**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of a facility policy titled Nursing Assessments, the facility failed to ensure a Quarterly Minimum Data Set (MDS) assessment was completed timely for Resident Identifier (RI) #4. This deficient practice affected RI #4, one of 20 residents reviewed for MDS assessments. Findings Include: A review of a facility policy Nursing Assessments with an effective date of August 15, 2018 revealed: . STANDARD: Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident/guest(s) condition. PROCESS: . III. Quarterly Nursing Assessments include: (once every 3 months). RI #4 was admitted to the facility on [DATE] with a diagnosis of Personal history of Traumatic Brain Injury. A review of RI #4's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 11/07/2021 indicated the assessment was complete. A review of a most recent Quarterly MDS assessment, with an ARD of 04/4/2022, was in progress and had not been completed. On 04/21/2022 at 8:09 AM, an interview was conducted with Employee Identifier (EI) #3, the Registered Nurse (RN)/MDS Coordinator. EI #3 was asked, how she knew when an MDS assessment was due. EI #3 replied she would run a report which indicated which MDS assessments were due. EI #3 was asked, when an MDS assessment was completed, how would it indicate completed. EI #3 replied she transmits, and it would be on a transmittal page. EI #3 was asked when was RI #4 admitted to the facility. EI #3 replied, 01/15/2021. EI #3 was asked when were RI #4's MDS assessments due; and what type MDS assessments would be due. EI #3 replied, on 11/07/2021 a Quarterly MDS assessment was done, and before then a Significant change MDS assessment was completed on 08/08/2021. EI #3 was asked, when was a MDS assessment due after the one dated 11/07/2021. EI #3 replied, one should have been done in February, and she realized it was not done on 04/04/2021. EI #3 was asked, if the MDS assessment dated [DATE], had been completed and submitted. EI #3 replied, not yet but it would be submitted today, 04/21/2022. EI #3 was asked why was the next MDS assessment due after 11/07/2021 not completed until April. EI #3 replied, it was an oversight not intentional. EI #3 was asked, if the MDS was submitted timely. EI #3 replied, no. EI #3 was asked, what was the concern with an MDS assessment not being submitted timely. EI #3 replied there could be missed information. EI #3 was asked who was responsible for ensuring timely submissions of the MDS assessments. EI #3 replied, it was hers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents receiving tube feedings, feeding pumps were kept clean and free of a tube-like feeding substance. This deficient practice affected Resident Identifier (RI) #'s 3, 41 and 96, three of four residents sampled for tube feedings, and was observed on three of four days of the survey. Findings Include: RI #3 was admitted to the facility on [DATE], with diagnoses to include Dysphagia and Encounter for Attention to Gastrostomy. RI #3's April 2022 Physician Orders revealed RI #3 had an order for tube feeding of Glucerna 1.5 CAL (calorie) to infuse at 60 cc (centimeters) an hour. On 04/19/2022 at 2:20 PM, RI #3 was observed lying in bed with the head of the bed elevated at a 30-degree angle. RI #3's continuous tube feeding of Glucerna 1.5 cal (Calorie) was observed infusing by way of a pump at 60 cc's hours. There was a dried feeding tube like substance observed on the feeding pump On 04/20/22 at 9:38 AM, RI #3 was observed up in a wheelchair and the tube feeding of Glucerna 1.5 cal continued to infuse by way of pump at 60 cc's hours. The dried feeding tube like substance remained on the feeding pump. On 04/21/2022 at 8:32 AM, RI #3 was again observed up in the wheelchair with the tube feeding of Glucerna 1.5 cal observed infusing by way of pump at 60 cc's an hour. The dried feeding tube like substance remained on the feeding pump. RI #41 was admitted to the facility on [DATE], with a diagnosis of Gastrostomy Status. RI #41's April 2022 Physician Orders revealed RI #4 had an order for Tube feeding of Jevity 1.5 to infuse at 50 cc's an hour. On 04/19/2022 at 2:30 PM, RI #41 was observed lying in bed with the continuous tube feeding of Jevity1.5 infusing at 50 cc's hour. The screen of the feeding tube pump has dried tube feeding looking substance on it. On 04/20/2022 at 9:40 AM, RI #41 was again observed lying in bed with the continuous tube feeding of Jevity1.5 