Based on observations, interviews, facility document review, and facility policy review, the facility failed to discard 3 expired medications from 1 of 2 medication carts observed for medication labeling and storage standards. Findings include: 1. A policy was requested related to dating multi-dose medication and expired medication. Facility had no policy related to these items. a. During an observation and interview on 09/04/2024 at 9:32 AM, three expired medications were found in the Northwest cart. One bottle of multi vitamins expired 06/2024, one vial of fiber laxative expired 08/2024 and one vial of a fast acting insulin with an opened date of 08/01/2024. Licensed Practical Nurse (LPN) #5 stated nurses are responsible for making sure medication are removed before it expires, and insulin should be discarded 28 days after opened and dated. b. During an interview on 09/05/2024 at 9:41 AM, the Director of Nursing (DON) stated the facility utilized the 28-day rule with opened multi use medications and the nurses are responsible for checking the medication in the carts daily for expired medications as well as our pharmacy consultant checks the carts monthly for expired medications.

Based on observation, record review, and interview, the facility failed to ensure food was prepared in a safe manner in order to prevent foodborne illness by not cleaning the deep fryer and grease traps. The findings are: On 9/03/2024 at 11:02 am, during the initial tour of the facility kitchen, the grease traps were pulled out by the Dietary Manager (DM) and they were covered in aluminum foil that had a dark brown substance with small light brown pieces of crumbs, along with hollow tubular shaped noodles about an inch and a half long, that were light brown in color, but black on top. On 9/03/2024 at 11:04 am, the DM was asked to open the lid on the deep fryer. Inside the deep fryer was dark brown colored liquid with a large number of small round crumbs gathered on top and around the edges of the fryer. On 9/03/2024 at 11:05 am, the DM said that the grease traps and fish fryer are cleaned every two weeks. On 9/05/2024 at 7:50 am, the DM said that grease traps and fish fryers should be cleaned often to keep from attracting bugs and keep the residents from getting sick from a foodborne illness. A policy, staff competencies, and trainings were requested on 9/05/2024 at 7:59 am. The facility could not provide a policy or staffing competencies pertaining to food preparation and cleaning of equipment.

Based on observation, interview, and record review, the facility failed to ensure resident preferences listed on tray cards were followed for 1 (Resident #47) of 1 sampled resident. The findings are: 1. On 08/08/23 at 8:30 AM, Resident #47 informed the Surveyor he did not get coffee, juice, or his [breakfast cereal] for breakfast. Resident #47 stated, I have told several people about not getting my breakfast foods and I have already drunk the milk so it is too late for them to bring my cereal. Resident #47 provided the Surveyor with his breakfast tray card which documented, .Notes: scrambled egg, biscuit, gravy, [cereal] or [cereal], pepper, margarine, jelly, sugar substitute .Standing Orders: 4 fl. [fluid] oz. [ounces] Asst. [assorted] fruit Juice (cranberry or apple) 8 fl. oz. Coffee 8 fl. oz. Milk Whole Dislikes: Orange juice . The Surveyor observed an empty cup with milk residue at the bottom. 2. On 08/08/23 at 12:33 PM, the Surveyor asked Resident #47 how his lunch was today. Resident #47 stated he did not receive his milk and they gave him sugar for his tea. The Surveyor asked if he asked anyone for milk. Resident #47 stated, I asked for my milk when she brought the food and it's still not here. The Surveyor asked if Resident #47 requested sugar instead of sugar substitute. Resident #47 stated, Sometimes they give me sugar and sometimes they give me substitute. I wish you two [Surveyors] would have come sooner and maybe they would have gotten this food issue fixed. Resident #47 provided the Surveyor with his lunch tray card which documented, .Notes: peas, beets, pudding ice cream cottage cheese, sandwiches, white bread, all meats, applesauce, pepper, margarine, sugar substitute .Standing orders: 8 fl.oz. Milk Whole 8 fl. Oz. Tea Iced Dislikes: Orange juice Carrots Chicken & [and] Dumpling . 3. On 08/08/23 at 2:30 PM, the Surveyor asked the Dietary Manager (DM) how she ensured tray cards were followed and who was responsible for ensuring beverages and condiments were accurate for each resident. The DM stated, I monitor them [Kitchen Staff] at the door to intervene if there are issues. My dishwasher staff makes and labels the beverages. The Surveyor presented Resident #47's breakfast and lunch tray cards and asked what beverages should be provided, who should provide them and if an item was missing or incorrect and who fixed that issue. The DM stated, He [Resident #47] should have received cranberry juice, coffee and milk. Kitchen would have provided the cranberry juice labeled with his name. The CNAs [Certified Nursing Assistants] would have provided the coffee and milk. The only coffee maker is out here [in dining area] and we provide them [CNAs] a container of milk. Anyone can come to us to let us know they need another or different thing. The Surveyor asked what beverages and condiments Resident #47 should have received for lunch. The DM stated, Milk and iced tea with sugar substitute provided by the CNAs. 4. On 08/08/23 at 2:38 PM, the Surveyor asked CNA #8 if she served trays to residents in their rooms and how CNAs knew what beverages and condiments should be provided. CNA #8 stated, Yes I do. Drinks come from the kitchen with their name on top and will have other drinks listed [on tray cards] that we provide. The Surveyor asked what the process was if a food item is incorrect, or an item is missing. CNA #8 stated, We ask the kitchen. We take off the wrong item and ask the kitchen for the right one, or you fix it yourself if you can. The Surveyor presented Resident #47's breakfast and lunch tray cards and asked what beverages and condiments should be provided for each meal. CNA #8 looked at the tray cards and stated, Juice, coffee, and milk for breakfast and milk and iced tea for lunch. The Surveyor asked what condiments for the iced tea should be provided. CNA #8 stated, Sugar, sugar substitute. 5. On 08/09/23 at 8:49 AM, the Surveyor asked the Director of Nursing (DON) how CNAs know to follow tray cards. The DON stated, Training. The DON was asked if tray cards should be followed in their entirety. The DON stated, Yes, completely. The DON was asked if Resident #47 should have received cereal for breakfast and what condiment should he have received with his iced tea. The DON stated, [named two cereals] and sugar substitute. 6. The facility policy titled Resident Rights provided by the DON on 8/9/23 at 11:15 AM documented, .Each and every resident in this facility has the right to: .40. Individual preferences regarding things such as food .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure medications were not left unattended at the bedside, and all medications were in their original container, contained a pharmacy label and dated when opened in Medication room [ROOM NUMBER] and a medication cart. The findings are: 1. On 08/08/23 at 8:16 AM, observed 1 unopened vial of clear liquid lying on the resident's bedside table beside a nebulizer machine. 2. On 08/08/23 at 11:45 AM, the Medication room [ROOM NUMBER] and a Medication Cart observation with Licensed Practical Nurses (LPN) #2 and #3 revealed: a. In Medication room [ROOM NUMBER] was one bottle of hemoccult solution, with no expiration date and had no box. b. In a Medication Cart was one opened bottle of Lidocaine, with no opened date and no pharmacy label. 3. On 08/10/23 at 11:59 AM, the Director of Nursing (DON) provided a form titled, Storage of Medications, which documented, .All medications . shall be in properly labeled containers dispensed upon prescription by the pharmacy . d. Each patient's prescription medication shall be kept in the original container and shall be clearly and adequately labeled . Labels shall be affixed to the immediate container. The immediate container is that which is in direct contact with the medication at all times .

