**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide the resident and the resident representative a notice in writing of the transfer to an acute care hospital for three (3) out of four (4) sampled residents who were discharged from the facility (Resident #4, Resident #13, and Resident #19). Findings include: Review of the facility's policy titled Therapeutic Leave, Transfer and Discharge, undated, revealed The facility will provide notice to you and your Resident Representative and, if known, a designated family member, of your transfer or discharge and the reason for it at least (30) thirty days before you are transferred or discharged . Where your health and safety or the health and safety of other individuals in the facility may be endangered, however, or where other good cause or legal reasons exist, notice may be given as soon as practicable before your transfer or discharge. 1. Review of Resident #4's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Obstructive Sleep Apnea. Review of Resident #4's clinical record revealed the resident was transferred to an acute care hospital on [DATE] and was subsequently admitted for respiratory distress. Resident #4 was readmitted to the facility on [DATE]. However, the clinical record lacked evidence that the facility issued a written transfer notice to the resident and legal representative. 2. Review of Resident #13's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Lupus, Essential Primary Hypertension and Dyspnea. Review of Resident #13's clinical record revealed he/she was transferred to an acute care hospital on 2/10/21 and was subsequently admitted with a diagnosis of Anemia. Resident #13 was readmitted to the facility on [DATE]. However, the clinical record lacked evidence that the facility issued a written transfer notice to the resident and legal representative. 3. Review of Resident #19's clinical record revealed the resident was admitted to the facility on [DATE] with diagnosis of COPD. Review of Resident #13's clinical record revealed the resident was transferred to an acute care hospital on [DATE] and subsequently admitted with a diagnosis of Respiratory Distress. Resident #19 was readmitted to the facility on [DATE]. However, the clinical record lacked evidence that the facility issued a written transfer notice to the resident and legal representative. On 3/17/21 at 1:45 p.m. an interview was conducted with the Office Manager (OM). The OM was asked where transfer notices would be located in the resident charts. The OM replied, Transfer and bed hold notices are not given when a resident is transferred to the hospital. Since COVID, we have just been holding the beds. We give them the transfer and discharge policy upon admission and that's the only time. The OM was asked when a resident goes to the emergency room, are they receiving a transfer notice with their right to appeal information. The OM replied, No they are not, just the stuff they get on admission. Since COVID, we have plenty of beds. The OM was then asked if the notices were given before COVID. The OM replied, No, we didn't do them then either. On 3/18/21 at 9:15 a.m. an interview was conducted with the Social Worker (SW). The SW was asked where transfer notices would be kept for residents. The SW replied, We have a notice, but we don't give them because we don't charge them for the bed, and we let them come back. We haven't done those for a long time, even before COVID, because we don't charge for the rooms and we let them come back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to ensure a bed-hold notice was given to the resident and the resident representative prior to the transfer to an acute care hospital for four (4) of 16 sampled residents (Resident #4, #13, #19, and #46). Findings include: A review of the facility's policy titled, Therapeutic Leave, Transfer and Discharge, undated, revealed the facility will provide written information to you and your Resident Representative prior to your discharge that specifies the Facility bed-hold policy and reserve bed payment policy under the State Plan. 1. Review of Resident #4's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Obstructive Sleep Apnea. Review of Resident #4's clinical record revealed he/she was transferred to an acute care hospital on [DATE] and was subsequently admitted with a diagnosis of Respiratory Distress. Resident #4 was readmitted to the facility on [DATE]. However, the clinical record lacked evidence that the facility issued a written bed-hold notice to the resident and legal representative. 2. Review of Resident #13's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Lupus, Essential Primary Hypertension and Dyspnea. Review of Resident #13's clinical record revealed he/she was transferred to an acute care hospital on 2/10/21 and was subsequently admitted with a diagnosis of Anemia. Resident #13 was readmitted to the facility on [DATE]. However, the clinical record lacked evidence that the facility issued a written bed-hold notice to the resident and legal representative. 3. Review of Resident #19's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of COPD. Review of Resident #19's clinical record revealed he/she was transferred to an acute care hospital on [DATE] and was subsequently admitted with a diagnosis of Respiratory Distress. Resident #19 was readmitted to the facility on [DATE]. However, the clinical record lacked evidence that the facility issued a written bed-hold notice to the resident and legal representative. 4. Review of Resident #46's closed clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease, Vascular Dementia with Behavioral Disturbances, Parkinson's Disease, and Diabetes Mellitus, Type II. Review of the Nurse's Progress Note, dated 12/27/2020 at 1:25 a.m., revealed staff heard a rattling, congestion sound coming from Resident #46. A nursing assessment was completed, and congestion was noted in all lung fields. A Physician's Order was obtained to send the resident to the emergency room (ER) where Resident #46 was subsequently admitted . The resident did not return to the facility. The clinical record lacked evidence that the facility issued a written bed-hold notice to the resident and legal representative. An interview was conducted with the Assistant Director of Nursing (ADON) on 3/18/21 at 5:36 p.m. After searching the clinical record, the ADON stated the facility had failed to issue Resident #46 and the legal representative a written bed-hold notice. On 3/17/21 at 1:45 p.m. an interview was conducted with the Office Manager (OM). The OM was asked where transfer and bed-hold notices would be located in the resident charts and the OM replied, Transfer and bed-hold notices are not given when a resident is transferred to the hospital. Since COVID, we have just been holding the beds. We give them the transfer and discharge policy upon admission and that's the only time. The OM was asked to clarify when a resident goes to the emergency room if they were providing a bed-hold notice with their right to appeal information. The OM replied, No they are not, just the stuff they get on admission. Since COVID, we have plenty of beds. The OM was then asked if the notices were given before COVID and the OM replied, No, we didn't do them then either. On 3/18/21 at 9:15 a.m. an interview was conducted with the Social Worker (SW). The SW was asked where bed-hold notices would be kept for residents. The SW replied We have a notice, but we don't give them because we don't charge them for the bed, and we let them come back. We haven't done those for a long time, even before COVID because we don't charge for the rooms and we let them come back. On 3/18/2021 at 9:25 a.m., the SW confirmed that the bed-hold notices had not been given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a person-centered, comprehensive care plan was implemented for one (1) of 16 sampled residents. Resident #37 was not provided assistance with positioning in bed per the assessment requirement and care planned intervention. Findings include: Review of a facility policy titled Care Plans (revised 9/28/10) revealed plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. The documented policy Standard states according to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs, that are identified in the comprehensive assessment. The policy Process for implementation included (1) Assessment and plan of care process. (2) Preparation for Care Plan Committee Meetings. (3) Conducting the interdisciplinary care plan meeting. The policy did not include procedures to address implementation of interventions after a care plan has been developed. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified the resident's current diagnoses as Hypertension, Alzheimer's Disease, Dementia, Anxiety Disorder, and Depression. Resident #37 was assessed to require total assistance of two (2) staff persons with bed mobility. The MDS assessment identified no pressure ulcers present at the time of the review and received a turning and repositioning program due to the resident being at risk for pressure ulcer development. Review of Care Area Assessment (CAA) summary documentation revealed a decision was made to proceed to the care plan to address an Activities of Daily Living (ADL) functional rehabilitation status and risk for pressure ulcer development. Review of the Care Plan (revised 2/10/21) for Resident #37 revealed the facility had addressed the problem deficits of ADL functional rehabilitation and risk for pressure ulcers. Interventions for each of the assessed problem deficits included providing the resident with turning and positioning, every two (2) hours, when in bed. Observations of Resident #37 on 3/18/21 from 8:52 a.m. until 11:30 a.m. revealed the resident remained in bed, on his/her back during each observation. A turn schedule was posted on a bulletin board above the resident's head that directed staff to turn and reposition the resident at specific, every two (2) hour intervals. An interview was conducted on 3/18/21 at 11:35 a.m. with the Certified Nurse Aide (CNA) #6 assigned to care for Resident #37. CNA #6 stated he/she had clocked into work that morning at 7:00 a.m. The CNA stated the resident had been positioned in bed on his/her back at the start of his/her shift. CNA #6 stated he/she had been unable to turn and reposition the resident off his/her back because there was no wedge pillow available to use as a positioning device to assist the resident with remaining on his/her back. The CNA stated without the wedge pillow Resident #37 would roll off his/her side and return to laying on his/her back. CNA #6 acknowledged being aware the resident had a care plan intervention in place to be turned/repositioned every two (2) hours while in bed. CNA #6 denied having reported the failure to implement the intervention to the Unit Charge Nurse. An interview was conducted with the Director of Nursing (DON) on 3/18/21 at 11:30 a.m. The DON stated direct care staff should have been implementing the care plan intervention of turning and repositioning Resident #37. It was the assigned CNA's responsibility to report to the Unit Charge Nurse when an intervention could not be implemented. Additionally, the Unit Charge Nurse should be monitoring to ensure residents received the care planned interventions required to meet each resident's needs (Refer to F684 for further information regarding Resident #37).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one (1) of 16 sampled residents received services in accordance with professional services and the person-centered care plan. Resident #37 did not receive the assessed treatment and care to address positioning needs when in bed. Findings include: Review of a facility policy titled Turning and Repositioning the Resident (effective 8/13/12) revealed residents who are unable to turn themselves in bed benefit from the staff performing the function. Proper positioning, and regular repositioning, helps to prevent pressure sores, contractures, and stagnation of respiratory secretions. Generally, residents who are unable to reposition themselves should be turned and repositioned every two (2) hours. A physician's order for turning is not necessary unless there is a specific medical contraindication. If the resident is in bed, turn the resident to the desired position, and use pillows or cushions to keep the resident comfortably in place, as needed. Use positioning and pressure relief devices, as needed, such as wedge cushions, as needed, for the resident's comfort and safety. Creative reminders, of turning and repositioning times, can be used to remind residents and staff when it is time to turn and reposition. Resident #37 was admitted to the facility on [DATE]. Review of the medical record revealed the resident's current diagnoses included Hypertension, Alzheimer's Disease, Dementia, Anxiety Disorder, and Depression. