Based on observation, interviews, and record review, it was determined that the facility failed to ensure dignity was maintained while performing Activities of Daily Living (ADL) for 1 resident (Resident #56) of 1 receiving incontinent care. Findings included: 1. Review of a facility policy titled, Resident Rights, (not dated), indicated, Each resident has the right to be treated with consideration, respect and full recognition of dignity and individuality. Review of an admission Record, indicated Resident #56 was admitted with a diagnosis of dementia and anxiety disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/8/2024 revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated Resident #56 was moderately cognitively impaired. On 10/15/2024 at 07:14 AM, observed Certified Nursing Assistants #6 and #7 performing incontinent care on Resident #56 without pulling the privacy curtain. On 10/15/2024 at 9:50 AM, Certified Nursing Assistant (CNA) #6 was asked if the privacy curtain should have been pulled completely. CNA #6 stated the curtain should have been closed all the way. On 10/15/2024 at 9:55 AM, Certified Nursing Assistant (CNA) #7 was asked if the privacy curtain should have been pulled completely. CNA #6 stated the curtain should have been pulled to provide privacy. Review of Resident #56's care plan with a revision date of 06/21/2024 showed the resident had bowel incontinence and had limited physical mobility related to dementia. Interventions with revision date of 09/05/2024 included that the resident was dependent on 2 staff for transferring and toileting. During an interview on 10/15/2024 at 11:00 AM, the Director of Nursing (DON) was asked if the privacy curtain should have been pulled completely. She stated the curtain should have been pulled to ensure privacy and dignity were provided to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) comprehensive assessment was completed within 14 calendar days from the determination that a significant change has occurred for one (Resident #2) of one resident reviewed for assessments. The findings are: Upon review of the residents admission Record, it showed Resident #2 was admitted on [DATE], with a primary diagnosis of encephalitis (inflammation of the brain). The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/25/2024 documented the resident scored 03 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. Upon review of Resident #2's (R#2) scanned documents, hospice care was ordered on 5/11/24. Upon review of all completed MDS assessments, R#2 did not have a significant change in status MDS comprehensive assessment completed within 14 calendar days following readmission on [DATE]. On 10/16/2024 at 10:30 AM, interviewed the MDS Coordinator regarding the MDS and care plan for R#2. She confirmed she was aware R#2 was currently receiving hospice care and was aware this was a change that took place upon the readmission on [DATE]. During the interview, the MDS Coordinator was asked to review the completed MDS assessments. Upon review, she confirmed a significant change MDS was not completed within 14 calendar days following the resident's readmission to the facility with hospice care ordered on 5/11/2024. Upon review of the most recent care plan, last updated 8/24/2024, the MDS Coordinator confirmed R#2 was no longer taking an anticoagulant, montelukast (medication used to control asthma and inflammation in the lungs), mirtazapine (a medication used to treat depression), or hydrocodone (a medication used to treat pain), however the medications remained on the care plan. In addition, she confirmed the care plan does not contain any new interventions addressing that the resident was receiving hospice care provided by named hospice provider. Under the Activities of Daily Living (ADL) section of the care plan, the MDS Coordinator confirmed it does not address the level of care needed during mealtimes. When asked about the importance of completing a significant change in status MDS assessment, the MDS Coordinator confirmed the MDS and care plans guide everyone providing care to the resident, and if the information is incorrect, this could have a negative impact on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and document review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to reflect the resident's needs, and failed to ensure it was accurate to represent the resident's current health status for one resident (Resident #2) of one resident reviewed for comprehensive care plans. The findings are: On 10/14/2024 at 12:55 PM, observed Resident #2 (R#2) sitting in a geriatric chair in the designated dayroom/dining area for the memory unit with Certified Nursing Assistant (CNA) #10 assisting R#2 with lunch. CNA #10 continued to offer each bite of food, and each drink of fluid to R#2. After the meal, CNA #10 was interviewed regarding care for R#2. When asked how much assistance R#2 requires for during meals and for fluids, and she confirmed R#2 requires full assistance with all food and drinks. Upon review of the residents admission Record, it showed Resident #2 (R#2) was admitted on [DATE] with a primary diagnosis of encephalitis (inflammation of the brain). Upon review of Resident #2's scanned documents, R#2 was readmitted to the facility on [DATE] with a significant change where hospice care orders were completed on 5/11/2024. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/25/2024 documented the resident scored 03 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. Under section GG regarding eating, it is documented R#2 requires Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity, however the care plan last updated 08/21/2024 does not address the assistance required for meals or fluids for R#2. The current level of care needed for R#2 is fully dependent on staff for eating meals and drinking fluids per staff interview and observations. Upon further review of the resident's physician orders and the care plan, the diet ordered stated: Regular diet, Mechanical Soft texture, Regular consistency. The diet in the care plan stated: Regular diet, Pureed texture, Regular consistency. There is a discrepancy between the orders and the care plan not stating the same diet. Confirmed with dietary staff that R #2 is receiving a Regular diet, Mechanical Soft texture, Regular consistency. Interviewed the MDS Coordinator on 10/16/2024 at 10:30 AM regarding R #2 and the MDS assessments and care plans. She confirmed she was aware R #2 is currently receiving hospice care and was aware this was a change that took place upon the readmission on [DATE]. During the interview, the MDS Coordinator was asked to review the completed MDS assessments. Upon review, she confirmed a significant change MDS was not completed within 14 calendar days following the resident's readmission to the facility with hospice care ordered on 5/11/2024. Upon review of the most recent care plan last updated 8/24/2024, the MDS Coordinator confirmed R#2's medications had changed, and the resident was no longer taking an anticoagulant, montelukast (a medication used to control asthma and inflammation in the lungs), mirtazapine (a medication used to treat depression), or hydrocodone (a medication used to control pain), however the medications remain on the care plan. The care plan did not include atropine (a medication used to control secretions) as a current medication which is ordered for this resident. In addition, she confirmed, under the Activities of Daily Living section of the care plan did not address the level of care needed during mealtimes. The MDS Coordinator confirmed the care plan did not address the changes regarding the significant change in status including new interventions related to hospice care. When asked about the importance of completing a significant change in status MDS assessment, the MDS Coordinator confirmed the MDS and care plans guide everyone providing care to the resident and if the information is incorrect, this could have a negative impact on the resident.

Based on observation, record review, and interview, the facility failed to ensure staff followed Enhanced Barrier Precautions to reduce the potential risk of infection for 1 (Resident #41) sampled resident who was reviewed for Enhanced Barrier Precautions. The findings are: Review of the admission Record revealed Resident #41 was admitted with a diagnosis of pressure ulcer of right heel, stage 3 (Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed). The quarterly 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/2024 revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated the resident had severe cognitive impairment. Review of Resident #41's care plan, completed 8/21/2024, revealed the resident had a stage 3 pressure ulcer to the right foot. Interventions included but were not limited to: Low Air Loss Mattress to bed for pressure relief as tolerated. Ensure functional and operational and encourage good nutrition and hydration in order to promote healthier skin. Review of Resident #41's physicians orders revealed the resident was on Enhanced Barrier Precautions related to wound to right heel and coccyx start date of 9/27/24. Review of the CMS (Centers for Medicare & Medicaid Services) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Memorandum, Subject, Enhanced Barrier Precautions [EBP] in Nursing Homes. provided by the Administrator revealed on page 1 that EBP recommendations now include use of EBP for residents with chronic wounds and on Page 3 Chronic wounds include, but are not limited to, pressure ulcers. During an observation on 10/14/2024 at 11:30 AM CNA #8 and CNA #9 witnessed incontinent care and a transfer with a lift. No PPE (Personal Protective Equipment) was used during incontinent care or transfer of Resident #41. During an interview on 10/14/2024 at 12:26 PM CNA #9 stated, Wound is healed up on resident's bottom so no longer on barrier precaution. During an interview on 10/16/24 at 11:06 AM the Wound Consultant and the Treatment Nurse were asked if the pressure ulcer of the right heel of Resident #41 was considered current with treatment. The Wound Consultant and the Treatment Nurse stated yes, and that the resident would be under enhanced barrier precaution and that PPE (personal protective equipment) was in the room for staff to use.

