audit the dining room and the food service to the residents. The auditor will assess: whether proper sanitation is maintained by staff;. Record Review of the facility's policies and procedures revised in July 2014, titled Preventing Foodborne Illness - Food Handling, stated in part: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. This facility recognizes that the critical factors implicated in foodborne illness are: poor personal hygiene of food service employees; All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.Record Review of the facility's policies and procedures revised in March 2022, titled Assistance with Meals, read in part: Residents shall receive assistance with meals in a manner that meet the individual needs of each resident. Dining Room Residents: All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Event ID: Facility ID: 676457 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 2 of 8 staff (the MDS Nurse and the Administrator) reviewed for training, in that:The facility failed to ensure infection prevention and control training was provided to the MDS Nurse and the Administrator.This failure could place residents at risk of illness due to lack of staff training. The findings were:Review of Facility Staff Roster, undated, revealed: Administrator - date of hire - 03/07/2016MDS Nurse - date of hire- 11/10/2021In an interview on 08/22/25 at 02:02 PM with Human Resources, she stated she did not have documentation for the Annual Infection Control training for the Administrator and the MDS Nurse. She stated she had only been working for a few months and did not have a reason why the facility did not have documentation for this course. She stated, in this case, she would issue the Administrator and the MDS Nurse retraining, meaning the staff would complete the required training. She stated Human Resources and the DON were responsible for ensuring staff were up to date with training. She stated she and the DON met monthly to discuss issues or concerns including training. She stated the staff not completing training for Infection Control could potentially place residents and others at risk for illness or infection.In an interview on 08/22/25 at 2:18 PM with the MDS Nurse, she stated all staff were responsible for keeping their training up to date. She stated she did not have a reason why there was no documentation of her Infection Control training. She stated the DON was responsible for monitoring staff for infection control training but was unsure how often it was being followed up. She stated risks of staff not completing their Infection Control training places residents at risk for exposure to bacteria or illness.In an interview on 08/22/25 at 02:30 PM with the Administrator, he stated he was sure to have completed his Infection Control training, but unable to state the most recent one he had completed. He stated the risks of staff not completing their annual required training would have included facility personnel not being in the most up to date with information, but all staff have their basic training including infection control. He was asked by this surveyor if CMS required annual documented trainings, he replied, yes. The Administrator added that staff had their basic training from school or when starting in the nursing facility. He stated the DON was responsible for Infection Control training, since she was also the Infection Preventionist. He stated the administration department, and Human Resources were also responsible for monitoring staff training. In an interview on 08/22/25 at 02:36 PM with the DON, she stated she was responsible for ensuring staff were up to date with their training. She stated she monitored her staff, including their training, on a daily basis. She stated all staff were to be updated on their training. She stated staff not having updated training included residents being at risk for infections.Record review of the facility's policy titled, In-Service Training, All Staff, read in part: Policy Statement- All Staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation- 1. All staff are required to participate in regular in-service education. In-service education participation is considered working time for which staff are paid their regular wages. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training . 6. Required training topics include the following: . e. The infection prevention and control program standards, policies and procedures. Event ID: Facility ID: 676457 If continuation sheet Page 9 of 9