infusing at 50 cc's hour. The screen of the feeding tube pump was again observed to have a dried tube feeding looking substance on it. On 04/21/2022 at 8:34 AM, the screen of RI #41's feeding tube pump remained with a dried tube feeding looking substance on the screen. RI #96 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Dysphagia and Encounter for Attention to Gastrostomy. RI #96's April 2022 Physician Orders revealed RI #96 was receiving the continuous tube feeding of Glucerna 1.5 to infuse at 42 cc's an hour. On 04/19/2022 at 2:01 PM, the surveyor observed RI #96's continuous tube feeding of Glucerna 1.5 cal infusing by way of a feeding pump at 42 cc's hour. There was a dried tube feeding like substance observed on the feeding tube pump. On 04/20/2022 at 9:32 AM, RI #96's feeding tube pump remained with the dried feeding tube like substance on it. On 04/21/2022 at 8:28 AM, RI #96's tube feeding of Glucerna 1.5 cal continued to infuse at 42 cc's hour with the dried feeding tube like substance remaining on the feeding tube pump. On 04/21/2022 at 8:45 AM, the surveyor conducted an interview with Employee Identifier (EI) #2, the LPN (Licensed Practical Nurse) caring for RI #'s 3, 41 and 96. The surveyor asked EI #2 how often were the resident's feeding tube pumps cleaned. EI #3 said every shift. When asked who would be responsible for ensuring the feeding tube pumps were kept clean, EI #2 said the individual caring for the residents. The surveyor asked EI #2 what could there be a potential for when feeding tube pumps are not kept clean. EI #2 said infection and the feeding tube pumps should be kept clean. EI #2 said not cleaning them would mean they are dirty. On 04/21/2022 at 8: 54 AM. EI #2 accompanied the surveyor to RI #96's room. When asked what did it look like was on the feeding tube pump, EI #2 said she was not sure but it looked dirty. On 04/21/2022 at 8: 55 AM, EI #2 accompanied the surveyor to RI #3 and RI #41's room. When asked what did it look like was on the feeding tube pumps, EI #2 stated it looked like it was dried feeding on RI #3's and 41's feeding pumps. On 04/21/22 at 9:06 AM, the surveyor conducted an interview with EI #4, the Registered Nurse Unit Manager. The surveyor asked EI #4 how often were the residents feeding pumps cleaned. EI #4 said she did not know the policy on that. When asked who would be responsible for ensuring the feeding pumps are kept clean, EI #4 said probably the nurses. EI #4 said there could be a potential for an infection control concern if the feeding pumps were not kept clean. On 04/21/2022 at 1:44 PM, the surveyor conducted an interview with EI #1, the Interim Director of Nursing. The surveyor asked EI #1 who would be responsible for ensuring the residents feeding pumps were kept clean. EI #1 said the nurses. When asked why should the feeding pumps be kept clean, EI #1 said because the feeding pump is a part of the resident's feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of a facility policy titled, Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #2 washed hands after removing gloves before placing a clean 4x4 over Resident Identifier (RI) #87 's wound during wound care. This was observed on 9/4/19, and affected one of two residents observed for wound care. Findings Include: A review of a facility policy titled, Hand Hygiene, with an effective date of September 1, 2017, revealed . III. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. After removing gloves . RI #87 was admitted to the facility on [DATE] and readmitted on [DATE]. A diagnosis included pressure ulcer of right ankle, stage 2. A review of RI #87's Physician Orders for September 2019 revealed, . Order date 8/20/19 Start date 8/20/19 Stage 2 Wound to Right Medial Ankle, Change Dressing PRN (as needed), Cleanse With Wound Cleanser, Apply Medi Honey, Cover with Tegaderm Foam Boarder Dressing . On 9/04/19 at10:55 AM, the surveyor observed EI #2, (RN) Registered Nurse and EI #7, Licensed Practical Nurse (LPN) perform wound care to RI #87's right ankle. EI #2 cleaned the top of the over the bed table. EI #2 and EI #7 washed and dried their hands. EI #7 put on gloves and entered the resident's room. EI #2 placed the needed supplies in zip lock bags. EI #2 dated and initialed the tegaderm. EI #2 then removed the old tegaderm dressing and discarded it into the garbage. EI #2 removed her soiled gloves and washed her hands. EI #2 put on gloves and measured the wound. EI #2 