Based on observation, record review, and interview, the facility failed to ensure lint traps for two of two dryers located in the facility laundry room were cleaned to prevent the potential for fire hazard. The findings are: During a tour of the facility laundry room on 10/16/2024 at 9:04 AM, two clothing dryers used to launder resident clothing were observed. The Housekeeping/Laundry Supervisor was asked to provide the surveyor with access to the dryer's lint traps. The lint trap of one dryer was found to contain what appeared to be five white pieces of paper, a dryer sheet, and a buildup of lint. The lint trap of the second dryer contained what appeared to be ten dryer sheets and a buildup of lint. During an interview on 10/16/24 at 9:04 AM, the Housekeeper/Laundry Supervisor explained that the lint area of dryers are cleaned every hour. Upon further observation of the dryer lint traps, it appeared to not be cleaned recently in either dryer. The Housekeeper/Laundry Supervisor explained that laundry was told to clean the lint screens every hour instead of every two hours as described on the schedule. Last time Housekeeper #12 verbalized cleaning the dryer lint traps was 7:40 am. A document titled, Lint Cleaning Schedule for the month of October was reviewed on 10/16/24 and revealed that it was signed off as being last cleaned at 6:00 AM. During an interview on 10/16/2024 at 9:45AM, the Housekeeper/Laundry Supervisor and Housekeeper #12 stated that they dried three or four loads of laundry between 6:00AM-9:00AM. On 10/17/2024 the Administrator provided two documents: a. A Laundry Cleaning Schedule which indicated that staff should clean the lint under the dryer with each use. b. A Lint Log Sheet that indicated the lint trap should be emptied after each load of laundry dried.

Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot to maintain palatability and encourage adequate nutritional intake for 1 of 2 meals observed. The findings are: 1. On 10/14/24 at 11:12AM, Resident #51 stated food is cold when served. 2. On10/15/24 at 8:11 AM, a food cart that contained 8 meal trays for breakfast was delivered to the 500 Hall by Certified Nursing Assistant (CNA) #3. At 8:22 PM, the temperature of the food items on the last resident tray, was taken and read by the District Dietary Manager. The temperatures were as follows: a. Scrambled eggs - 98 degrees Fahrenheit. b. Sausage - 84 degrees Fahrenheit. c. Pan cake - 100 degrees Fahrenheit. d. Gravy - 102 degrees Fahrenheit. 3. On 10/15/24 at 8:11 AM, the first breakfast meal tray for the 300 Hall was placed in an unheated food cart in the hall outside the kitchen window by Certified Nursing Assistant (CNA) #4, who left it open while loading the meal trays. When the staff began removing the meal trays, there were 7 trays in the food cart to be delivered to the residents who ate in their rooms. At 8:21 AM, Certified Nursing Assistant (CNA) #5 delivered the same unheated food cart with 3 remaining breakfast trays in it to the 300Hall. At 8:29 AM, the temperature of the food items on the test tray after the last residents was served in their room was taken and read by the District Dietary Manager. The temperatures were as follows: a. Sausage - 80 degrees Fahrenheit. The District Dietary Manager stated it was just warm. b. Scrambled eggs - 112 degrees Fahrenheit. c. Pureed oatmeal - 110 degrees Fahrenheit. d. Pureed eggs - 110 degrees Fahrenheit. e. Pureed sausage - 114 degrees Fahrenheit. 4. On 10/15/24 at 11:52 AM, when asked during an interview Certified Nursing Assistant #4 who loaded the breakfast meal trays into the food cart stated he was instructed to leave the food cart open during the loading process. CNA #4 stated that leaving it open while loading would cause the food to cool down.