Based on record review and interview, the facility failed to administer pneumococcal vaccines in a timely manner after receiving a signed consent for 1 (Resident #33) of 5 (Residents #11, #14, #19, #33 and #48) sampled residents whose immunizations were reviewed. The findings are: 1. On 08/07/23 at 8:50 PM, a review of Resident #33's Immunization documentation did not have a pneumococcal vaccine documented in the electronic medical record. 2. A review of Resident #33 Consent for Vaccination noted the resident signed the consent authorizing administration of the pneumococcal vaccine on 11/11/22. 3. On 08/09/23 at 9:04 AM, the Surveyor asked the Director of Nursing (DON) how long does it typically take for the resident to receive a pneumococcal vaccination after the consent is signed. The DON stated, when we get it from the pharmacy. Usually 2 weeks to 30 days. The DON confirmed the resident signed a consent for the pneumococcal vaccine. The DON used a pneumococcal calculator program on her phone and stated, The resident received a pneumococcal vaccine on 4/11/16 which is not in our system, and they were due for one a year after that. The Surveyor asked if it should have already been provided to Resident #33. The DON stated, Yes ma'am. The Surveyor asked for the possible outcomes of not receiving a pneumococcal vaccine. The DON stated, Pneumonia. 4. The facility policy titled Immunizations Influenza, Pneumococcal and COVID-19, provided by the Administrator on 08/08/23 at 2:00 PM documented, .2. Each resident will be offered a pneumococcal immunization .

3. Resident #53: a. On 08/07/23 at 12:54 PM, the Surveyor observed Resident #53 attempting to feed himself with a teaspoon; a portion of the food fell off the spoon each time he lifted it to his mouth. CNA #9 fed one bite to Resident #53 from a standing position. CNA #9 approached Resident #53 from behind and fed him an additional 2 bites from a standing position. CNA #9 moved Resident #53's chair closer to her and stood and fed him 3 more bites before walking away. b. On 08/07/23 at 1:21 PM, the Surveyor asked CNA #9 how staff should be positioned when feeding a resident. CNA #9 stated, I needed to be sitting down. It's been busy today. c. On 08/08/23 at 3:00 PM, the Surveyor asked LPN #3 how a staff should be positioned when assisting a resident with feeding. LPN #3 stated, They should be facing the resident. LPN #4 stated, They should be eye level and should not be standing. It's disrespectful and my pet peeve. If I see them hovering over a resident, I talk to them right away. d. On 08/09/23 at 8:49 AM, the Surveyor asked the DON how staff should be positioned when assisting a resident with feeding. The DON stated, Sitting at eye level. The Surveyor asked the possible outcome of standing to feed a resident. The DON stated, May make the resident uncomfortable and they might not see if the resident is having trouble. 4. A facility policy titled, Resident Rights, provided by the Administrator on 08/09/23 at 11:15 AM documented, .Each and every resident in this facility has the right to: .34. To be treated with consideration, respect and full recognition of dignity and individuality. 35. To privacy during treatment and care of personal needs . Based on observation, record review and interview, the facility failed to ensure signs containing resident care instructions were posted in a manner to provide privacy and dignity for 2 (Resident #35 and #44) of 6 (Residents #22, #24, #33, #35, #44 and #50) sampled residents who had a low air loss mattress as documented on a list provided by the Director of Nursing (DON) on 08/08/23 at 2:10 PM, and staff members sat at eye level when assisting residents with meals for 1 (Resident #53) of 2 (Residents #33 and #53) sampled residents who required assistance with meals as documented on a list provided by the Administrator on 08/10/23 at 8:36 AM. The findings are: 1. Resident #35: a. On 08/07/23 at 11:06 AM, Resident #35 was lying in bed on a low air loss mattress. A sign on the wall over the bed read, Reusable incont [incontinent] pads are not to be used on this resident while on low air loss mattress - Tx [treatment] nurse. b. On 08/08/23 at 8:23 AM, Resident #35's room had a sign on the wall over the bed that read, Reusable incont pads are not to be used on this resident while on low air loss mattress - Tx nurse. c. On 08/08/23 at 11:12 AM, Resident #35's Care Plan did not mention reusable incontinent pads are not to be used while on low air loss mattress. 2. Resident #44: a. On 08/07/23 at 11:14 AM, Resident #44 was lying in bed on a low air loss mattress. A sign on the wall over the bed read, Reusable incont pads are not to be used on this resident while on low air loss mattress - Tx nurse. b. On 08/08/23 at 8:35 AM, Resident #44 was sitting in the wheelchair in the room. A sign on the wall over the bed read, Reusable incont pads are not to be used on this resident while on low air loss mattress - Tx nurse. c. On 08/08/23 at 11:09 AM, Resident #44's Care Plan did not mention reusable incontinent pads are not to be used while on low air loss mattress. d. On 08/08/23 at 8:46 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, How do you know what each resident needs and how to care for each resident? CNA #1 answered, They have a paper on the inside of the closet door, and there's instructions on the computer. e. On 08/08/23 at 2:50 PM, the Surveyor asked CNA #2, How do you know what each resident needs and how to care for each resident? CNA #2 answered, It's on the computer and on the closet care plan. The Surveyor asked, Would you want your family member to have a sign on the wall that allows anyone who may walk in the room see that your loved one uses incontinent products? CNA #2 answered, No. The Surveyor asked, Why not? CNA #2 answered, It would be a dignity issue. f. On 08/08/23 at 3:02 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, How do the staff know what each resident needs and how to care for each resident? LPN #1 answered, It's on the closet care plan or they can ask the nurse. The Surveyor asked, Would you want your family member to have a sign on the wall that lets anyone who may walk in the room see that your loved one uses incontinent products? LPN #1 answered, No. The Surveyor asked, Why not? LPN #1 answered, Dignity. But we have therapists who put signs on the walls. g. On 08/08/23 at 3:07 PM, the Surveyor asked the Director of Nursing (DON), How do the staff know what each resident needs and how to care for each resident? The DON answered, It's on the tasks and the closet care plan. The Surveyor asked, Would you want your family member to have a sign on the wall that lets anyone who may walk in the room see that your loved one uses incontinent products? The DON answered, No that would be a dignity issue.