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was assessed to be severely impaired in cognitive skills for daily decision making. The assessment identified the resident to have exhibited no behavioral symptoms during the review period. Assessment of functional status revealed Resident #37 required the total assistance of two (2) persons with bed mobility and transfer. The resident was assessed to have no range of motion limitations to upper and lower extremities. Resident #37 was assessed to have no pressure ulcers, however, was identified to be at risk for pressure ulcer development. The assessment identified the resident to be on a turning/repositioning program as treatment to assist in preventing skin injury. Review of the Care Plan (revised 2/10/21) revealed a problem deficit for Resident #37 as being at risk for impairment of skin integrity due to Alzheimer's Disease, Dementia, bed/chair bound status, incontinence, decreased mobility, and need for assistance. A goal was established for the resident to experience no skin breakdown over the next assessment period. Interventions planned to meet the established goal included to turn and reposition the resident every two (2) hours. The care plan further identified an Activities of Daily Living (ADL) functional status deficit for the resident. Interventions planned to address this deficit included reminding and assisting the resident to change positions every two (2) hours while in bed. Resident #37 was observed on 3/17/21 at 9:39 a.m. lying in bed on his/her back. The head of the bed was raised approximately 35 degrees. The resident's heels were floated off the bed with a cushion. A cork bulletin board was attached to the wall above the resident's head. A paper turn schedule clock was attached to the bulletin board that directed staff to turn and reposition the resident every two (2) hours and designated what position the resident should be assisted to lay in at specific times. According to the turn clock, Resident #37 should have been positioned on his/her right side, toward the window, during the observation at 9:39 a.m. Resident #37 was observed on 3/18/21 at 8:52 a.m. lying in bed on his/her back. The resident's heels were floated off the bed with a cushion. According to the posted turn schedule, the resident should have been positioned on his/her right side, facing the window, from 8:00 a.m. to 10:00 a.m. The resident was again observed at 11:15 a.m. to remain in bed, positioned on his/her back, with heels floated off the bed. According to the turn schedule, Resident #37 was required to be positioned on his/her back from 10:00 a.m. to 12:00 p.m. However, at the time of this observation, Resident #37 had remained on his/her back for a minimum of two (2) hours and 23 minutes. The Director of Nursing (DON) was requested to accompany the surveyor on 3/18/21 at 11:30 a.m., to Resident #37's room. The resident remained in bed positioned on his/her back. The DON stated in an interview that the resident should be turned and repositioned in bed in accordance with the posted turn schedule. The DON stated it was the Unit Nurse Manager's responsibility to monitor to ensure staff were turning and repositioning the resident as required by the plan of care. An interview was conducted on 3/18/21 at 1:41 p.m. with the Assistant Director of Nursing (ADON) who oversaw the facility's wound care program. According to the ADON, in February 2021 Resident #37 received a physician's order to wear protective heel booties to prevent skin breakdown. The resident was noted to frequently rub his/her heels against the booties in an apparent attempt to remove them and on 2/21/21 was noted to have a fluid filled blister on the left heel. The physician discontinued use of the protective heel booties, gave an order for wound care to the left heel, daily, and float heels, at all times. The ADON stated the Unit Charge Nurses applied the wound care to the left heel, daily and he/she conducted weekly skin assessments. The surveyor accompanied the ADON to Resident #37's room following the interview where the resident was observed sitting in a recliner. The ADON donned gloves and removed the resident's sock exposing the left foot. A round, dry scab, approximately two (2) centimeters x three (3) centimeters, surrounded by dry, peeling skin was noted to the resident's left heel. There was no odor or drainage noted. The ADON stated there had been no change since her most recent assessment of the resident's left heel area. The ADON stated the resident had no other pressure ulcers or skin issues. An interview conducted on 3/18/21 at 11:35 a.m. with Certified Nurse Aide (CNA) #6 revealed the CNA had started the shift at 7:00 a.m. and he/she was assigned to care for Resident #37. CNA #6 stated Resident #37 had been positioned on his/her back when he/she had arrived at work. CNA #6 stated he/she had gone in the resident's room during rounds at 9:30 a.m. to check/change the resident's adult brief but had left Resident #37 positioned on his/her back because there had been no wedge pillow available to use to prop/position the resident onto his/her side. CNA #6 stated in the past there had been a wedge pillow in the room to be used for positioning the resident onto his/her side. The CNA did not know how long the wedge pillow had been missing, stating it was impossible to keep Resident #37 positioned on his/her side without it. CNA #6 denied having reported to the Unit Charge Nurse the inability to turn and reposition the resident due to the unavailability of a wedge cushion. CNA #6 acknowledged awareness of the positioning schedule being part of the nursing care plan for Resident #37. An interview was conducted on 3/18/21 at 11:40 a.m. with the Unit Charge Registered Nurse (RN) #7, assigned to work on the unit where Resident #37 resided. RN #7 stated it was his/her responsibility to monitor to ensure residents are receiving the care and services required and planned, per the care plan. RN #7 stated he/she did conduct the required monitoring, however, was not aware Resident #37 had remained in bed throughout the morning without being turned and repositioned. RN #7 stated the assigned CNA had not made him/her aware there was no wedge pillow available to provide support for repositioning the resident. RN #7 stated Resident #37 did have a pressure ulcer to the left heel area that received wound care, daily. The RN stated the resident had no other pressure ulcers or skin issues. Immediately following the interview with RN #7, CNA #6 was observed walking down the hallway carrying a wedge pillow. CNA #6 stated he/she had found the wedge pillow in a closet and was preparing to use it to turn and reposition Resident #37 in the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure the staff labeled and dated the oxygen tubing when changed for one (1) of 16 sampled residents (Resident #33). Findings include: Review of the facility's policy titled, Oxygen Administration, undated, revealed under Process: 11. Cannulas and masks should be changed weekly. However, the policy didn't address the procedure to change the oxygen tubing weekly. Review of Resident #33's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Respiratory Disease (COPD). Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 2/9/21, revealed the resident received oxygen therapy. Review of Resident #33's Physician's Order, dated 3/1/21, revealed an order for oxygen at two (2) liters (L)/minute (min) per nasal cannula (NC) continuous for COPD. On 03/16/21 at 8:45 a.m., Resident #33 was observed sitting on his/her bed with the NC in his/her nostrils. The oxygen (02) concentrator was running at 2 L/min, however, the tubing was not labeled with the date it was changed. On 3/16/21 at 11:30 a.m., Resident #33 was observed sitting on his/her bed with the NC in his/her nostrils with the 02 concentrator sitting next to the recliner. The 02 tubing was observed not labeled with a date. Further observation on 3/16/21 at 12:15 p.m. revealed Resident #33 was sitting on his/her bed with the NC in his/her nostrils with the O2 concentrator on the floor. The 02 tubing was not labeled with a date. Continued observation of Resident #33 on 3/18/21 at 8:35 a.m., revealed the resident was laying on his/her bed with the NC in his/her nostrils. The O2 concentrator was running at 2 L/min with humidification and the 02 tubing with not labeled with a date. In an interview on 3/18/21 at 2:25 p.m. the Licensed Practical Nurse (LPN) #5 revealed the oxygen tubing should be changed weekly and should be dated which is done on the night shift usually. On 3/18/21 at 2:35 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked how often oxygen tubing should be changed. The DON stated that there was no official policy in place, just an oxygen procedure for nurses and policy was to change it weekly so it should be done regardless. The DON was then asked if a resident who was receiving oxygen should have an order to change the tubing weekly. The DON responded, Yes, they should.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to perform a gradual dose reduction [(GDR) - a periodic attempt to taper a medication in order to use the lowest effective dose or to discontinue the medication] and document the clinical rationale as to why an attempt would be contraindicated (likely to cause harm) for one (1) of 16 sampled residents (Resident #10). Resident #10 was receiving Risperdal (an antipsychotic medication) for Unspecified Dementia with Behavioral Disturbance, however, a GDR attempt had not been performed since 1/14/2020. Findings include: Review of the facility's policy titled Psychotropic Medication Monitoring, dated 11/1/12, indicated Psychotropic medication usage will be monitored, and gradual dose reductions attempted in accordance with state and federal guidelines. Antipsychotic medications will be utilized only as clinically indicated and necessary to treat a specific condition and target symptoms as diagnosed and documented in the medical record. Monitoring of psychotropic medications will be accomplished utilizing the following methods: Routine psychiatry consult for those receiving psychotropic medications with evaluation of indications/side effects/reductions/continuation or discontinuation. Consultant pharmacist monitoring for appropriate use of medications including timing of GDRs (gradual dose reductions). Review of Resident #10's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Behavioral Disturbance, Hypertensive Chronic Kidney Disease, Type II Diabetes Mellitus without Complications, Mild Intellectual Disabilities, Delusional Disorder, Essential Primary Hypertension, Insomnia, and Other Specified Depressive Episodes. Review of Resident #10's Annual Minimum Data Set (MDS) Assessment, dated 1/5/21, indicated the resident had both long term and short-term memory problems, had not demonstrated any behaviors, and showed minor depression. The MDS indicated the resident received an antipsychotic for seven (7) days of the look back period. Under the Medication section regarding the Antipsychotic Medication Review, it was documented that a GDR had not been attempted and the physician had not documented that a GDR was clinically contraindicated. According to the MDS, the last GDR attempt for the risperidone medication was on 1/14/2020. Review of Resident #10's Physician's Orders dated 3/1/2020 through 3/31/2020 indicated the resident was ordered risperidone .5 milligrams (mg) tablet twice a day (BID) for the diagnosis of Unspecified Dementia with Behavioral Disturbance. Review of the GDR documentation from the pharmacist to the physician, dated 1/14/2020, revealed the physician reduced the dose of Risperdal from five (5) mg three times a day (TID) to one (1) mg TID. Review of Resident #10's Nurse's Progress Note dated 3/12/2020 indicated the resident had an appointment with the psychiatrist and there was a new order to discontinue the current order of risperidone one (1) mg TID and start risperidone .5 mg twice a day (BID). During observation on 3/17/21 from 3:00 p.m. to 4:50 p.m., Resident #10 cried out while sitting in the corridor during a tornado warning and was calmed down by staff. Interview on 3/18/21 at 4:05 p.m. with the Director of Nursing (DON) indicated Resident #10's Power of Attorney (POA) had not wanted them to do anything with Resident #10's medications that the psychiatrist he/she saw would deal with it. Continued interview on 3/18/21 at 5:00 p.m. with the DON revealed there was no other documentation of GDR attempts for Resident #10. The Surveyor attempted to contact Resident #10's Power of Attorney (POA) on 3/16/21 at 6:39 p.m. but was unsuccessful.