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure dietary employees washed their hands or changed gloves before handling food items and clean equipment when contaminated; expired food products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria. The findings are: 1. On 10/14/24 at 9:42 AM, Dietary [NAME] (DC) #1 wore gloves on her hands while using scissors to cut open a bag of shredded cheese which contaminated the gloves. Without washing her hands, she removed shredded cheese from the bag and sprinkled it on top of enchiladas to be baked and served to the residents for lunch. 2. On 10/14/24 at 9:52 AM, an opened box of fish was on a shelf in the walk-in refrigerator. The box was not covered or sealed 3. On 10/14/24 at 9:56 AM, the following observations were made in the storage room: a. One box with 24 count of probiotics drink, was on a shelf with an expiration date of 10/6/2024. b. On bag of butter fingers was on a shelf with an expiration date of 6/19/2024. c. One bag of hamburger buns was on the bread rack in the storage room with an expiration date of 10/12/2024. 4. On 10/14/24 at 10:28 AM, the following observations were made in the kitchen cabinet: a. One container of whole celery with an expiration date of 9/18/2024. b. One container of sage rub with an expiration date of or 9/19/2024. On 10/14/24 at 11:04 AM, the following observations were made on a shelf in the refrigerator: a. An opened bottle of chicken sauce. There was no open date on the bottle. b. An opened bottle of nutritional drink. There was no received date or name listed on it. c. An opened cup of vanilla ice cream with a straw in it. The cup was not covered. d. An opened container of sherbet was in the freezer. The sherbet appeared discolored. The Dietary Manager stated it had thawed and refrozen, with all the layers of the sherbet mixed as one shade. 5. On 10/15/24 at 07:19 AM, Dietary Aide (DA) #2 picked up a rag from the counter with food stains on it and dried inside a pan. Without washing his hands, DA #2 attached a clean blade at the base of the blender to be used in pureeing food items to be served to the residents. DA #2 stated he should have washed his hands. 6. A review of facility policy titled, Handwashing and Glove Usage in Food service, initiated 2016, provided by the Dietary Manager on 10/15/2024 indicated employees must wash their hands after starting work and after touching dirty equipment.

Based on observation, record review and interview, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) and mask were properly changed and bagged in a closed container to prevent infections for 1 of 1 sampled resident (Resident # 8) who had a physician's order for the use of a CPAP. The findings are: On 9/05/23 at 11:22 AM Resident #8 was sitting in the resident room with a CPAP on the bedside table with no date on the tubing. The tubing and mask were not bagged. On 9/06/23 at 10:56 AM, observed the mask and tubing on a bedside table. The CPAP was not bagged or dated. On 9/06/23 at 3:35 PM observed the CPAP was not in a bag or dated and the mask was lying on the bed. Review of a Physician's order dated 8/13/23 for Resident #8 showed the oxygen tubing for the CPAP machine to be changed every Sunday night. Review of a care plan with an initiated date of 6/30/23, for Resident #8 for oxygen therapy showed the Resident wears CPAP at night, and the nurse to assist with putting it on at night and removing it in the morning. On 9/7/23 at 8:30 AM Certified Nurse assistant (CNA) #1 confirmed there was no date on the tubing, and it was not stored in a bag. During an interview on 9/7/23 at 8:38 AM, Licensed Practical Nurse (LPN) #3 stated the tubing should be changed weekly and stated Resident #8 tubing was dirty. LPN #3 confirmed there was no date on the tube, and it was not stored in a bag. During an interview on 9/7/23 at 12:20 PM the Director of Nurses (DON) stated the tubing should be changed weekly on Sunday night. On 9/8/23 at 10:32 AM the DON provided a manufactures guideline Titled Cleaning and Maintaining your [Brand] headgear .For best Performance, remember to clean your headgear on a weekly basis .