Based on observation, record review and interview, the facility failed to ensure fingernails were trimmed, smooth, clean, and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #37) of 29 (Residents #1, #2, #3, #4, #9, #11, #14, #19, #22, #24, #26, #30, #32, #33, #34, #35, #36, #37, #38, #40, #41, #42, #44, #47, #48, #49, #50, #53 and #55) sampled residents who were dependent for nail care as documented on a list provided by the Administrator on 08/10/23 at 8:14 AM and facial and nose hair was removed to promote good personal hygiene and grooming for 1 (Resident #53) of 22 (Residents #2, #3, #4, #11, #14, #19, #22, #26, #30, #32, #33, #35, #37, #38, #40, #41, #42, #44, #49, #50, #53 and #55) sampled residents who were dependent for shaving as documented on a list provided by the Administrator on 08/10/23 at 8:00 AM. The findings are: 1. Resident #37: a. On 08/07/23 at 10:49 AM, Resident #37 was lying in bed. The fingernails on both hands were approximately 1/8 inch past the fingertip with a brown substance under them. b. On 08/08/23 at 8:27 AM, Resident #37 was in the hallway in a Geri chair with fingernails approximately 1/8 inch past the fingertip with a brown substance under them. c. On 08/08/23 at 3:26 PM, Resident #37 was lying in bed. The fingernails on both hands were approximately 1/8 inch beyond the fingertips with a brown substance under them. d. On 08/08/23 at 3:29 PM, the Surveyor accompanied Certified Nursing Assistants (CNA) #3 and #4 in Resident #37's room. The Surveyor asked CNA #3 to describe Resident #37's fingernails. CNA #3 stated, Nasty and dirty and further stated it could cause an infection. CNA #4 stated, It's dark brown gunk. They should be cut. and further stated, It can make them real sick. e. On 08/08/23 at 3:44 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #2 in Resident #37's room and was asked to describe Resident #37's fingernails. LPN #2 stated, They are too long and dirty. The Surveyor asked what the brown substance might be. LPN #2 stated, Could be feces. The Surveyor asked what could occur by the brown substance being under the nails. She stated, It can cause different Infections. f. A Care Plan with an initiated date of 01/21/21 documented the resident has an ADL [activities of daily living] self-care performance deficit and requires extensive assistance of 1 staff for personal hygiene and oral care. g. On 08/09/23 at 3:55 PM, the Administrator stated, We don't have a policy on nail care. h. On 8/10/23 at 9:45 AM, the Surveyor asked the Director of Nursing (DON) how she ensured the residents are receiving nail care. She stated, We provide it on shower days and PRN [as needed]. Our supervisor [Administrator Assistant] is responsible for checking facial hair and nails. What could be the outcome of residents having long jagged nails with a brown substance under the nails. She stated, Self-injuries and infections.2. Resident #37: a. On 08/07/23 at 10:48 AM, the Surveyor observed Resident #53 sitting in his wheelchair on the 100 Hall with 1/2 inch long grey and brown chin and cheek hair, and ½ inch long nose hair. b. On 08/07/23 at 3:35 PM, the Surveyor observed Resident #53 sitting at a table near the Southeast Hall Nurses' Station with 1/2 inch long grey and brown chin and cheek hair, and ½ inch long nose hair visible from 5 feet away. c. On 08/07/23 at 8:17 AM, the Surveyor observed Resident #53 sitting at table near the Southeast Hall Nurses' Station with a partially shaved face and upper lip and ½ inch long nose hair. d. Resident #53's Care Plan with an initiated date of 04/04/23 documented, .PERSONAL HYGIENE: The resident requires extensive assistance by 1 staff with personal hygiene . e. On 08/09/23 at 10:34 AM, the Surveyor asked CNA #5 when residents' facial hair was shaved. CNA #5 stated, I do it every shower day and when it looks scruffy. Some do not want their mustache shaved. The Surveyor asked CNA #5 to look at Resident #53's upper lip and nose hair and describe. CNA #5 stated, His nose hair is significant. It is about an inch long. We don't have anything to shave in their nose. All we have is a razor that could have it to the end of his nose. f. On 08/09/23 at 10:40 AM, the Surveyor asked the DON when the residents received assistance with shaving. The DON stated, Shower days and PRN unless they refuse. The Surveyor asked if a male residents chin and cheeks were shaved should his upper lip and nose hair also be shaved. The DON stated, Yes, I would think so. The Surveyor asked if one inch nostril hair was an acceptable length. The DON stated, Not an inch long. The Surveyor asked the possible outcomes. The DON stated, A chance stuff could get in their mouth and dignity wise. The Surveyor asked if the staff were provided with the proper equipment to trim nose hair. The DON stated, We don't have nose hair trimmers. They would need to let us know. I don't think we've ever run into that before. g. On 08/09/23 at 10:48 AM, the Surveyor asked the Administrator if she ordered supplies and if the facility provided the staff with nose hair trimmers. The Administrator stated, Yes I do, but I don't think we've ever ordered them, but we can go to [Store] and get one. 3. On 08/09/23 at 11:15 AM, the DON stated the facility did not have an Activity of Daily Living policy.

Based on observation, record review, and interview, the facility failed to ensure Physician Orders were followed for 1 (Resident #47) of 4 (Residents #19, #26, #47 and #50) sampled residents with orders for daily dressing changes. The findings are: 1. On 08/07/23 at 10:50 AM, observed a mesh dressing to Resident #47's right foot. The Surveyor asked the resident the reason for the bandage on his right foot. Resident #47 stated, I have a sore on my foot and the doctor said I have a bacteria on my toe. a. Resident #47's Physicians Orders dated 07/19/23 documented .Clean ulcer to right foot with wound cleanser, pat dry apply Santyl Ointment, cover with ABD [abdominal pad] and wrap with [Brand gauze] daily. Every day shift . b. Resident #47's August 2023 Treatment Administration Record (TAR) had blanks on August 3rd and August 6th for the ordered dressing change. The July 2023 TAR had a blank on July 26th for the ordered dressing change. 2. On 08/07/23 at 3:33 PM, observed the dressing on Resident #47's right foot did not have a date on it. 3. On 08/08/23 at 2:55 PM, the Surveyor asked Licensed Practical Nurse (LPN) #3 how do you know when a dressing has been changed. LPN #3 stated, We sign it off on the TAR. 4. On 08/09/23 at 11:05 AM, the Surveyor asked the Director of Nursing (DON) how someone would know if a dressing had been changed. The DON stated, The nurse signs it off on the TAR. The Surveyor asked if the TAR isn't signed off what does that mean. The DON stated, That it wasn't changed. 5. On 08/10/23 at 9:58 AM, the Surveyor asked the DON the possible outcomes of a dressing not being changed. The DON stated, The effect of the healing of the wound. 6. The facility policy titled, Dressing Change Using Aseptic Techniques, provided by the DON on 08/09/23 at 11:15 AM failed to note instructions related to documentation pertaining to dressing changes.