removed her gloves and washed her hands. EI #2 put on clean gloves, took a gauze pre-moistened with wound cleanser from the zip-lock bag and cleaned the wound. EI #2 removed her soiled gloves. EI #2 removed a clean dry 4x4 from the zip-lock bag and placed it on the wound using her bare hand. EI #2 did not wash her hands or put on clean gloves before getting the clean 4 x 4 from the zip lock bag and placing it on the wound. On 9/4/19 at 12:00 PM, an interview was conducted with EI #2. EI #2 was asked if she followed the facility policy to prevent causing contamination to the wound. EI #2 replied, I thought I did, but after thinking about it, I should have left the wound uncovered and after taking my gloves off, went and washed my hands, put gloves on, then got a clean, dry gauze out of the zip lock bag and laid it on top of the wound. On 9/05/19 at 8:00 AM, an interview was conducted with EI #1, RN, Director of Nursing, (DON). EI #1 was asked, what could not washing one's hands and putting on gloves during wound care, according to policy, result in. EI #1 replied, it could cause a wound to get infected. We don't know what's on our hands when we touch a clean gauze with our bare hands. We could be introducing germs. We could be putting a wound in harms way.

Based on observations, interviews, and review of the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to ensure the 3-compartment sink drain pipes did not extend into the wall and have a direct connection with sewage system to create potential for backflow. This had the potential to affect 87 of 87 residents receiving meals from kitchen. Findings Include: 1. A review of the FDA 2017 Food Code revealed: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 9/3/19 at 3:38 PM, an observation was made of the 3-compartment sink. The drain extended below the 3-compartment sink and made a direct connection into the wall. At that time Employee Identifier (EI) #4, Dietary Supervisor, was asked if the 3-compartment sink had backflow prevention device. EI #4 replied that she did not know, but would ask maintenance. On 9/4/19 at 11:04 AM, an interview was conducted with EI #3, Registered Dietitian Nutritionists, Licensed Dietitian. EI #3 was asked if the 3-compartment sink had an air gap. EI #3 replied that she did not see an air gap in the plumbing of the 3-compartment sink. On 9/5/19 at 8:53 AM, a second interview was conducted with EI #4. EI #4 was asked, what was washed or placed in the 3-compartment sink. EI #4 replied, pots, pans, plates, bowls, glasses, anything they used was washed in the 3-compartment sink. EI #4 was asked, did the drain pipe from the 3- compartment sink have a direct connection to the sewage pipe. EI #4 replied, it looked like it did. On 9/5/19 at 10:12 AM, an interview was with EI #5, Maintenance. EI #5 was asked, if the drain pipe, which drained the 3-compartment sink, had a direct connection with the main sewage pipe. EI #5 replied, I am going to be honest and I think it does. It goes from the sink into the wall. EI #5 was asked, what was the potential harm for residents that existed because of the direct connection between the 3-compartment sink and sewage pipe. EI #5 replied, germs, food particles, anything that was in the sewage line could backflow into the sink and contaminant the sink and its' contents. On 9/5/19 at 10:24 AM, an interview was conducted with the Plumber. The Plumber was asked, did the drain pipe that drains the 3-compartment sink have a direct connection with the main sewage pipe. EI #6 replied, Yes, the issue is the sewage could back-up into the sink when the plumbing is tight, like this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and review of a facility document titled, RESIDENTS: These are YOUR Rights, the facility failed to ensure Employee Identifier (EI) #5, Activity Director, allowed Resident Identifier (RI) #12 to attend the Resident Council Meeting on 08/15/18. This affected RI #12, one of 94 residents residing in the facility. Findings Include: A review of a document titled, RESIDENTS: These are YOUR Rights, with no date, documented: .YOU have the right to choose the groups and activities in which you choose to participate. RI #12 was readmitted to the facility on [DATE]. A review of RI #12's Annual Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact and that it was very important to the resident to attend group activities. A review of RI #12's Activity Care Plan dated 11/15/2017, revealed: .ENJOYS ATTENDING GROUP ACTIVITIES . On 08/15/18 at 10:00 a.m., a Resident Council Meeting was conducted. During the meeting, two residents stated that one of the residents that normally attended the meeting was not present because he/she was told by Employee Identifier (EI) #5, Activity Director, to leave the meeting. Both residents stated they were also told to leave the meeting, but they refused. On 08/15/18 at 10:26 a.m., when leaving the Resident Council Meeting, RI #12 was observed sitting in a wheelchair in the hallway outside the room. RI #32 asked RI #12 why he/she did not come to the meeting. RI #12 said he/she was told not to come. RI #32 asked who told you that. EI #5, stepped up to the resident and told her/him that she/he did no need to attend because RI #12 had already talked to the surveyors and she wanted to give other residents the chance to talk. On 08/15/18 at 10:46 a.m., an interview was conducted with RI #12. RI #12 was asked if he/she would like to talk in the conference room since he/she was not permitted to attend the Resident Council Meeting. RI #12 said yes. RI #12 then stated that he/she had been told by EI #5 not to come into the Resident Council Meeting because he/she had already talked to two surveyors. RI #12 said EI #5 instructed him/her to go play dominos after the morning devotional. RI #12 further stated that he/she regularly attended the Resident Council Meetings and had wanted to attend the meeting today as well. On 08/16/18 at 1:50 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked had she been made aware of the situation regarding RI #12 not being allowed to attend the Resident Council Meeting on 08/15/18. EI #1 said yes. She stated that EI #5 had told her that RI #12 had already talked to the surveyors and she was giving someone else the opportunity to speak with them. EI #1 then stated that she told EI #5 that she could not refuse any resident access to participate in a Resident Council Meeting. The surveyor asked EI #1 was preventing a resident from attending the meeting a violation of a resident's rights. EI #1 said, yes it was. EI #1 was asked was RI #12 prevented from attending the meeting yesterday. EI #1 stated she did not feel EI #5 did it on purpose, but it did happen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of a facility policy titled, Hand Hygiene, the facility failed to ensure a licensed staff washed her hands when removing gloves during wound care observation of Resident Identifier (RI) #72. This affected RI #72, one of three residents observed during wound care. Findings Include: A review of a facility policy titled, Hand Hygiene, with an effective date of September 1, 2017, revealed: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some of the situations that require hand hygiene .After handling soiled equipment or utensils .After removing gloves or aprons . RI #72 was readmitted to the facility on [DATE]. A current diagnosis included a pressure ulcer of unspecified elbow, Stage 3. On 08/16/18 at 10:36 a.m., an observation was made during the wound care of RI # 72. Registered Nurse (RN) Employee Identifier (EI) #3, entered RI #72's room. She washed her hands and donned gloves. EI #3 pulled the privacy curtain, then removed the gloves and put on clean gloves, without washing her hands. She then removed the wound dressing and cleaned the area. After providing additional care to the wound area, EI #3 removed her gloves and donned clean gloves, again without washing her hands. She initialed and dated the dressing, took her gloves off and washed her hands. On 08/16/18 at 11:01 a.m., an interview was conducted with EI #3. She was asked when should she wash her hands when using gloves. EI #3 answered, before and after putting them on and when taking them off. EI #3 was asked did she wash her hands after pulling the privacy curtain wearing gloves and before applying a clean pair. The RN replied, no ma'am. The surveyor asked EI #3 if she washed her hands when removing her gloves after applying the collagen matrix. She answered, no ma'am. EI #3 was asked what was the concern with not washing her hands when removing gloves and before applying clean gloves. EI #3 replied, you may touch something on the outside of the gloves when removing the dirty ones and expose your skin to something dirty that you put in the new gloves, making them dirty. EI #3 was asked what was the concern with that. She responded with, infection control.