Based on Observation, Interview and Policy Review the facility failed to remove expired medications from 1 of 2 medication carts. The Findings include: On 9/6/23 at 2:15 PM observed the following medications on medication cart # 2. a. one vial of Novolin R insulin with an opened date of 6/3/23. b. one Albuterol Inhaler with an opened date of 7/21/03. c. one ProAir Inhaler with an opened date of 7/2/23. d. one Albuterol Inhaler with an opened date of 6/13/23. e. one Albuterol Inhaler with an opened date of 10/31/22. f. four bottles of Artificial Tears with an opened date of 6/20/23, 7/20/23, and 7/26/23 and 1 was not dated. g. one bottle of Dorzolamide eye drops with an opened date of 7/28/23. h. one bottle of Timol Eye drops with an opened date of 7/27/23. i. one Albuterol Sulfate Inhaler with an opened date of 6/15/23. j. one bottle of Latanoprost eye drops with an expiration date of 6/30/23. k. one bottle of Xalatan eye drops not dated. l. one bottle of Latanoprost eye drops with an opened date of 4/21/23. During an interview on 9/6/23 at 2:40 PM, Licensed Practical Nurse (LPN) #1 stated insulin is good for 28 days after it is opened. On 9/6/2023 at 4:19 PM, the Director of Nursing provided a policy titled, Storage of Medications IN THE FACILITY. This policy documented, H .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medication disposal . J. Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 12 residents who received pureed diets and 13 residents who received mechanical soft diets and 33 residents who received regular diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 09/06/2023 at 9:00 AM. findings are: 1. The menu for the dinner meal showed the residents who received pureed diets were to receive 2 #8 scoop (1 Cup) of fish sandwich with 2 slices of cheese, residents on mechanical soft diets were to receive 3 ounces of hamburger patties with 2 slices of cheese and residents on regular diets were to receive 2 slices of cheese. 2. On 8/05/23 at 3:28 PM during the supper meal preparation Dietary Employee (DE) #4 placed 4 breaded fried fish cod pieces into a blender, ground and poured it into a pan. He covered the pan with foil and placed it in the oven to be served to 13 residents on mechanical soft diets. At 5:09 PM DE #4 used a 2-ounce spoon to serve a single portion of ground breaded fish cod with a slice of cheese to the residents on mechanical soft diets. instead of 3 ounces of ground breaded fish cod. 3. On 09/05/23 at 3:32 PM DE #4 placed 4 breaded fish cod pieces into a blender, then added 2 more breaded fish cod pieces, added 2 cartons of whole milk and pureed. DE #4 added 2 more cartons of milk and pureed. At 3:38 PM DE #4 poured the pureed fish into a pan, covered with foil, and placed it in the oven to be served to 12 residents on pureed diets. At 5:03 PM DE #4 used a 4-ounce spoon to serve a single portion of pureed fish to the residents on pureed diets, instead of 2 #8 scoop of pureed fish sandwich with cheese. At 5:25 PM the surveyor asked DE #4 the reason residents on pureed diets did not receive any type of bread or cheese. He stated, I forgot to puree bread and cheese. 4. On 9/05/23 5:11 PM DE #4 served a single slice of cheese to the residents on regular diets. 5. On 9/06/23 at 8:02 AM the surveyor asked DE #4 how many servings of fish he prepared for the residents on pureed diets and residents on mechanical soft diets. He stated, I did 6 servings for the pureed dets and 4 servings for the mechanical soft diets. He was asked how many residents you have on pureed diets and on mechanical soft diets. He stated, We have 12 residents on pureed diets and 13 on mechanical. I thought that would be enough when I used milk. 6. On 9/06/23 at 11:23 AM the surveyor asked the Dietary Supervisor to weigh a slice of cheese. She did and stated, it weighed 0.5 ounce. She was asked to weigh 2 slices. She did and stated, it weighed 1 ounce.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 12 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 09/06/2023 The findings are: On 09/05/23 at 11:48 AM, the following observations were made on the steam table: a. A pan of pureed potato salad was on the cold side of the steam table. The consistency of the pureed potato salad was lumpy and was not smooth. Pieces of potatoes were visible in the mixture. b. A pan of pureed barbeque chicken was on the steam table. The consistency of the pureed barbeque chicken was lumpy and not smooth. On 09/05/23 at 12:55 PM The surveyor asked Dietary Employee (DE) #3 to describe the consistency of the pureed foods served to the residents on pureed diets. She stated, pureed barbeque chicken has little pieces of chicken in it. Pureed potatoes have lumps in it. On 09/05/23 at 03:14 PM DE #4 placed 75 tater tots into a blender, added 2 cartons of whole milk and pureed. At 03:18 PM DE #4 poured the pureed tater tots into a pan; he covered it with foil and placed it in the oven. The consistency of the pureed tater tots was lumpy and not smooth. 09/05/23 03:32 PM DE #4 placed 4 breaded fish pieces into a blender, then added 2 more breaded fish pieces, added 2 cartons of whole milk and pureed. He added 2 more cartons of milk and pureed. At 03:38 PM DE #4 poured the pureed fish into a pan, covered with foil, and placed it in the oven. The consistency of the pureed fish pieces was lumpy and not smooth. On 09/05/23 at 03:40 PM pureed cabbage in a pan in the oven to be served to the residents for supper was runny. On 09/05/23 at 05:27 PM the surveyor asked the Dietary Supervisor to describe the pureed food items served to the residents on pureed diets at the dinner meal. She stated, pureed cabbage was too runny, pureed fish and pureed tater tots had lumps.