2. Resident #32: a. On 08/07/23 at 11:49 AM Resident #32 was lying in bed with oxygen being administered by nasal cannula. A CPAP machine was at the bedside, the CPAP tubing was in a bag dated 4/1. A nebulizer tubing and mouthpiece were on the bedside table not in a bag or closed container. Oxygen tubing connected to an oxygen tank on the back of a wheelchair was lying in the seat of the wheelchair dated 7/2/23 and was not in a bag. b. On 08/07/23 at 3:41 PM, Resident #32 was lying in bed. A CPAP machine was at the bedside, the CPAP tubing was in a bag dated 4/1. Nebulizer tubing and mouthpiece were on a bedside table not in a bag or closed container. Oxygen tubing connected to an oxygen tank on the back of a wheelchair was lying in the seat of the wheelchair dated 7/2/23 and was not in a bag. c. On 08/08/23 at 08:16 AM Resident #32 was lying in bed. Nebulizer tubing and mouthpiece were on a bedside table not in a bag or closed container. Oxygen tubing connected to an oxygen tank on the back of a wheelchair was lying in the seat of the wheelchair dated 7/2/23 and was not in a bag. d. Review of Resident #32's Physicians Orders dated 02/15/23 documented, change O2 tubing, clean filter and O2 cabinet, date all tubing every Sunday night on 11-7 shift . CPAP per home settings with 2-3 liters of O2 bled in at HS [hour of sleep] every evening shift . 3. Resident #50: a. On 08/07/23 at 11:19 AM, Resident #50 was lying in bed receiving oxygen via nasal cannula. Nebulizer tubing and mouthpiece at the bedside was dated 08/07/23 and not in a bag or closed container. Oxygen tubing and nasal cannula connected to an oxygen tank on the back of a wheelchair was dated 7/2/23 and was not in a bag or closed container. b. On 08/07/23 at 3:19 PM, Resident #50 was lying in bed. Nebulizer tubing and mouthpiece were not in a bag or closed container. Oxygen tubing connected to an oxygen tank on the back of a wheelchair was dated 7/2/23 and was not in a bag or closed container. c. On 08/08/23 at 8:03 AM, Resident #50 was sitting in bed eating breakfast. Oxygen tubing connected to an oxygen tank on the back of a wheelchair was dated 7/2/23 and was not in a bag or closed container. Nebulizer tubing and mask were lying on the recliner seat, not in a bag or closed container. d. On 08/08/23 at 3:05 PM, Resident #50's Nebulizer tubing and mouthpiece were not in a closed container and oxygen tubing was lying in a wheelchair not in a bag or closed container. e. On 08/08/23 at 3:30 PM, Resident #50's Physicians Orders dated 01/28/23 documented, Change and date updraft tubing and nebulizer every Sunday night on 11-7 shift . change O2 tubing, clean filter and O2 cabinet, date all tubing every Sunday night on 11-7 shift . f. On 08/08/23 at 3:44 PM, the Surveyor asked LPN #2 to observe Resident #50's respiratory equipment and explain what she saw. LPN #2 stated, All the tubing's, cannulas, and nebulizer equipment should be bagged up and dated because it can get bacteria on them and cause infections. Without a date, we aren't sure of the change out. g. On 08/10/23 at 9:40 AM, the Surveyor asked the DON to explain the procedures required for changing tubing for oxygen, nebulizers, and CPAP machines. The DON stated, We change out all tubing on night shift every Sunday and when necessary, when contaminated. I follow up visually. The Surveyor asked if she felt like four plus months was too long to have a tubing changed. The DON stated, Yes. The Surveyor asked what the outcome could be by not ensuring tubing is kept clean from bacteria. She stated, Infections. 4. The facility policies titled, Oxygen Safety and Oxygen Portable, provided by the Administrator on 08/09/23 at 11:57 AM failed to address how respiratory therapy tubing and supplies were to be changed and stored. Based on observation, record review and interview, the facility failed to ensure oxygen tubing, nasal cannulas, Continuous Positive Airway Pressure (CPAP) tubing, nebulizer tubing and mouth pieces/mask were properly changed, dated, and bagged in a closed container to prevent infections for 3 (Residents #11, #32 and #50) of 7 (Residents #1, #11, #32, #33, #36, #40 and #50) sampled residents who had a Physician Orders for respiratory treatments. The findings are: 1. Resident #11: a. On 08/07/23 at 10:23 AM, observed Resident #11's oxygen tubing draped over the handle of a wheelchair and lying on the floor. b. On 08/07/23 at 12:15 PM, observed Resident #11's oxygen bag and tubing hanging on the back of her wheelchair, not dated. Resident #11 stated she was on oxygen all the time. c. On 08/07/23 at 3:31 PM, observed Resident #11's oxygen bag and tubing hanging on the back of her wheelchair with the tubing lying on the floor, not dated. d. Resident #11's Physicians Order for documented, change O2 [oxygen] tubing, clean filter and O2 cabinet, date all tubing every Sunday night on 11-7 shift . Order Date 08/28/2020 . e. On 08/08/23 at 2:48 PM, the Surveyor asked Certified Nursing Assistant (CNA) #8 if Resident #11 could transfer herself out of her wheelchair. CNA #8 stated, No, she needs help. She would probably fall. f. On 08/08/23 at 3:00 PM, the Surveyor asked Licensed Practical Nurse (LPN) #3 how a resident's oxygen supplies were stored when not in use. LPN #3 stated, In plastic bags. They are to be dated. The Surveyor accompanied LPN #3 to Resident #11's room and asked LPN #3 to locate the date on the oxygen tubing storage bag and how the tubing should be stored. LPN #3 stated, I cannot find a date. The tubing should be in the bag and not on the floor. I will get a new bag and tubing and replace them. g. Resident #11's Care Plan with an initiated date of 10/09/18 documented, .There is potential for tubing not be stored properly due to resident is able to remove at random . h. On 08/09/23 at 2:06 PM, the Surveyor asked the Minimum Data Set (MDS) Coordinator if Resident #11's care plan was accurate with regards to Resident #11 being able to remove and improperly store tubing if she was not in her wheelchair. The MDS Consultant stated that the care plan applied only to her physically being able to remove the oxygen tubing from her body while in use and not regarding the storage of the tubing when not in use. i. On 08/09/23 at 8:49 AM, the Surveyor asked the Director of Nursing (DON) how oxygen supplies were to be stored when not in use by a resident. The DON stated, In their patient's bag with the resident's name and the date on it. The DON was asked who was responsible for the storage of oxygen tubing and cannulas on a wheelchair after a resident was assisted with a transfer from wheelchair to the bed. The DON stated, When the resident takes off their oxygen for the transfer, it is OK for the CNAs to put the tubing and cannula in the storage bag after they assist the resident with the transfer. The Surveyor asked the DON if Resident #11 could transfer herself from her wheelchair to her bed. The DON stated, No, she has to have assistance.