Based on interview, record review, and facility policy review, the facility failed to act promptly upon the grievances of the resident group regarding food complaints for 15 out of 47 total residents. Interview with the Resident Council on 3/17/21 revealed their food concerns expressed in the 11/6/2020 meeting had not been addressed. Findings include: Review of the facility's policy titled Resident and Family Grievances, dated 3/15/21, revealed the Social Services Director has been designated as the Grievance Official who is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations .Grievances may be voiced verbally during resident or family council meetings. The Grievance Official will take steps to resolve the grievance, and record information about the grievance and those actions, on the grievance form The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance .In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. During the group interview on 3/17/21 at 10:55 a.m., the Resident Council (RC) indicated that things regarding their complaints about food did not change. They did not know what the staff that attended the RC meetings was doing with concerns expressed about food. They indicated the Social Worker attended the meetings and took notes. The RC President (Resident #3) indicated the bacon was still greasy, the bread was still soggy, and there still wasn't a variety of breakfast foods. The RC members also stated that other than the occasional tomato and lettuce salad, the facility did not serve fresh vegetables. The RC members indicated staff were not coming back to RC meetings to tell them anything about how their food complaints would be addressed. Review of the RC Meeting Minutes, dated 11/6/2020, revealed the members felt there were problems with the food such as the bacon was greasy; biscuits were often undercooked; dinner rolls and bread were being placed on top of the meal so the bread gets soggy; the kitchen often ran out of food items; there was too much fried food; and they would like to see more vegetables served. In an interview on 3/18/21 at 1:03 p.m., the Dietary Manager (DM) indicated he/she had developed a plan of correction that addressed food issues identified in February 2021 by the Ombudsman. The DM indicated that he/she worked for a contracted company that provided food services for the facility. The DM said he/she shared everything with his/her boss who was the District Manager of the contracted company. Review of the Felder Nutrition and Food Service Training Session Sign-In Sheet, dated 2/8/21, showed kitchen staff were in-serviced on not overcooking vegetables, and cooking meat until tender. Review of the Felder Nutrition and Food Service Training Session Sign-In Sheet, dated 2/10/21, showed kitchen staff were trained on following the recipes. Review of the Felder Nutrition and Food Services Training Session Sign-In Sheet, dated 2/11/21, showed kitchen staff were trained on proper temperature of foods. However, none of the trainings addressed the RC's food concerns. In an interview on 3/18/21 at 1:19 p.m., the Social Worker (SW) indicated that he/she attended the RC meetings when they met as a group and conducted a room to room meeting with residents to learn of their concerns. The SW indicated he/she emailed the concerns from the 11/6/2020 meeting to the Business Office Manager who notified the contracted company of the food complaints. Continued review revealed he/she was told to follow this undocumented process six (6) months ago but he/she was not sure who told him/her to do that. The SW showed the Surveyor the 11/10/2020 email that was sent to the Business Office Manager, the former DON (Director of Nursing), the former ADON (Assistant Director of Nursing) and the former Nurse Unit Manager. The SW also indicated he/she took the food concerns to the DM but does not document that he/she does this. Interview with the Business Office Manager on 3/18/21 at 4:00 p.m., indicated that there wasn't any documented evidence that he/she emailed the contracted food services company after receiving the 11/10/2020 email regarding the RC's food concerns on 11/6/2020 from the SW. The Business Office Manager also indicated that there wasn't a policy for how the staff would address the concerns of the RC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to provide necessary housekeeping services to maintain a clean environment and maintenance services necessary to maintain good repair of equipment. Observations on 3/16/21, 3/17/21 and 3/18/21 revealed the heating/air-conditioning (AC) unit vents in two (2) rooms (rooms #127 and #135) had buildup of dust/debris. The exhaust vents in six (6) bathrooms (rooms #111, #113, #125, #127, #130 and #135) had buildup of dust/debris on the Hill Hall and Back Door Hall units. In addition, the bathroom in room [ROOM NUMBER] was observed to contain a metal trash can that was completely covered with rust. Observations on 3/17/21 and 3/18/21, revealed a thick black buildup on the secured unit floors in three (3) resident rooms (rooms #4, #7, and #9), the bathroom next to room [ROOM NUMBER] and in the sitting room. Findings include: Review of a housekeeping policy titled Housekeeping Job Overview (not dated) revealed housekeeping staff were to perform daily housekeeping activities to assure that the facility is maintained in a clean and safe manner. Essential job functions listed included: (1) Perform day-to-day housekeeping activities in accordance with daily work assignments. (2) Clean/polish furnishings, fixtures, ledges, room heating/cooling units, etc., in resident rooms, recreational areas, etc., daily as instructed. (3) Clean floors to include sweeping, dusting, damp/wet mopping, disinfecting, etc. (4) Clean walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting, and deodorizing. (5) Remove dirt, dust, grease, film, etc., from surfaces using proper cleaning/disinfecting solutions. 1. On 3/16/21, 3/17/21 and 3/18/21 between the hours of 8:20 a.m. and 4:30 p.m. the following was noted on the Hill Hall and Back Door Hall units: -An exhaust vent in a shared bathroom between rooms #111 and #112 had buildup of dust/debris. -A metal trash can for resident and staff use in a shared bathroom between rooms #111 and #112 was completely rust covered. -An exhaust vent in a shared bathroom between rooms #125 and #126 had buildup of dust/debris. -An exhaust vent in a shared bathroom between rooms #127 and #128 had buildup of dust/debris. -A wall mounted heater/air-conditioning unit in room [ROOM NUMBER] had debris in the vent. -An exhaust vent in a shared bathroom between rooms #129 and #130 had buildup of dust/debris. -A wall mounted heater/air-conditioning unit in room [ROOM NUMBER] had debris in the vent. -An exhaust vent in a shared bathroom between rooms #134 and #135 had buildup of dust/debris. On 3/17/21 at 9:00 a.m., in an interview, Housekeeper (HK) #11 was asked who was responsible for cleaning the heater/air-conditioning units in resident rooms. HK #11 stated, We wipe the heater down but that is it. HK #11 was then asked who was responsible for cleaning the resident's bathroom exhaust vents. HK #11 stated that it was performed by maintenance. HK #11 was then asked how maintenance would be made aware of any of these concerns. HK #11 stated, I would tell my manager and he/she would tell maintenance. On 3/18/21 at 10:00 a.m. an interview with Housekeeper (HK) #8 revealed housekeeping staff were responsible for wiping down the heater on the wall, but they didn't clean the inside. HK #8 stated, We do have to clean the bathroom ceiling vents though. Observation of the bathroom in room [ROOM NUMBER] revealed thick dust/debris hanging from the exhaust vent. Continued interview with HK #11 revealed he/she would make sure to clean it up. Further observation on 3/18/21 at 3:15 p.m., along with the Activity Director (AD), revealed the bathroom exhaust fan in room [ROOM NUMBER] had been cleaned; however, multiple piles of dust/debris were found on the bathroom floor. On 3/18/21 at 11:45 a.m., in an interview, the Housekeeping Supervisor (HKS) stated, Housekeepers are supposed to wipe down the front of the heating/air-conditioning units every day, but if there is dirt inside then maintenance has to take them apart. Housekeeping is responsible for cleaning the ceiling vents in the bathrooms, but if they are really dirty, we need to ask maintenance to take them down so they can be cleaned. The HKS was then asked if maintenance had been aware of the dirty vents. The HKS confirmed they had been notified. On 3/18/21 at 1:15 p.m., in an interview, the Maintenance Supervisor (MS) stated, I am responsible for cleaning the wall heating/air-conditioning units and bathroom ceiling vents if they're really bad, I do have a list I like to go by but I've been alone for a bit and have been busy with other things. I am aware that they need to be cleaned. 2. Observations on 3/17/21 from 2:32 p.m. to 4:50 p.m. and on 3/18/21 from 8:58 a.m. to 10:30 a.m., revealed a thick black buildup on the door frame and floor of the following areas in the lower unit hallway (dementia unit): Resident #10's room [ROOM NUMBER], Resident #28's room [ROOM NUMBER], Resident #39's room [ROOM NUMBER], bathroom next to room [ROOM NUMBER] as well as in the sitting room (a large room with three couches, television and sun room). In an interview on 3/17/21 at 10:09 a.m., Housekeeper (HK) #14 said the dirty buildup had been that way for a while. HK #14 stated that the floor tech would be responsible for cleaning that and they could get it up with their scraper. In an interview on 03/18/21 at 10:19 a.m., the HKS said he/she had been at the facility a year and that buildup around doorframe and on the floor was from wax, glue and dirt. The HKS said they had a floor tech for about six (6) months but has not had one since December 2020. He/she also stated it was the floor tech's responsibility to remove the buildup, but apparently, he/she was not been doing his/her job. Continued interview on 3/18/21 at 11:41 a.m. with the HKS revealed the floor tech should have been able to clean up the buildup on the floor with a scraper. Review of the Job Description for the Floor Technician, dated 1/1/2016, listed the task of cleaning the floors which included sweeping, dusting, damp/wet mopping, disinfecting, etc. Coordinate daily floor maintenance with facility management when performing routine assignments in resident/patient living and/or recreational areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to properly date and ensure expired medications were removed from the supply in two (2) of four (4) medication carts (medication cart #1 and #2). In addition, the facility failed to ensure expired medical supplies were removed from the supply, properly date medications and dispose of expired medications in two (2) of three (3) medication rooms. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated August 2018, revealed: Procedures. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of accordingly to procedures for medication disposal. D. 1) The nurse shall place a 'date opened' sticker on the medication and enter the date opened and the new date of expiration .The expiration date of the vial or container will be 30 days .E. The nurse will check the expiration date of each medication before administering it. F. No expired medication will be administered to a resident. Beyond Use Dating: A. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing. D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. 1. On 3/17/21 at 9:30 a.m., observation with Licensed Practical Nurse (LPN) #5, revealed medication cart #2 contained opened stock medications without an opened date as follows: Aspirin (an anti-inflammatory) 81 milligrams (mg); Calcium (supplement) 600 mg + D3; Forastor (probiotic supplement); Iron (supplement) tablet 325 mg; Osteo BI Flex (joint supplement); Resinol medicated ointment (topical analgesic); Vitamin C (supplement) 500 mg; Vitamin D3 (supplement) 125 micrograms (mcg) (5000 IU); Vitamin E (supplement) 180 mg (400 IU); and Vitamin B12 (supplement) 1000 mcg. Additionally, the following prescribed medications were observed in medication cart #2 opened but not labeled with an opened date: Resident #9's artificial tears; Resident #11's Fluticasone propionate 50 mcg; Resident #23's desonide cream 0.05% and hydrocortisone cream 1%; and Resident #34's potassium chloride 10% (20 mcg). 2. Observation on 3/17/21 at 10:00 a.m. of medication cart #1 with Registered Nurse, Charge Nurse (RN) #7 revealed opened stock medications but not labeled with an opened date as follows: Anti-diarrheal; Bisacodyl (stimulant laxative); [NAME] Sulfate (iron supplement) 325 mg grain tablet; Magnesium Oxide (supplement) 400 mg tablets with an expiration date of 11/2020; Multivitamin + Iron (supplement); Senna Plus Natural Vegetable (laxative) with Stool Softener with an expiration date of 1/21; [NAME]-gram tablet 300 mg tablet with an expiration date of 2/12/21; Vitamin B-12 (supplement) 1000 mg; Vitamin E 180 (supplement) mg (400 IU) soft gel; Vitamin C (supplement) 500 mg; and two (2) bottles of Zinc Sulfate (supplement) 220 mg. Additionally, the following prescribed medications were observed in medication cart #1: - Resident #25's Humulin R (insulin) 300 units/3 ml opened on 2/12/21 with directions to discard after 30 days at room temperature and expired 30 days at room temperature. - Resident #25's Advair (corticosteroid) discus 250/50 with no directions for use. - Resident #30's albuterol (bronchodilator) four (4) bottles were not labeled with directions for use or with an opened date. - Resident #37's Venelex (wound ointment) tube was in a clear bag and not capped. The ointment was leaking from the tube into the bag with an opened date of 2/22/21. 3. On 3/17/21 at 10:55 a.m., observation of the medication room in Building B with Registered Nurse, Charge Nurse (RN) #7 revealed the following expired medical supplies: - Eight (8) Rate flow regulator extensions with an expiration date of 2/15. - Five (5) Rate flow regulator extension sets with an expiration date of 1/16. - Three (3) BD IV Start Packs with an expiration date of 10/16. - One (1) BD IV Start Pack with an expiration date of 6/16. - Six (6) Rate Flows with an expiration date of 7/17. - Seven (7) Rate Flows with an expiration date of 6/18. - Five (5) [NAME] 20 G needles with an expiration date of 5/2020. - Five (5) Med Stream Flow Regulator IV Sets with an expiration date of 9/2020. - Two (2) BD Vacutainers with an expiration date of 6/19. - Two (2) BD Vacutainers with an expiration date of 12/2020. - Three (3) Rate Flow Regular Extension Sets with an expiration date of 1/16. - One (1) Rate Flow Regular Extension Set with an expiration date of 6/18. - Two (2) Rate Flow Regular Extension Sets with an expiration date of 7/17. - Five (5) Whin Infusion Sets with an expiration date of 2/19. - 16 BD Start Pack Kits with an expiration date of 10/16. - One (1) Female Speci Cath Kit 8 French with an expiration date of 5/17. - One (1) Female Speci Cath Kit 8 French with an expiration date of 6/2020. - Two (2) Male Speci Cath Kits 8 French with an expiration date of 11/30/18. Additionally, observation of the medication storage room in Building B revealed the following prescription for Resident #8: Five (5) boxes of 0.9% Sodium Chloride Injection Normal Saline (NS) Flush syringe containing a total of 87 syringes, with pharmacy directions to discard after 2/24/21 with original fill date of 1/16/2020. Review of Resident #8's Physician's Order, dated 3/6/2020, revealed an order to discontinue Sodium Chloride Injection Normal Saline (NS) Flush. On 3/17/21 at 12:00 p.m. an interview conducted with RN #7 revealed insulin in the medication cart should be discarded after 30 days and that there was no way to tell if the expired insulin or the current insulin was administered to the resident. RN #7 was asked what the procedure was for opening a new bottle of stock medications and RN #7 replied that they are supposed to be labeled with the open date every time. 4. Observation of the second-floor medication storage room on 3/17/21 at 9:49 a.m. revealed an opened, undated multi-dose vial of Tubersol for Tuberculosis testing. During interview at that time, LPN #10 stated the vial or box should have been dated when opened and kept for only 30 days before discarding. LPN #10 further stated the vial appeared to contain one (1) dose of the Tubersol remaining. During interview on 3/18/21 at 9:21 a.m. the Director of Nursing (DON) stated multi-dose vials should be marked with the open date and used or discarded after 30 days. The DON stated the last nine (9) admissions to the second floor began on 1/11/21 and ended on 3/15/21, therefore some of those residents could have received an expired ineffective dose of Tubersol for testing. During interview on 3/18/21 at 4:20 p.m. the Pharmacy Consultant stated the facility should always follow the policy and procedure for multi-dose vials, and it would be impossible to say if the testing Tubersol was effective or not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure standard precautions were followed regarding performing hand hygiene and wearing personal protective equipment (PPE) appropriately to prevent the transmission of communicable disease and infection for eight (8) out of 16 sampled residents (Resident #10, #16, #20, #28, #33, #36, #39 and #198). Observation on 3/16/21 revealed Certified Nurse Aide (CNA) #6 did not wash his/her hands after doffing gloves. Observation on 3/17/2021 revealed Housekeeper (HK) #14 walked down the front Hall without wearing the face mask appropriately. Observations on 3/16/21 revealed CNAs #9 and #13 didn't wash their hands or change their gloves between residents when delivering the meal trays during lunch. Findings include: Review of the facility's policy titled Hand Washing, dated 11/2016, revealed 6. Additional considerations: b. The use of gloves does not replace hand washing. Wash hands after removing gloves. Review of the facility's policy titled Infection Prevention and Control Program, undated, revealed. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during providing resident care services. B. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Review of the facility's Infection Control Procedures Policy titled Using Masks, undated, stated the use of masks helped prevent the inhalation or splashing of potentially infectious materials into the mouth or nose of the caregiver. A review of the Centers for Disease Control and Prevention (CDC) recommendations titled Interim Infection Prevention and Control Recommendation for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic updated 5/22/2020, revealed the following recommendation for Long-Term Care Facilities: Implement Universal source Control Measures-source control refers to the use of cloth face coverings or face masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. 1. During an observation of the lunch meal on 3/16/2021 at 12:00 p.m., Certified Nurse Aide (CNA) #6 walked up the hall, opened the lunch cart, removed the tray and walked it into Resident #20's room [ROOM NUMBER]. He/she then placed the tray on the resident's bed. He/she then walked over to the doorway and donned a pair of gloves, walked up to the resident, took a small mouth basin from the resident, then walked into the bathroom and rinsed the basin in the sink. He/she came out of the bathroom, then the resident handed him/her two (2) tubes of toothpaste which he/she took and placed them in the basin then placed it on top of the dresser. Continued observation revealed CNA #6 walked to the trash can located at the doorway, doffed the gloves, picked up the meal tray using bare hands then placed it on the over bed table in front of the resident. He/she walked out of the room, opened the food cart and removed a tray belonging to Resident #33 in room [ROOM NUMBER] then carried the tray down the hall. During an interview with CNA #6 on 3/16/21 at 11:45 a.m., he/she stated, I didn't sanitize my hands between, but I did wash them before I started the lunch pass. I'll be sure to sanitize between from now on, I know I'm supposed to. Interview with Licensed Practical Nurse (LPN) #5 on 3/16/21 at 11:55 a.m. revealed CNA #6 should have performed hand hygiene between residents and after doffing his/her gloves. LPN #5 stated, We have gotten educated on this multiple times and we should all be using sanitizer when we leave rooms. That could end up as a cross contamination situation. Interview with the Director of Nursing/Infection Preventionist (DON/IP) on 3/17/21 at 12:45 p.m., revealed staff should be performing hand hygiene between rooms. 2. On 3/17/21 at 11:35 a.m., Housekeeper (HK) #14 was observed walking down a resident occupied front Hall and around the corner to the beauty shop door with his/her mask below his/her nose. HK #14 placed his/her mask over his/her nose after surveyor intervention. Interview with HK #14 revealed he/she was supposed to have the facemask over his/her nose. HK #14 stated he/she had been trained that the mask should always cover his/her nose and mouth. Interview on 3/17/21 at 11:40 a.m. with Registered Nurse/Charge Nurse (RN) #7 revealed all staff are required to wear a face mask at all times while in the building that covers their nose and mouth. Interview conducted on 3/17/21 at 3:45 p.m. with the DON/IP revealed, It's supposed to cover the nose and mouth. He/she should have it on at all times, I will educate him/her right now. Upon arrival to the facility on 3/18/21 at approximately 8:30 a.m. the DON/IP stated, We don't have a specific statement in writing that says masks have to be worn at all times and how to wear them, but we do have a mask policy. 