Based on observation and interview, the facility failed to ensure leftover food items were used to maintain food quality; 1 ice machine and 1 scoop holder were maintained in clean and sanitary condition to prevent contamination of airborne particles; foods stored in the dry storage area refrigerator, and freezer were covered, and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; cold foods on ice were maintained at a temperature at or below 41 degrees Fahrenheit while awaiting service to prevent potential bacteria growth; hot food items on the steamtable were maintained at a temperature at or above 135 degrees Fahrenheit while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 58 residents who received meals from the kitchen, (total census: 59) as documented on a list provided by the Dietary Supervisor on 09/06 /2023 at 09:00 AM The findings are: 1 On 09/05/23 09:45. A zip lock bag that contained leftover sausage was on a shelf in the refrigerator. On 09/06/23 at 07:58 AM the surveyor asked Dietary Employee (DE) #3 what do you use leftover sausage for? She stated, we use it for the pureed meal the next morning. 2. On 09/05/23 at 09:52 AM, an opened box of bacon was on a shelf in the walk-in refrigerator. The box was not covered or sealed. 3. On 09/05/23 at 09:53 The ice scoop holder on the wall by the ice machine had gray residue at the bottom of it. The ice scoop was in direct contact with the gray matter residue. The surveyor asked the DE #1 to wipe the inside of the ice scoop holder. She did so and stated, it was gray residue. The surveyor asked DE #1 how often they clean the scoop holder. She stated, I clean it every day. 4. On 09/05/23 at 09:54 AM the top panel of the ice machine in the room between the dining room and the kitchen window had wet black residue on it. The surveyor asked DE #1 to wipe the top panel. The wet residue easily transferred to the tissue. DE #1 stated, that was black matter on it. I clean it every day. The Surveyor asked the Dietary Supervisor, who uses the ice from the ice machine from the ice machine? She stated, that's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms and the residents' beverages at the mealtimes. 5. On 09/05/23 at 09:55 AM an opened box of biscuits was on a shelf in the walk-in freezer. The box was not covered or sealed. 6. On 09/05/23 at 11:19 AM a box of crackers was on top of the freezer in the nourishment room on 200 Hall had best used by 10/12/2022 on it. 7. On 09/05/23 at 11:40 AM DE #2 removed a carton of nectar cranberry juice from the refrigerator and placed it on the counter. Without washing his hands, he picked glasses by their rims and poured beverages in them to be served to the residents on nectar thickened liquid diets. 8. On 09/05/23 at 11:48 AM the temperatures of the food items on the steam table were checked by DE #3 were: a. Potato salad 50 degrees Fahrenheit. b. Pureed potato salad 50 degrees Fahrenheit. c. Baked beans 115 degrees Fahrenheit. The baked beans were not reheated before being served to the residents. 9. On 09/05/23 at 11:50 AM DE #1, picked up the water hose with bare hands, used it to spray leftover food from inside of the blender. DE #1 placed the blender, a blade and the lid in the dirty racks and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, DE #1 moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who received pureed diets for lunch. DE #1 then picked up clean dishes and stacked them in a rubber container on the cart to be used in portioning food items to be served to the residents for lunch. The Surveyor asked what you should have done after touching dirty objects or before handling clean equipment? DE #1 stated, I should have washed my hands. 10. On 09/05/23 at 12:43 PM DE #2 was on the tray line assisting with lunch meal service, picked up condiments, cartons of milk, shakes, cans of soda and placed them on the trays. Without washing hands, DE #2 picked up glasses that contained beverages by their rims and placed them on the meal trays to be served to the residents for lunch. At 01:00 PM the Surveyor asked DE #2 what should you have done after touching dirty objects or before handling clean equipment? DE#2 stated, I should have washed my hands. 