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 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets, and 20 resident who received mechanical soft diets from 1 of 1 kitchen (total census: 56) according to a list provided by the Dietary Supervisor on 08/10/23 at 10:33 AM. The findings are: 1. On 08/09/23, the menu for the supper meal documented residents who received mechanical soft diets were to receive 3 ounces of cheeseburger and residents on pureed diets were to receive 2 #8 (4 ounces) scoops of pureed cheeseburger. 2. On 08/09/23 at 3:20 PM, the following observations were made during the supper meal preparation: a. At 3:20 PM, Dietary Employee (DE) #3 placed 11 servings of hamburger patties topped with a slice of cheese into a blender and ground. She poured the ground patties into a large bowl. b. At 3:22 PM, DE #3 placed 15 more servings of hamburger patties topped with a slice of cheese into a blender, ground and poured in the same pan. She added mayonnaise and mixed them up. c. At 3:29 PM, DE #3 used a #16 scoop (2 ounces) to remove 6 servings of ground hamburger patties with cheese mixed with mayonnaise and transferred into a blender. d. At 3:31 PM, DE #2 added a total of 6 buns, added broth and pureed. e. At 3:38 PM, DE #3 poured the pureed mixture into a pan. She covered the pan with a lid and placed it in the oven. 3. On 08/09/23 at 3:40 PM, DE #3 used a #16 scoop (2 ounces) to place a serving of ground hamburger patties with cheese mixed with mayonnaise on 24 buns and prepared cheeseburgers for the residents who received mechanical soft diets. She had more servings left in the bowl. When she was ready to dispose of the remaining ones in the bowl. The Surveyor immediately asked her to use the same #16 scoop to measure what was left in the bowl. She did so and stated, I have 4 servings left. She took the remaining portions left in the bowl and disposed of them.

Based on observation, record review and interview, the facility failed to ensure food was prepared by methods that maintained flavor and appearance to the residents to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. The failed practices had the potential to affect 56 residents who received meal trays from the kitchen (total census: 56), as documented on a list provided by the Dietary Supervisor on 08/10/23 at 10:33 AM. The findings. 1. On 08/09/23 at 12:42 PM, the garlic bread served to the residents for lunch was too hard. The Surveyor asked Certified Nursing Assistant (CNA) #2 who was assisting residents in the Dining Room to describe the appearance of the garlic bread served to the residents. She stated, Bread is too hard. It's hard to break. 2. On 08/09/23 at 12:44 PM, the Surveyor asked a resident about the garlic bread served to her. She stated, It's pretty hard, it is not usually like that. 3. On 08/09/23 at 1:02 PM, the Surveyor asked CNA #5 to describe the texture of the garlic bread served the residents for lunch. She stated, It was too hard, and very stiff. I am not going to give it to the resident because her teeth are bad because she can ' t chew it. 4. On 08/09/23 at 1:23 PM, the Surveyor asked Therapist #1 to describe the texture of the garlic bread served to the residents for lunch. He stated, It was hard as a rock. 5. On 08/09/23 at 1:10 PM, the Surveyor asked the Dietary Supervisor to describe the texture of the garlic bread served to the residents for lunch. She stated, It started to harden when I first pulled it out. 6. On 08/09/23 at 3:24 PM, DE #2 picked up a bag of hamburger buns from the bread rack and placed it on the counter and untied the bun bag. She removed a glove from the glove box and placed it on her right hand, contaminating the glove. She used the contaminated gloved hand to pick up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 6 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 08/09/23 at 10:33 AM. The findings are: 1. On 08/09/23 at 11:12 AM, Dietary Employee (DE) #1 placed 8 servings of garlic bread into a blender, added milk and pureed. At 11:14 AM, she added more milk and pureed some more. At 11:15 AM, she added more milk and pureed some more. At 11:18 AM, she poured the pureed bread into a pan. She covered the pan with a lid and placed it in the oven. The consistency of the pureed bread was thick. 2. On 08/09/23 at 12:50 PM, the pureed cheesecake served to the residents on pureed diets was gritty and was not smooth. There were pieces of crumbs visible in the mixture. 3. On 08/09/23 at 12:47 PM, the Surveyor asked DE #3 to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, The pureed bread was thick, and the pureed dessert was gritty. 4. On 08/09/23 at 1:16 PM, the Surveyor asked DE #2 to describe the pureed cheesecake served to the residents on pureed diets. She stated, It was gritty. 5. On 08/09/23 at 3:32 PM, DE #3 poured 6 servings of ground hamburger patties with a mixture of cheese and mayonnaise into a blender, added 6 hamburger buns, broth, and pureed it. At 3:38 PM, she poured the pureed mixture into a pan. She covered the pan with a lid and placed it in the oven. The consistency of the pureed cheeseburger was thick.