3. Observation on the quarantine unit on 3/16/21 at 11:34 a.m. revealed all doors had signs for transmission-based precautions. CNA #9 exited a room, opened the door and closed it behind him/her. CNA #9 then cleaned his/her gloved hands with hand sanitizer and did not remove his/her gloves after cleaning his/her hands. CNA #9 picked up another lunch tray and entered Resident #198's room [ROOM NUMBER], opening and closing the door and setting up the resident's tray in that room. During interview on 3/16/21 at 11:37 a.m., CNA #9 stated that was how he/she was taught to do it, just wash his/her gloved hands with sanitizer if he/she was just passing trays for a meal. CNA #9 stated the residents on the quarantine unit were under transmission-based precautions. During interview on 3/17/21 at 11:58 a.m., LPN #10 stated he/she instructed the CNAs to clean hands and change gloves between rooms on the quarantine unit. LPN #10 agreed the residents on the quarantine unit were presumed positive and on transmission-based precautions. During interview on 3/18/21 at 8:43 a.m., the DON stated CNA #9 should have changed his/her gloves and not just used hand sanitizer to clean them. The DON stated the training was from the CDC's Personal Protective Equipment Contingency and Crisis training, and they did discuss this method with the staff, but staff may be confused about the practice and when to use it appropriately. The DON further stated they have not had a crisis shortage of gloves in the building and TBP rooms should always use PPE including clean gloves even if there was a shortage. The DON stated the observation (quarantine) unit was considered presumed positive for COVID during the two-week observation period upon admission. 4. During observation of the lunch meal service on the secured unit on 3/16/21 at 11:30 a.m., CNA #13 wore gloves as he/she took the lunch trays to Resident #10, #39, #16, #36 and #28. CNA #13 opened straws and placed the straws in the resident's drinks. CNA #13 did not wash his/her hands or change her/his gloves between serving the trays to each individual resident.

Based on observation, review of facility policy and cleaning schedules, and interview it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety. Sanitation concerns were identified in all areas of the kitchen and had the potential to affect 47 of 47 residents who received meals from the kitchen. Findings include: Review of a facility policy titled General Sanitation of Kitchen (dated 2019) revealed food and nutrition services staff would maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Procedures included: (1) Cleaning and sanitation tasks for the kitchen would be outlined in a written cleaning schedule. (2) Tasks would be assigned to be the responsibility of specific positions. (3) Frequency of cleaning for each task would be defined. Further review revealed a policy titled Cleaning Instructions: Floors, Tables, and Chairs (dated 2019) specified kitchen floors would be cleaned and sanitized regularly. Procedures included sweeping and cleaning kitchen floors after each meal, sanitizing at least once daily and moving major appliances at least once a month (as appropriate) to facilitate cleaning behind and underneath them. Review of the facility's dietary cleaning schedule revealed cleaning tasks were documented with assignments made to specific staff positions. The cleaning schedule specified all dietary employees must initial tasks when completed. The schedule further specified all cleaning assignments must also be checked for completion and initialed by the cook to ensure all cleaning is done. A review of the cleaning schedules from 12/1/2020 through the survey date of 3/17/21 revealed the assigned cleaning tasks had not been initialed by staff as having been completed or by the cook as verifying the cleaning had been done. An in-depth environmental tour of the kitchen was conducted on 3/17/21 at 11:10 a.m. Concerns identified with professional standards for food safety included: Food Storage Area: -Tile floors of the food pantry (dry food storage) were noted to be sticky with the surveyor's shoes sticking to the floor when taking steps. -Tile floors were noted to be stained and contained dirt, dust, liquid spills, and debris. -A build-up of dirt and debris noted under the shelves on the floor where dry foods are stored. -Baseboards in food pantry were noted to have gray tape applied to hold the baseboards against the wall. The tape was dislodged, and a build-up of dirt/debris was noted between the baseboards and the wall behind them. -The baseboard behind the entrance door to the food pantry were stained and dirty. -An accumulation of dirt and debris was noted behind the entrance door to the food pantry. Mouse droppings and one dead bug were observed to be included in the accumulation of dirt and debris. -Floors in the walk-in cooler and the walk-in freezer were noted to have dirt, debris, and stains in the areas under shelves, close to the walls, where cold and frozen foods were stored. -The floor in middle of the walk-in cooler had broken through and dropped down when stepped on. Food Preparation Area: -Beneath the counters where foods were prepared for residents' meals were lower shelves that were stained, sticky, and had a build-up of dirt and dust. The counter where silverware was rolled was noted to have an approximately eight (8) inch length of dirty tape hanging down from the bottom of the counter. The shelf beneath the dirty, hanging, tape was observed to be sticky and covered with dust. -A build up of grease, dirt, and debris was noted underneath the fryer. -The sides and front of the oven contained food spills and dirt/debris had accumulated on all areas of the oven. Additionally, the handles to the oven doors were noted to be sticky to the touch and contained dirt and food stains. -The ice machine had a blue, plastic container attached to the left, outside area. An ice scoop was noted to be stored in the blue container. The outside of the blue container was stained with dirt/debris and was sticky to the touch. -Floors throughout the food preparation area were observed to be dirty and sticky. Floor areas closer to the walls and under equipment were noted to have a greater build-up of dirt, dust, and debris. -A three (3)-compartment sink was noted to have water dripping onto the floor. Towels were observed to be placed on the floor area underneath the three (3)-compartment sink to catch the dripping water. -A portable cart (with wheels) was observed in the food preparation area. Both the top and lower shelves of the portable cart were noted to be sticky and have a build-up of food stains, dirt, and debris. Food Service Area: -The steam table where residents' meals were being served was noted to have a holding hot box unit to the right of the steam table. Hot food items for resident use were stored in the unit and staff were observed to remove food items to serve residents. The glass doors to the unit had dirt and food stains on them. The sides and bottom areas of the unit were noted to be stained with food drips, were sticky, and had dirt/debris particles stuck to all areas of the outside of the unit. -A reach-in refrigerator, located to the left of the steam table, was noted to be used during meal service to hold cold food items that were served to residents. The unit was noted to have a build-up of food/dirt stains on the outside. The unit was also noted to be sticky and have food spills dripping down the front of the unit. -The floor area to the right of the steam table was observed to have an accumulation of dirt and debris pushed up against the wall. The floor area was sticky and stained with food and liquid build-up. -An enclosed food cart was observed to be stationed adjacent to the steam table and staff were noted to be loading resident meal trays onto the cart. Observation of the wheels on the food cart revealed a build-up of dirt, stains, and debris. An interview was conducted on 3/17/21 at 11:35 a.m. with the Dietary District Support (DDS) staff person. The DDS stated dietary services were provided under contract and he/she worked in the contracted company's district office. The DDS stated he/she visited the facility at least once monthly to provide oversight of the dietary department. The DDS stated the Dietary Manager (DM) was ultimately responsible for ensuring the cleaning schedule was implemented and all areas were cleaned. The DDS stated he/she had observed the build-up under the fryer during a previous visit to the facility and had informed the DM of the concern. The DDS acknowledged the area under the fryer continued to have the build-up of grease, dirt, and debris and had not been cleaned since his/her previous visit. An interview conducted on 3/17/21 at 11:40 a.m. with the Dietary Manager (DM) who revealed the dietary staff were responsible for cleaning all areas of the kitchen/dietary department. The DM acknowledged it was his/her responsibility to ensure staff were completing assigned cleaning tasks and initialing the posted cleaning schedule when each task was completed. A request was made to review the cleaning schedules from 12/1/2020 through 3/17/21 that identified staff were initialing completion of assigned tasks. A review of the cleaning schedules for that timeframe revealed staff were not documenting the completion of assigned tasks. The DM acknowledged he/she had not been monitoring to ensure staff followed protocol for completing assigned cleaning tasks. The DM stated the dietary department had been down two staff positions and he/she had been filling in until the positions could be filled. This had affected his/her ability to perform some of the duties of a Dietary Manager. Interview on 3/17/21 at 11:55 a.m. with Dietary Aide (DA) #2 revealed he/she was aware of the cleaning schedule. DA #2 indicated being aware of which tasks on the cleaning schedule he/she was responsible for and stated he/she always completed the assigned cleaning tasks. DA #2 acknowledged not initialing the assigned task on the cleaning schedule when a task was completed. DA #2 was shown the floor area to the right of the steam table that was observed to have a build-up of dirt and debris and questioned regarding whose responsibility it would be to clean the area. DA #2 stated the noted floor area was not on the cleaning schedule and so would not be routinely cleaned.