Based on observation, interview and a review of the facility's policy titled, Food Receipt and Storage, the facility failed to ensure mighty shakes were labeled and properly dated with use by dates. This had the potential to affect 93 of 95 residents receiving meals from the kitchen. Findings Include: A review of the facility's policy titled, Food Receipt and Storage' with an effective date August 23, 2017, revealed: . PURPOSE: Foods should be received and stored properly to prevent food borne illnesses. PROCESS: . II. Storage of Foods: . j. Label the case or tray of frozen supplements(without expiration dates) with the date they are thawed, or with a used by date which is 14 days from thaw date. On 08/13/18 at 4:15 p.m., during the initial kitchen tour, the surveyor observed three Vanilla Sugar Free Mighty Shakes with a use by date of 7/27/18, four Vanilla Sugar Free Mighty Shakes with a use by date of 8/8/18, and one Vanilla Sugar Free Mighty Shake with no use by date. An interview was conducted on 8/16/18 at 1:16 p.m., with Employee Identifier (EI) #4, Dietary Manager. EI #4 was asked what was the policy and procedure for dating and labeling mighty shakes. She replied, when thawed out in the cooler the date is 14 days from the thawed date. EI #4 was asked were the 8 mighty shakes within the 14 day time limit. She responded, no ma'am. EI #4 was asked what was the concern with the mighty shakes being out of date and having no date. She stated that the mighty shakes were not safe to be consumed by the residents. EI #4 was asked if the mighty shakes were not safe to be consumed by the residents, what potential harm was it to the residents. The dietary manager answered, the residents could become sick, nausea, and vomiting. EI #4 was asked who had the ultimate responsibility to ensure the food/ mighty shakes were properly labeled. She answered, she was,as dietary manager.

Based on observation, interview and review of the facility's policy titled, Garbage and Refuse the facility failed to ensure the outside garbage dumpster doors were closed and soiled items and other refuse were not lying on the concrete around the dumpster area. Findings include: The facility policy titled, Garbage and Refuse with an effective date of February 1, 2002, documented the purpose, To prevent the spread of bacteria that may cause food borne illnesses. Process: a. Garbage should be disposed of in refuse containers, . e. Refuse containers and dumpsters kept outside the facility should . be kept covered when not being loaded. 08/16/18 01:38 PM an observation was made of the six outside dumpster's and the surrounding area. One dumpster was noted with the door open, odor noted and gnats flying around the door. Around the dumpster's were noted a pair of soiled gloves, 13 cup lids, 3 plastic cups, 1 Ensure Plus box, 1 newspaper and 1 paper towel, all lying on the concrete outside the open dumpster. On 08/16/18 12:51 PM, and interview was conducted with Employee Identifier (EI) #4, the Dietary Manager. She was asked what was the facility policy regarding garbage and refuse. EI #4 replied, the dumpster lid should have been tightly fitted/ closed. She was asked was the door open on one of the dumpster's and she replied, yes ma'am. EI #4 was asked was there an odor noted, gnats flying around the door, and trash lying on the concrete. The dietary manager answered, yes ma'am. EI #4 was asked what was the concern with the dumpster door being open, smell of odor, gnats flying around the door of the dumpster, and trash lying on the concrete beside the open dumpster. EI #4 replied, it can cause more insects and rodents, which can be harmful to the food and residents.