Based on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was disinfected after each use to prevent potential spread of infection for 2 of 2 observations (Residents #1 and #30). The findings are: 1. On 08/09/23 at 11:24 AM, Licensed Practical Nurse (LPN) #5 performed a glucose finger stick to Resident #1. LPN #5 took a bleach wipe and cleaned the glucose machine for approximately 25 seconds then placed the machine on the medication cart. 2. On 08/09/23 at 11:48 AM, LPN #5 used the same glucose machine and obtained a glucose finger stick on Resident #30. LPN #5 did not clean the Glucose machine prior to obtaining the blood sugar. After the glucose fingerstick check on Resident #30, LPN #5 cleaned the glucose machine with a bleach wipe for approximately 25 seconds. 3. On 08/09/23 at 12:30 PM, the Surveyor asked LPN #5 how long she cleaned the Glucose machine. LPN #5 stated, I wiped it down all over. The Surveyor asked how long the machine should have been left wet. LPN #5 stated, I'm not sure. The Surveyor asked how many glucometer machines are on each cart. LPN #5 replied, One. 4. On 08/10/23 at 10:24 AM, the Administrator provided a document titled, [Brand] Bleach Wipes General Guidelines For Use .4. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4-minute wet contact time . 5. On 08/10/23 at 9:40 AM, the Surveyor asked the Director of Nursing (DON) how long the Glucometer should be cleaned with wet contact. The DON stated, I know it should be 4 minutes. The Surveyor asked the DON to explain what could happen by incorrectly cleaning the glucometer machine. The DON stated, Infection and spreading it from one patient to another patient. The Surveyor asked how do you educate on performing glucose finger sticks. The DON stated annually and quarterly with in-servicing. The Surveyor asked what the outcome could be of not correctly cleaning the glucose machine. The DON stated, Transmission of infections between residents. 6. On 08/10/23 at 10:24 AM, the Administrator provided the [Manufacturer] Blood Glucose Monitoring System User Instruction Manual, Page 38 documented, .To minimize the risk of transmission of blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended . Cleaning and Disinfecting: The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the Manufacture's disinfection procedures are followed .

Based on observation, record review and interview, the facility failed to ensure a resident's personal fans was properly cleaned to prevent the potential for infection for 1 (Resident #11) of 3 (Residents #1, #11 and #48) sampled residents who used personal fans at the bedside and toiletries and elimination receptacles were bagged and labeled properly for 2 bathrooms on the Southeast (SE) Hall. The findings are: 1. On 08/07/23 at 10:24 AM, observed Resident #11's eye lid edges were red with white dried matter and a fan covered in brownish grey particles sitting on the bedside table 18 inches from Resident #11's face. a. A Physicians Order dated 10/16/20 noted an order for eye gel in both eyes at bedtime for allergic rhinitis. b. On 08/08/23 at 8:18 AM, the Surveyor observed Resident #11's eye lid edges were red with white dried matter and a fan covered in brownish grey particles sitting on the bedside table 18 inches from Resident #11's face. 2. On 08/07/23 at 10:29 AM, the Surveyor entered Resident Room SE50's bathroom. A hot pink and white toothbrush and a royal blue and white toothbrush was on the left side of the bathroom sink not bagged or labeled. A pink wash basin containing a white washcloth, a foam bottle of peri wash, and a gold emesis basin was under the sink, not bagged or labeled. 3. On 08/07/23 at 10:39 AM, the Surveyor entered Resident Room SE47's bathroom. A clear white urinal was on top of a bedside table, and a pink bedpan was resting on the stainless grab bar above the toilet. Neither elimination receptacles were bagged or labeled. 4. On 08/07/23 at 3:32 PM, the Surveyor entered the bathroom of Resident Room SE50 and noted a hot pink and white toothbrush and a royal blue and white toothbrush on the left side of the bathroom sink, not bagged or labeled. A pink wash basin containing a white washcloth, a foam bottle of peri wash, and a gold emesis basin was under the sink, not bagged or labeled. The surveyor entered Room SE47 and noted a clear white urinal on top of the bedside table, and a pink bedpan resting on the stainless grab bar above the toilet. Neither elimination receptacles were bagged or labeled. 5. On 08/08/23 at 2:38 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, When two residents are sharing a bathroom, how should their personal items be stored? CNA #6 stated, You should place them in a ziplock baggie and write their name on it. The Surveyor asked if two residents share a bathroom how should their wash basin be stored. CNA #6 stated, The basin should be bagged, and the residents name placed on it. 6. On 08/09/2023 at 8:49AM, the Surveyor asked the Director of Nursing (DON) how toiletries, bedpans, urinals, and wash basins be stored in the resident bathrooms. The DON stated, Usually with a bag over them. The Surveyor asked how to store toothbrushes. The DON stated, Ziploc with their name on it. 7. On 08/09/23 at 2:02 PM, the Surveyor asked Housekeeper #1 who was responsible for cleaning a resident's personal fan. Housekeeper #1 stated, We are maybe, not for sure, but I would if I was asked. 8. On 08/09/23 at 2:04 PM, the Surveyor asked CNA #7 who was responsible for cleaning a resident's personal fan. CNA #7 stated, I would assume Housekeeping. 9. On 08/09/23 at 2:10 PM, the Surveyor asked Licensed Practical Nurse (LPN) #3 who was responsible for cleaning a resident's personal fan. LPN #3 stated, I reckon anyone could do that. You don't need a title to do it. 10. On 08/09/23 at 2:18 PM, the Surveyor asked the DON if she would go into Resident #11's room and observe the condition of the resident's fan. The DON stated, It's nasty. The Surveyor asked the DON if Resident #11 had a diagnosis of allergic rhinitis and received eye drops, how a dirty fan could affect the resident. The DON stated, It could cause conjunctivitis and air quality issues. 11. The facility policy titled, Housekeeping, provided by the Administrator on 08/09/23 at 2:58 PM documented, .Housekeeping services are planned, operated, and maintained to provide a safe and sanitary environment .1. Housekeeping staff will be skilled in the six basic functions of sweeping, mopping, dusting, cleaning, waxing and polishing. 2. Housekeeping staff will strive to keep the facility free from offensive odors, accumulation of dirt, rubbish, dust, and safety hazards .7. Bedpans, commodes, and urinals covered after use .This may be done by nursing personnel . 12. The facility policy titled Resident Rights, provided by the DON on 08/09/23 at 11:15 AM documented, .15. Receive adequate and appropriate medical care, nursing care, protective and support services, and personal cleanliness in a safe and clean environment .