11. On 09/05/23 at 01:22 PM DE #4 removed onion from the walk-in refrigerator and placed it on the counter. DE #4 peeled off the papery layers from the onion, turned on the 3-compartment sink faucet and rinsed it. DE #4 then turned off the faucet with bare hands, therefore. DE #4 then placed the onion on the cutting board and held it with his hands while he sliced it with a knife. DE #4 then transferred slices of onion into a pot on the stove to be used in cooking cabbage to be served to the residents for supper. The surveyor asked DE #4 what should you have done after touching dirty objects or before handling clean equipment? DE #4 stated, I should have washed my hands. 12. On 09/05/23 at 02:50 PM a bag of hamburger buns that contained 8 buns was on the rack in the walk-in refrigerator. The bag showed best used by 8/29/2023. Six bags of hamburger buns with 8 buns in each bag were on the bread rack in the walk-in refrigerator. Each bag showed best used by 9/2/2023. 13. On 09/05/23 at 3:00 PM DE #5 removed a tray that contained glasses of beverages from the walk-in refrigerator and placed it on the counter. DE #5 removed cartons of grape juice from the refrigerator and placed them on the counter. Without washing hands, DE #5 picked up glasses by the rims and poured beverages, then placed them on the trays to be served to the residents for supper. The surveyor asked what you should have done after touching dirty objects or before handling clean equipment? DE #5 stated, I should have washed my hands. 14. The facility policy on hand washing provided by the Dietary Supervisor on 09/06/2023 at 09:00 AM documented, After engaging in other activities that contaminate the hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected the resident's status to for Hospice for 1 of 1 (Resident #29) sample resident reviewed. This failed practice had the potential to effect 5 residents who received hospice services according to a list provided by the Assistant Director of Nursing (ADON) on 06/23/22 at 1:00 PM. The findings are: Resident #29 was admitted to the facility on [DATE] with Diagnoses of Alzheimer's Disease with Late Onset, Dementia in Other Diseases Classified Elsewhere With Behavioral Disturbance, Parkinson's Disease, and Major Depressive Disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/22 documented the resident scored 00 (0-7 indicates severe impairment) on a Brief Interview for Mental Status and did not receive Hospice. The admission MDS with ARD of 02/04/22 did not document the resident received Hospice. a. A Hospice form documented a Hospice admission Date of 09/21/21. b. A Physician Order active 01/26/22 documented . ADMIT to LTC [Long-Term Care]-Hospice . c. On 06/21/22 at 3:00 PM, Resident # 29's Power of Attorney stated the resident received Hospice Services. d. On 06/23/22 at 11:40 AM, the ADON was asked, When did the hospice services started? She stated, [Resident # 29] was admitted to the facility on hospice services. She was asked to look at the admission MDS with ARD of 02/04/22 Block O and if the hospice services were documented there. She said it documented, No. The DON and ADON was asked, Should it be documented in section O of the admission MDS with ARD of 02/04/22? They both stated, Yes, it should be there. e. On 06/23/22 at 1:38 PM, the DON was asked if the hospice services should be documented on the Quarterly MDS? The DON stated, Yes f. On 06/23/22 at 1:45 PM, the Facility Resident Assessment policy and procedure provided by the Administrator on 06/23/22 at 12:36 PM was reviewed and documented, . The comprehensive assessment shall include all information specified in the State-approved resident assessment instrument and all other evaluations and assessments completed by health care professionals treating the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Hospice services were documented on the care plan for 1 of 1 (Resident #29) sampled resident who received hospice services. This failed practice had the potential to effect 5 resident's that receive hospice services according to a list provided by the ADON [Assistant Director of Nursing] on 06/23/22 at 1:00 PM. The findings are: Resident #29 was admitted to the facility on [DATE] with Diagnoses of Alzheimer's Disease with Late Onset, Dementia In Other Diseases Classified Elsewhere With Behavioral Disturbance, Parkinson's Disease, and Major Depressive Disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/22 documented the resident scored 00 (0-7 indicates severe impairment) on a Brief Interview for Mental Status and did not