Based on observations and interviews, the facility failed to ensure the beauty shops within the facility were clean and free of dust like substance in the fan and the supply carts, free of hair in the hair rollers and the floors were not dirty. This was observed on 2/5/19 and had the potential to affect 29 of 29 residents who received services from the beauty shops. This deficient practice was cited as a result of the investigation of complaint AL 00035908. Findings Include: On 2/05/19 at 8:38 AM, the surveyor observed the beautician open the beauty shop. The surveyor asked her name and how many days a week the beauty shop was open. Employee Identifier (EI) #5, Beautician, replied three or four times a week. EI #5 was asked what did she do for residents. EI #5 replied, hair cuts, perms, wash and roll hair, hair sets and styled. EI #5 and the surveyor observed around the beauty shop and EI #5 was asked to describe what she noticed. EI #5 replied, the floor was dirty, there was some dust on the fan. The surveyor asked her to describe the black cart containing hair rollers and hair sprays. EI #5 replied, there was dust on the cart, and hair in the rollers. EI #5 was asked why was hair in the rollers. EI #5 replied, they did not take it out. EI #5 was asked if there should there be hair left in the rollers. EI #5 replied, no. EI #5 was asked who did the hair belong to. EI #5 replied, different residents. EI #5 was asked how long had the dust build up on the black cart been there. EI #5 replied, probably a while. EI #5 was asked if the the dust was from last week. EI #5 replied, probably not, it had been some time. EI #5 was asked who was responsible for cleaning the beauty shop. EI #5 replied, housekeeping did the floors and the beauticians did the carts, curlers and supplies used. EI #5 was asked what was the harm in hair in rollers being used on multiple resident. EI #5 replied, infection control and she said she would not want a curler in her hair that had another persons hair in it. EI #5 was asked how were supplies sanitized. EI #5 replied, she was not sure. On 2/05/19 at 9:00 AM, during an observation of the beauty shop with EI #1,Director of Nursing (DON), she was asked to describe what she saw. EI #1 replied the floor was dirty, the supply cart was dusty and hair was in rollers on top of the cart. EI #1 was asked who was responsible for cleaning the beauty shop. EI #1 replied, the beauticians and housekeeping. EI #1 was asked what was the harm in the beauty shop room being dirty. EI #1 replied, infection control. EI #1 was asked what was the harm in dirty rollers and hair in the rollers. EI #1 replied, infection control. On 2/05/19 at 9:10 AM, the beauty shop on the 200 hall was observed with EI #1. EI #1 was asked to describe what she saw. EI #1 replied, the floor was dirty and dusty carts. There was no curlers observed in this room. EI #1 was asked if this beauty shop was used. EI #1 replied, yes at times. On 2/05/19 at 11:05 AM, an interview was conducted with EI #10, one of the housekeepers that cleaned the beauty shops. EI #10 was asked when was the beauty shop cleaned. EI #10 replied, it was to be done every Friday. EI #10 was asked if she cleaned the beauty shop last Friday. EI #10 replied, yes. EI #10 was asked what was included in the cleaning. EI #10 replied, sweep and mop the floor and clean the mirrors; they did not do the carts and sinks

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of a facility policy titled, Charting and Documentation Guidelines, the facility failed to ensure information regarding antibiotic therapy and Urinary Tract Infection were documented in Progress Notes Record for Resident Identifier (RI) #13 and RI #128. This affected 2 of 2 sampled residents identified receiving antibiotic treatment for UTI's. Findings include: A review of the undated facility policy titled, Charting and Documentation Guidelines revealed: . PROCESS: I. a) Chart all pertinent changes in the resident's condition, reaction to treatments, medication, as well as routine observations. 1. RI# 13 was admitted to facility on 8/1/207 and readmitted on 10/29.2018 with a diagnosis of urinary tract infection. A review of RI #13's nursing Progress Notes Report, dated 1/31/2019 revealed . sponsor requested that UA (Urinary Analysis)/ C&S (Culture & Sensitivity) be collected. The notes did revealed if the nurse collected the UA/C&S. Furthermore, the notes did not reveal whether RI#13 had a urinary tract infection, or if the medication was ordered. There was no other documentation noted until 2/4/2019. A Physician's Orders, dated 1/31/2019, revealed the order to collect UA/C&S per the family request. Another Physician's Orders, dated 2/2/2019, revealed the order to start Cipro 500mg (milligrams) BID (twice a day) x (for) 5 days for UTI. Base on Lab results, dated 2/1/19, the culture grew the bacteria Morganella Morgani of 97.16%. On 02/06/19 04:46 at PM, an interview was conducted with Employee Identifier (EI) #7 Register Nurse (RN) Unit manger. EI #7 was asked what did the facility policy say regarding charting and documentation of antibiotic therapy. EI#7 replied, to document the symptoms, attain Medical Doctor order and notify the family. EI # 7 was asked, looking at the nurse notes, could she tell the surveyor what was missing, or if anything was missing. EI #7 replied there was nothing documented between 2/1/-2/3 on the progress notes. EI #7 was asked who was responsible for charting on the resident. EI #7 replied, the nurse. EI #7 was asked what was the potential harm in not documenting on antibiotic therapy. EI #7 replied, you won't know if symptoms were continuing. EI #7 was asked how could she verify that the medication had been effective if there was no documentation. EI #7 replied, well the only way if the nurse assessed the resident and saw if the symptoms existed. EI#7 was asked how often should the staff document on residents receiving antiboitic therapy. EI #7 replied, at least once a shift, or as often as the antiboitic was given. 2. RI # 128 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Heart Failure. A review of a Laboratory report for RI #128 revealed urine was collected on 9/18/18 and results were reported to the facility on 9/23/18 with the identified organism Escherichia coli (E-coli). A review of RI #128's Physicians orders dated 9/23/18 revealed, . Bactrim DS (Double Strength) BID (twice a day) x 5 days . A review of RI #128's Nurse Progress Notes revealed no entries for 9/23/18 when the medication was ordered, nor for 9/24/18 when the medication was started. On 2/07/19 at 9:06 AM, an interview was conducted with EI #9, Licensed Practical Nurse. EI #9 was asked when was the Urinalysis (UA) done. EI #9 replied, 9/18/18. EI #9 was asked why was the UA done. EI #9 replied RI #128 was with altered mental status and the family expressed concerns. EI #9 was asked when were the results reported back to the facility. EI #9 replied, on 9/23/18. EI #9 was asked what was done. EI #9 replied the Medical Doctor was notified and Bactrim was ordered two times a day for five days. EI #9 was asked where was that documented. EI #9 reviewed the Progress Notes and replied it was not. EI #9 was asked why not. EI #9 replied it was an error on her part. EI #9 was asked how long did it take to get the results of a UA back. EI #9 replied it looked like five days. EI #9 was asked why it took so long. EI #9 replied, the lab did a C & S (culture and sensitivity) which took longer to get final results. EI #9 was asked who started the medication. EI #9 replied, she did. EI #9 was asked to review the Medication Record, then asked who gave the medication doses on 9/24, 9/25, 9/26, 9/27 and 9/28. EI #9 replied she did. EI #9 was asked what was the policy on documenting in nurse progress notes related to antibiotic therapy and change in status. EI #9 replied, they were to make an entry of vital signs and how the resident was tolerating the treatment. EI #9 was asked what was the harm in no entries in the nurse progress notes. EI #9 replied, in the event of side effects, they should be monitoring the resident, they should have vital signs and how the resident was tolerating the medication. EI #9 added, if it was not in the record they would not know what was going on with the resident. On 2/07/19 at 9:24 AM, an interview was conducted EI #7, Registered Nurse. EI #7 was asked when was a UA done on RI #128. EI #7 replied, on 9/18/18. EI #7 was asked when were the results returned to the