Based on observation and interview, the facility failed to ensure food stored in the walk-in refrigerator, the refrigerator/freezer in the Medication Room on the South Hall, the Nourishment Room on the Unit, and the Dry Storage Room were dated, labeled, and discarded promptly; kitchen appliances on the shelf below the deep fryer (can opener) and the ceiling vent were maintained in clean sanitary conditions for food preparation; expired food items were promptly removed/discarded by the expiration or use by dates; foods were dated when received to assure first in, first out usage; dietary staff washed their hands before handling clean equipment or food items; and hot food was maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illnesses for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 56 residents who received meal trays from the kitchen (total census: 56), as documented on a list provided by the Dietary Supervisor on 08/10/23 at 10:33 AM. The findings. 1. On 08/09/23 at 8:46 AM, the following observations were made in the walk-in refrigerator: a. An opened bottle of juice contained no opened date. b. 3 containers of orange juice with an expiration date of 6/10/2023. c. A bottle of Worcestershire sauce contained no opened date. d. The spout to a pitcher containing orange juice was not covered. e. Two ziplock bags containing leftover sausage and leftover bacon from breakfast was on a shelf. At 12:26 PM, the Surveyor asked Dietary Employee (DE) #3 what the leftover sausage and bacon were used for. She stated, We use it in the morning for mechanical soft meat. 2. On 08/09/23 at 9:03 AM, a bottle of lemon juice was on a shelf in the Dry Storage Room. There was no opened date on the bottle. The manufacture specification on the bottle documented, Refrigerate after opening. At 9:48 AM, the Surveyor asked the Dietary Supervisor what the lemon juice was used for. She stated, We use it sometimes when cooking, it should have been put in the refrigerator. 3. On 08/09/23 at 9:05 AM, the following observations were made on the bread rack: a. A bag of bread on a bread rack by the wall leading to the dish washing machine room contained no received date. b. A bag of bread and a bag of wheat bread contained no received date. 4. On 08/09/23 at 9:15 AM, an opened gallon of vanilla ice cream was in the upright freezer. There was no date when it was opened. 5. On 08/09/23 at 9:24 AM, the following observations were made in the kitchen area: a. Four pallets attached below the cabinet to the deeper fryer had grease built up on them. The Surveyor asked the Dietary Supervisor how often they clean the area. She stated, Once a week. b. A can opener attached at the end of the food preparation counter had shavings of metal on the blade. c. The air vent between the oven and the food preparation counter had black dirt all around the edges of impact. There was a wet sticky black residue from the vent slats. 6. On 08/09/23 at 9:30 AM, the following observations were made in the South Medication Room freezer and refrigerator: a. In the freezer compartment there was a clear bag of sausage biscuits with freezer burn on the door shelf with freezer burn. The bag contained no name, no date. The Surveyor asked the Dietary Supervisor to describe the appearance of the biscuit. She stated, It was grayish in color and has freezer burn. 7. In the refrigerator compartment the following observations were made: a. Three containers of orange juice with an expiration date of 6/10/2023. c. An opened bottle of Zero Gatorade had no opened date. d. Three containers of mini muffins had no received date. e. Four containers of High Calorie Nutritional Drink had no received date. f. Two cans of Meal Replacement Shake had no received date. 8. On 08/09/23 at 9:43 AM, DE #2 opened the refrigerator and took out a gallon of whole milk and a bottle of clear, lemon and lime-flavored soft drink and placed them on the counter, contaminating her hands. Without washing her hands, she picked up glasses by their rims and poured beverages to be served to the residents for lunch. 9. On 08/09/23 at 9:44 AM, DE #2 turned on the sink faucet and obtained water in a pitcher. She then turned off the faucet with her bare hands, without washing her hands, she picked up glasses by the rims and poured water to be served to the residents for lunch. 10. On 08/09/23 at 3:24 PM, DE #2 picked up a bag of hamburger buns from the bread rack and placed it on the counter and united the bag. She removed a glove from the glove box and placed it on her right hand, contaminating the glove. She used the contaminated gloved hand to pick up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. At 3:29 PM, when she was ready to pour it into a blender to puree, the Surveyor immediately asked her what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 11. On 08/09/23 at 3:54 PM, DE #4 pushed a cart into the kitchen containing 3 cartons of milk left from distributing snacks to the residents. When she was ready to put them back in the refrigerator, the Surveyor immediately asked her to check the temperature of the milk. She did so and stated, It is 47.8 degrees Fahrenheit. She was instructed by the Dietary Supervisor to discard them. 12. On 08/10/23 at 12:40 AM, the following observations were made in the Nourishment Room of the Unit (Southwest Hall): a. There was no temperature gauge in the refrigerator. b. One sealed container of pudding in the refrigerator was dated 08/05/2023 and to be used 08/08/2023, without a name or date. c. A carton of milk was cool to the touch. d. The freezer temperature was 7 degrees Fahrenheit. e. One carton of orange juice in the refrigerator had an expiration date of 06/10/2023. f. A bowl containing boiled eggs was not covered and had a packet of mustard inside of it. g. Three containers of vanilla ice cream were in the freezer. The cartons of vanilla ice cream were discolored and soft to the touch. h. A cup of milkshake with spout to lid open had no name and no date when stored. The LPN described the milkshake as clabbered and looked nasty. i. Two tall cans of energy drink were stored in refrigerator without an opened date, received date, or name. 13. The facility policy titled, Hand Washing, provided by the Administrator on 08/10/23 at 8:38 AM documented, .Purpose: To remove contamination after entering the kitchen . handling soiled utensils or equipment, during food preparation, .before donning gloves for working with food, and after engaging in other activities that contaminates the hands .