receive Hospice. The admission MDS with ARD of 02/04/22 did not document the resident received Hospice. a. A Hospice form documented a Hospice admission Date of 09/21/21. b. A Physician Order dated 01/26/22 documented, ADMIT to LTC [Long-Term Care]-Hospice . c. On 06/21/22 at 3:00 PM, Resident #29's Power of Attorney stated the resident received Hospice Services. d. On 06/23/22 at 11:40 AM, the ADON was asked, When did the hospice services started? She stated, [Resident # 29] was admitted to the facility on hospice services. The ADON was asked to look at Resident # 29's care plan and asked if the hospice services were documented on the care plan. She stated, No, it is not. The ADON was asked if the hospice services should be documented on the care plan? The ADON stated, Yes, it should be documented on the care plan. e. On 06/23/22 at 1:38 PM, the DON was asked if the hospice services should be documented on the care plan? The DON stated, Yes f. On 06/23/22 at 1:45 PM, the Facility Resident Assessment policy and procedure provided by the Administrator on 06/23/22 at 12:36 PM was reviewed and documented, . A comprehensive care plan will be developed for each resident using the results of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetables to meet the needs identified in the comprehensive assessment .

Based on observation, record review and interview, the facility failed to ensure toenail care was consistently provided to prevent potential complications for 1 (Resident #43) of 5 (Residents #43, #42, #16, #46 and #26) sampled mix residents who had a diagnosis of Diabetes Mellitus. The findings are: Resident #43 had diagnoses of Type II Diabetes Mellitus, Gout and Cerebral Infarction. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/22 documented the resident scored 00 (0-7 indicates Severe impairment) on the Brief Interview for Mental Status, required total assistant of two-person assist for transfers, extensive assistance of two-person assistance for bed mobility and personal hygiene, and extensive assistant of one-person assist with bathing. a. The Initial Care Plan dated 11/26/21 documented, [Resident #43] has Diabetes Mellitus . Refer to pediatrist/foot care nurse to monitor/document foot care needs and to cut long nails. b. The Physicians Order dated 6/21/22 documented, Check diabetic feet every day shift every Sat [Saturday] . trim diabetic nails every day shift starting on the 15th and ending on the 15th every month . c. On 6/20/22 at 11:40 AM, the resident was resting in bed, and both feet were visible from under the sheets. Her husband stated, It's been a long time since they trimmed her toenails, they are long and need to be trimmed. The resident's toenails had on a pink polish that covered half of the toenails. The toenails were approximately 1/8 inch from the tip of the toes and the right and left big toenail and left third toe was uneven and jagged. d. On 6/21/22 at 3:03 PM, Licensed Practical Nurse (LPN) #1, was asked, Who performs the nail care of trimming and filing on the diabetic residents? She replied, I do their nail care on the 15th of every month and the RN [Registered Nurse] on the weekends checks the diabetic's feet on Saturday for care and skin issues. The LPN was accompanied the surveyor to the resident's room. The LPN was asked, Can you describe her toenails? She stated, They are long, uneven, and a few are jagged. Her toenails have been polished but that's been awhile. I'm going to file and trim them right now. The LPN was asked, What could happen if her toenails are not kept trimmed and filed? She stated, She could get a skin tear or tear off her toenail. e. On 6/23/22 at 10:25 AM, the Director of Nursing (DON) was asked, How often is nail care, including trimming and filing the toenails, completed? She stated, For the diabetics they are trimmed once a month on the 15th. The DON was asked, Who is responsible for trimming the resident's nails? She replied, The diabetics the treatment nurse, weekend RN and/or the floor nurses as needed. The DON was asked, Who is responsible to ensure the nail care is being completed as needed? She stated, me and the Assistant Director of Nursing (ADON). f. On 6/23/22 the Policy of Nail, Care of [Finger and Toe] from the DON documented, . NOTE: Toenails of Diabetic patients and patients with Peripheral Vascular Disease are to be cut by the podiatrist or licensed nurse .