facility. EI #7 replied, on 9/23/18. EI #7 was asked why did it take so long to return results to the facility. EI #7 replied a UA was done then requires a C & S which took longer to determine the organism and what it was sensitive to. EI #7 was asked once the results were returned to the facility what was done. EI #7 replied, the Doctor was notified and Bactrim was ordered to be started on 9/24/18. EI #7 was asked what was the policy for documenting in the nurse progress notes. EI #7 replied, the one receiving the order should have documented the order and the sponsor notified and vital signs. EI #7 was asked was there documentation each day while RI #128 received the Bactrim. EI #7 replied, no. EI #7 was asked why not. EI #7 replied, she was not sure, it appeared the nurse did not make an entry. EI #7 was asked if there should be an entry. EI #7 replied, yes at least daily while on the antibiotics. EI #7 was asked if there should be documentation in the progress notes that was not there. EI #7 replied, yes. EI #7 was asked what was the harm in staff not documenting in a resident's medical record. EI #7 replied, they could not be sure of what may have occurred, how the resident tolerated the medication, vital signs while on the medication and if the resident was still having negative symptoms or if no symptoms if the medication was effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of a facility policy titled Dressings -Clean, the facility failed to ensure licensed staff did not clean Resident Identifier (RI) # 52's wound then place the soiled 4 x 4's gauze on the over bedtable. This was observed on 2/5/19 and affected one of one resident's observed for wound care. Findings Include: A review of an undated facility policy titled Dressings - Clean, revealed . PROCESS: . 3. A disposable cloth (paper towel is adequate) is placed on the overbed table to establish a clean field; .10. Cleanse the wound as ordered; . RI #52 was admitted to facility on 4/3/18 and readmitted on [DATE] with a diagnosis of pressure ulcer of sacral region, stage 4. A review of RI #52's February 2019 Physician Orders revealed . Start Date: 1/4/19 clean sacrum, pat dry apply NS (normal saline) soaked gauze, cover with foam adhesive dressing, . On 2/05/19 at 10:30 AM, Employee Identifier (EI) #4, Registered Nurse, was observed performing wound care to RI #52. After washing her hands and putting on gloves, EI #4 took several 4 x 4 gauze and poured normal saline solution on them then cleaned the wound. EI #4 then laid the stack of soiled 4 x 4's on RI #52's over bedtable, then wearing the same soiled gloves prepared the outer dressing. EI #4 removed her gloves, washed her hands, put on clean gloves and moistened a 4 x 4 and placed it in the wound. EI #4 then placed the outer cover. On 2/05/19 at 10:42 AM, an interview was conducted with EI #4. EI #4 was asked what was the policy on performing wound care. EI #4 replied, gather supplies, wash hands, put on gloves, clean the wound, put soiled in trash bag, wash your hands, put on clean gloves and apply the dressing as ordered. EI #4 was asked where was she supposed to put the soiled items. EI #4 replied, in a trash bag. EI #4 was asked where did she put the soiled 4 x 4's. EI #4 replied, on the overbed table. EI #4 was asked what was the harm in putting the soiled 4 x 4's on the overbed table. EI #4 replied, infection could be spread. On 2/06/19 at 1:48 PM, an interview was conducted with EI #1, Director of Nursing (DON), Infection control. EI #1 was asked what was the policy on where to place soiled dressings and supplies used to clean a resident's wound. EI #1 replied, in a trash bag. EI #1 was asked when should a licensed nurse clean a wound with 4 x 4's then place the soiled 4 x 4's on a resident's overbed table. EI #1 replied, never. EI #1 was asked what was the harm in a licensed nurse placing used 4 x 4's, that she cleaned a wound with, on a resident's overbed table. EI #1 replied, cross contamination from the wound to the resident surface.

Based on observations, interviews, and review of facility policies titled, Food Storage and Cleaning Instructions: Hoods and Filters, the facility failed to ensure: 1) vents over the stove were free of grease and dust like substance; 2) biscuits in the freezer were sealed tightly and; 3) eggs in the reach in refrigerator were sealed and had an opened and use by date on the bag. This had the potential to affect 81 of 81 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Cleaning Instructions: Hoods and Filters with a date of 2013, revealed Policy: Stove and filters will be cleaned according to the cleaning schedule, or at least monthly. On 2/4/2019 at 3:55 p.m., the surveyor observed the vents over the stove were dirty. The surveyor observed grease like and dust like substance on the vents and grease like substance was running down on the panels. On 2/5/2019 at 10:05 a.m., the surveyor conducted an interview with (Employee Identifier) EI #2, Kitchen Manager. EI #2 was asked what was in the vents over the stove. EI #2 replied, build up grease. EI #2 was asked when were the vents cleaned last. EI #2 replied, November 2018. EI #2 was asked who was responsible for cleaning the vents over the stove. EI #2 replied, the cooks. EI #2 was asked what did the facility policy say regarding the cleaning of the vents over the stove. EI #2 replied, to clean every three months and when needed by the cooks. EI #2 was asked why was it important to keep the vents free of grease. EI #2 replied, because of fire hazard and cross contamination. EI #2 was asked when should the vents over the stove be cleaned. EI #2 replied once dietary staff see a build up of grease or dust. 2) A review of a facility policy titled, Food Storage with a date of 2013, revealed: . Procedure . 13. Leftover food is stored in covered or wrapped carefully and securely. On 2/4/2019 at 3:55 p.m., the surveyor observed in the freezer biscuits in a two point two ounce box with the plastic bag opened. The biscuits were not sealed. They were exposed to the freezer temperature. On 2/5/2019 at 3:28 p.m., the surveyor conducted an interview with EI #3, Cook. EI #3 was asked what was in the kitchen freezer opened. EI #3 replied, biscuits. EI #3 was asked why were the biscuits opened. EI #3 replied, someone did not close them back. EI #3 was asked who was responsible for making sure items were sealed in the freezer once opened. EI #3 replied, the person that opened the item. EI #3 replied the cook usually opened them and they should put a use by date on the food items. EI #3 was asked why was it important that food items were sealed in the freezer. EI #3 replied, so it won't get contaminated or freezer burnt. EI #3 was asked when should food items be sealed in the freezer. EI #3 replied, as soon as you get through using them. EI #3 was asked what was the facility policy regarding sealing food in the freezer. EI #3 replied, to seal it up, put the date it was opened and the use by date. 3) A review of a facility policy titled, Food Storage, with a date of 2013 revealed: . Procedure . 13. Leftover food is stored in covered container or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within three days or discarded.14. f. All foods should be covered, labeled and dated. On 2/4/2019 at 3:55 p.m., the surveyor observed in the number one reach in refrigerator a large bag, opened at the top, containing a yellow liquid. The cook stated it was liquid eggs. The bag was not labeled. On 2/5//2019 at 3:36 p.m., the surveyor conducted an interview with EI #3. EI #3 was asked what was opened in the reach in refrigerator. EI #3 replied, eggs. EI #3 was asked what information was on the bag. EI #3 replied, there was nothing on the bag. EI #3 was asked was there an opened date. EI #3 replied, no. EI #3 stated there was no open or closed date on it. EI #3 was asked what was the opened date. EI #3 replied he did not see a date. EI #3 was asked what was the use by date. EI #3 replied he did not see one. EI #3 was asked what name was on the bag. EI #3 replied, there was no name on the bag. EI #3 was asked what did the facility policy say regarding food items in the refrigerator when opened and out of the original container. EI #3 replied, package up in another container, put the date you opened it and a use by date. EI #3 stated eggs should be used the next day. EI #3 was asked who was responsible for sealing and labeling items once opened. EI #3 replied, every body, the person that opened the items.

Based on observation, interview and a review of a facility policy titled, Garbage and Refuse, the facility failed to ensure the dumpster door was closed on 2/4/2018. This affected 1 of 2 facility dumpster's. Findings include: The facility policy titled, Garbage and Refuse, with an effective date of February 1, 2013, was reviewed. The purpose revealed: To prevent the spread of bacteria that may cause food borne illness. The standard include, Garbage and refuse containers . covered when not in use. On 2/4/20/19 at 4:21 p.m., the surveyor observed two dumpster's located outside in back of kitchen. Dumpster number one's door was not completely closed/covered. On 2/5/2019 at 10:00 a.m., the surveyor conducted an interview with(Employee Indentifer) EI #2, Kitchen Manager. EI #2 was asked to describe the dumpster doors on 2/4/19 at dumpster number one. EI #2 replied, it was not closed all the way properly, it was opened about 3/4 inches. EI #2 was asked why was the dumpster door opened. EI #2 replied, a CNA (Certified Nurse Assistant) left it opened. EI #2 was asked how far was it opened. EI #2 replied, 3/4 inches. EI #2 was asked what was the facility policy on keeping the dumpster doors closed. EI #2 replied, it be must closed at all times. EI #2 was asked why should the dumpster doors be kept closed. EI #2 replied, it was a hazard condition. EI #2 was asked who was responsible for making sure the dumpster doors were kept closed. EI #2 replied, dietary staff. EI #2 was asked why was it important to keep the dumpster doors closed at all times. EI #2 replied, because of hazard condition, water when it rained could get in, bugs and insects could get in and it kept the smell down.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of a facility policy, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #26 received oxygen as ordered. This was observed on 3/7/18 and affected one of four residents observed for oxygen use. Findings Include: A review of an undated facility policy titled, Oxygen Administration revealed: .STANDARD: Oxygen should be administered under orders of the attending physician, .PROCESS: 1. Obtain physician's orders for the rate of flow and route . 8. Check oxygen flowmeter for correct liter flow . RI #26 was admitted to the facility on [DATE] with diagnoses to include Chronic Pulmonary Edema and Unspecified Systolic (congestive) Heart Failure. A review of RI #26's March 2018 Physicians Orders revealed: .Treatment Apply oxygen at 2 L/min (Liters per minute) NC (nasal cannula) continuous - QS (every shift) . On 3/7/18 at 11:00 a.m., RI #26 was observed with oxygen infusing at 1 liter per minute by nasal cannula. On 3/7/18 at 12:00 p.m., RI #26 was observed with oxygen infusing at 1 liter per minute by way of nasal cannula. On 3/7/18 at 12:10 p.m., Employee Identifier (EI) #3, Registered Nurse, Unit Manager was asked to observe RI #26's oxygen. EI #3 was asked how many liters were infusing. EI #3 replied one. EI #3 was asked how many liters were to be infusing. EI #3 replied two, however she would check the doctor's order to verify. Once verified, EI #3 was asked how often was RI #26 to receive the oxygen. EI #3 replied, continuously at 2 liters per minute EI #3 was asked if the oxygen order was to be at 2 liters per minute however was infusing at 1 liter per minute, were the doctor's orders being followed. EI #3 replied no. EI #3 was asked what was the harm in the doctor's orders not being followed. EI #3 replied RI #26's oxygen saturation could be low.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure a Certified Nursing Assistant (CNA) did not perform incontinent care and catheter care for Resident Identifier (RI) #18 and then touch clean pads and a clean brief with the same soiled gloves. This was observed on 3/7/18 and affected one of one residents observed for incontinent care and catheter care. Findings Include: RI #18 was admitted to the facility on [DATE], with a diagnosis of Dementia without Behavioral Disturbance. On 3/7/18 at 10:00 a.m., Employee Identifier (EI) #4 (a CNA) was observed performing catheter care for RI #18. EI #4 cleaned the front of the perineal area and the catheter, then with the same gloves picked up a clean pad and opened it. EI #4 picked up another clean pad and opened it and placed it on top of the first pad. EI #4 picked up a clean brief and opened it and placed it on top of both pads. EI #4 rolled the pads and brief together and placed it under RI #18. EI #4 turned RI #18 to the side and cleaned the bowel movement from the buttocks. EI #4 removed the soiled pads and rolled out the clean pads and brief from under RI #18 with the same soiled gloves. EI #4 removed her gloves and washed her hands. EI #4 put on clean gloves and applied skin barrier to the perineal area. On 3/7/18 at 10:15 a.m., an interview was conducted with EI #4. EI #4 was asked what was the policy on glove changing during incontinent and catheter care. EI #4 replied she should have changed her gloves after she cleaned the front side of RI #18. EI #4 was asked if she touched two clean pads and a clean brief as she rolled them together with the same gloves she had on to clean RI #18. EI #4 replied yes. EI #4 was asked what was the harm in touching clean pads and a clean brief with soiled gloves. EI #4 replied contamination from the bowel movement she may have gotten on her gloves. On 3/8/18 at 2:00 p.m., EI #1, Director of Nursing/Infection Control Nurse was interviewed. EI #1 was asked what was policy on changing gloves during incontinent care. EI #1 replied they should change gloves before going to clean items. EI #1 was asked if staff should clean a resident that had a bowel movement, then with the same gloves touch the clean pads and brief. EI #1 replied no. EI #1 was asked what was the potential for harm in the staff touching clean pads and a brief with soiled gloves. EI #1 replied the possibility of contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and an observation of a breakfast meal tested on [DATE], the facility failed to serve food at palatably warm temperatures. This had the potential to affect all 94 residents for whom meals were prepared and served at the time of this survey. Findings Include: During the initial tour on 03/06/18 between 3:00 PM and 6:00 PM, four of 36 residents questioned about food palatability commented the morning coffee was lukewarm, the food was not always hot, and breakfast foods were cold. A Resident Council Meeting was held on 03/07/18, with ten residents in attendance. All residents reported the food was served cold and was not appetizing. On 03/07/18 at 7:49 AM, the surveyor requested a breakfast tray to determine the temperature and palatability of foods and beverages served. A Dietary Aide delivered the food cart to the D Hall at 7:52 AM, and nursing staff began distributing the trays three minutes later. The last tray was delivered at 8:15 AM, after which Employee Identifier (EI) #2, the Corporate Dietary Manager, checked each food item and beverage on the test tray with her thermometer. The findings were as follows: SCRAMBLED EGGS: 105 degrees Fahrenheit (F). A surveyor present tasted the eggs and described the eggs as cool; could be warmer. GRITS: 110 degrees F; cool to taste; could not melt butter. EI #2 made no comment on the taste. BOLOGNA: 96 degrees F; EI #2 folded the cooked bologna in half and inserted her thermometer, stating, It's cold. BISCUIT: 99 degrees F (untasted). COFFEE: 110 degrees F. After checking the temperature, EI #2 immediately took a sip of the coffee and commented it was, Luke (warm). On 03/07/18 at 5:20 PM, the surveyor questioned the Dietary Manager (EI #5) and the Corporate Dietary Manager (EI #2) about the food temperatures. When asked why the coffee was not hot, EI #2 explained the coffee was pre-poured into mugs and set into a hot box prior to service, but sometimes the trays would stay in the food cart after delivered to each hall, a long time before staff started serving them. EI #5 (the Dietary Manager) explained that she attended every monthly Resident Council meeting and was aware of some of the residents' comments, including complaints about watered down soup and hard cooked meat.

Based on observation, review of the facility's policies regarding Manual Dishwashing and Personal Refrigerators and Food Storage and interviews with staff, the facility failed to: 1) discard commercially-prepared chicken salad after the date of expiration; 2) maintain the solution used to sanitize food preparation counters at the recommended concentration; and 3) discard expired Ensure pudding and yogurt in one of three nursing station refrigerators checked on 03/08/18. These concerns had the potential to affect all 94 residents for whom meals were prepared and served or snacks provided at the time of this survey. Findings Include: 1) On 03/06/18 at 2:15 PM, during the initial kitchen tour, a five-pound container (80% consumed) of commercially prepared chicken salad was stored in the reach-in refrigerator with an expiration date of 2/25/18 (nine days prior). When questioned, the Co-Dietary Manager, Employee Identifier (EI) #6, stated the alternate menu served on the previous evening had included chicken salad, however due to the inadequate amount remaining in the container, staff had prepared fresh chicken salad. 2) A facility policy related to Cleaning Dishes - Manual Dishwashing dated 12/05/12, specifies the concentration of quaternary ammonium must be at a strength of 150 to 200 parts per million (ppm) to effectively sanitize. On 03/07/18 at 9:33 AM, the [NAME] wiped off the preparation counter with a cloth stored in a bucket of sanitizing solution. At 9:44 AM, the surveyor requested a check of the concentration of chemical sanitizer (quaternary ammonium) inside the bucket used by the Cook, as well as a second bucket of sanitizing solution available for use, stored on a shelf under the food processor. Staff determined the concentration of each bucket of solution was (inadequate at) 100 ppm. No change in the solution was made at this time. The surveyor interviewed the Co-Dietary Manager (EI #6) on 03/08/18 at 10:00 AM. EI #6 verified the recommended concentration needed to be 150 to 200 ppm. When asked the purpose of wiping the preparation counters with the quaternary ammonium, EI #6 explained the counters were supposed to be washed and sanitized after every use and the buckets were supposed to be changed every two hours. EI #6 confirmed that a concentration of 100 (ppm) was a problem (too low). Twelve minutes later (at 10:12 AM), a staff member used a cloth from one of the buckets of sanitizing solution (with an inadequate concentration) to wipe the counter on which sandwiches had just been prepared. 3) A facility policy titled: Personal Refrigerators and Food Storage Policy and Procedure (undated) directs staff as follows: .1. Individuals will be educated on safe food handling and storage techniques by designated facility staff as needed. Staff will examine food for quality (visual, smell, packaging, manufacturers expiration date) to identify potential concerns . On 03/08/18 at 8:03 AM, the pantry refrigerator at Nursing Station A-2, contained three 4-ounce containers of expired yogurt (dated 02/16/18), and one 4-ounce container of chocolate Ensure pudding with a use-by date of 1 October 2017. On 03/08/18 at 8:19 AM, the licensed medication nurse (EI #7) was asked who was responsible for the monitoring of food in the pantry refrigerator. EI #7 stated all of the staff were responsible. When asked what potential hazard the expired food could cause, EI #7 stated the food could have soured; she would not want to eat it herself.