Based on observation, record review and interview, the facility failed to ensure food items stored in the refrigerator and/or freezer were labeled, dated, covered and/or sealed; foods were stored dated and sealed; / foods were prepared under sanitary conditions; the kitchen was free of pests to prevent the potential to spread illness; the facility prepared food in a manner to prevent foodborne illness to the residents; utensils and equipment were cleaned and stored to prevent foodborne illness; and failed to ensure sanitizing solution was at level required per manufacturer's instructions to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen in facility. These failed practices had the potential to affect 53 residents (total census: 54) who received meals from the kitchen as documented on a list provided by the Director of Nursing on 6/2/22 at 8:04 AM. The findings are: 1. On 05/30/22 at 10:22 AM, the following observations were made in the walk-in refrigerator during the initial tour of kitchen with Dietary Staff (DS) #1: a. One bag of shredded lettuce with no date on the bag. DS #1 called DS #3 into the refrigerator and informed him that anything taken out of a box needed to be dated. b. A plastic bag of 10 chicken fillets, thawed in plastic tub on bottom shelf was not dated. 2. On 05/30/22 at 10:29 AM, the following observations were made in the walk-in freezer: a. One bag of peas and carrots mix - not dated or completely closed. DS#1 stated, Everything that is opened should be dated and zip tied closed. b. A ziplock bag with 10 pieces of Turkey Bacon. The bag was dated received 9/27/21. The bag did not have an opened date and there were blotches of grayish ice crystals. c. A ziploc bag containing 2 cups of mozzarella cheese dated 2/2/22. DS #1 was unsure if it was a received date or an opened date. DS #1 stated, It should have both a received date and opened date just like the bacon should have. DS #1 stated she puts the received date on the left and the opened date on the right. d. An opened ziploc bag of a partial roll of ground beef dated 2/7/22 with grayish white crystals in it and the meat on the end was grayish pink in color. 3. On 05/30/22 at 10:41 AM, in the Dry Storage Room flies were on the potatoes, boxes of food, the walls, and the ceiling. 4. On 05/30/22 at 10:51 AM, flies were in the Dish Washing Room. DS #1 stated they use the end of the three compartment sink with a sanitizer when the rinse cycle does not get hot enough. DS #4 was asked if she had made a compartment full of sanitizer solution today and she stated she had not. DS #1 filled the compartment in the sink and tested the sanitizer. The sanitizer sign stated 150-400 ppm [parts per million], The first test strip placed in the sanitizer registered below 100 ppm. The second test strip was put directly in the tube filling the sink registered between 250 and 400 ppm. The third test strip put into the sanitizer registered below 250 ppm but above 100 ppm. Both DS #1 and DS #2 stated they were unsure why the sink sanitizer would register less than what is coming out of the tube filling the sink. 5. On 05/30/22 at 11:07 AM, the Dietary Manager (DM) arrived, and DS #1 informed the DM of the issues with the sanitizer. The DM stated she ordered the wrong strips one time and asked if they were using the correct ones. DS #1 showed DM the strips and DM stated they were the correct ones. 6. On 05/30/22 at 11:09 AM, the DM accompanied the Surveyor on the remainder of the kitchen tour. On a Bread Rack in the kitchen was a ziplock bag with six blueberry muffins, the bag was not dated. The DM stated they were not there yesterday and gave them to DS #2 to discard. One loaf of white bread not dated. The DM stated they arrive frozen, and she knows when the loaf was thawed. She was asked if she could find a thawed date or expiration date on the loaf. The DM stated she could not. 7. On 05/30/22 at 11:11 AM, in the Standing Refrigerator near the Bread Rack were four bowls of relish and two bowls of salad not dated. The DM asked DS #3 if those were for today and DS #3 stated they were but did not date them. 8. On 05/30/22 at 11:17 AM, a fly landed on the edge of a pan of cherry crumble dessert that was sitting on the counter next to the steam table. Flies were also on the walls, the ceiling, the prep table, and the lids of items on steam table. 9. On 05/31/22 at 7:39 AM, a trash can and a large trash disposal container area located behind the building were organized stacks of garbage from a remodel and flies. 10. On 05/31/22 at 11:02 AM, DS #4 stated the dish washer was not at appropriate rinse and had been that way all day, so she was dunking the items in the sanitizer in the 3 compartment sink. The DM had two fly swatters, one in each hand, killing flies around kitchen and they were falling on floor. DS #1 was sweeping up dead flies with a broom. The DM was asked to check the sanitizer level. The DM checked the level and it registered at 100 ppm. The DM stated it was too old and was too low ppm and emptied the solution from the sink. The DM was asked whose responsibility it was to check to make sure the sanitizer was at the appropriate level solution. The DM stated, Whoever is doing the dishes. 11. On 05/31/22 at 11:14 AM, DS #3 took pureed bread rolls to the stove to reheat. While the surveyor was waiting for DS #3 to check the temperature of the pureed rolls, six flies landed at different moments in barbeque sauce that was in a metal bowl not covered on the prep table, under the hanging pans and on scoops 12. On 05/31/22 at 11:31 AM, DS #3 was reheating mix vegetables on the stove, the DM was spreading barbeque sauce on the meatloaf. The DM was asked if the bowl of barbeque sauce was covered. The DM stated it was not. She was informed of the six flies the Surveyor observed in the bowl on the sauce. The DM raised her voice at DS #3 and stated, all items needed to be covered when waiting to be used or served later. 13. On 05/31/22 at 11:33 AM, the DM left the kitchen and left two pans of meatloaf uncovered on the prep table. Surveyor observed 2 flies land on the meatloaf. 14. On 05/31/22 at 11:35 AM, there were more than 30 flies on the clean scoops, utensils, and pots hanging above the prep table. 15. On 05/31/22 at 11:41 AM, the DM returned and informed all kitchen staff to throw away the meatloaf. The Administrative Supervisor stated he had been filling in as Dietary Manager until the facility found a Dietary Manager and almost all of the kitchen staff were brand new, and this is their first survey. 16. On 05/31/22 at 11:55 AM, DS #1 left covering off of the bread rolls on the steam table after retrieving rolls to make a new batch of roll puree Flies were landing on the cover of the bread roll pan. 17. On 06/01/22 at 10:37 AM, the DM was asked to check the sanitizer solution. The DM asked DS #2 to check solution. DS #2 held the test strip under the water for ten seconds and removed and verified against chart. DS #2 was asked what it registered. DS #2 stated it was 100 ppm at most and did not turn darker like it should. DS #2 stated she wanted to try it again and held another test strip under the water for forty seconds and removed and verified against chart. The test strip read 150 ppm. DS #2 was asked what the instructions on the test strips stated. DS #2 stated, It says ten seconds, but I wanted to make sure it registered, so I held it under longer. 18. On 06/02/22 at 7:03 AM, when the Surveyor entered the kitchen there were various types of cereal in bowls on the carts about to be given to the Certified Nursing Assistants to be served to the residents. There were 6 flies climbing on the bowls. On the steam table were food items (eggs, sausage, biscuits) that were not covered and flies were landing on the food. DS #3 and DS #5 were asked if the food was ready to be served and DS #3 stated it was. 19. On 06/02/22 at 7:06 AM, DS #4 was asked to check the sanitizing solution. DS #4 held a test strip in for ten seconds. DS #4 showed the strip to this surveyor and stated it is at 0 ppm. DS #4 was asked about the water not being as clear as yesterday's solution and it is steaming a little. DS#4 stated, I added some hot water to see if that would help. 20. On 06/02/22 at 7:14 AM, the Administrator was informed flies were seen on uncovered food due to the DM not being at facility yet. The Administrator stated, Oh, I hate that. 21. On 06/02/22 at 8:09 AM, Maintenance #1 was asked when he was notified of the issue with the sanitizing solution. He stated he was not notified. DS #4 stated that [Company] suggested yesterday To keep running it more. DS #4 stated, They think that means to change the solution more often. DS #4 stated she had changed it twice since arriving. DS #4 checked the solution and it registered at 200 ppm. DS #4 stated, I did not add hot water this time. 22. On 06/02/22 at 8:58 AM, The Administrator was asked if she was notified of the sanitizer solution issue. The Administrator stated she was not notified. 23. On 06/02/22 at 9:10 AM, the Administrator was asked who the Director of Food & Nutrition Services was, referring to one in their policies. The Administrator stated, That is [Dietary Manager] the Dietary Manager. 24. On 06/02/22 at 10:00 AM, the Administrator was asked what if anything she did after being notified this morning about the flies. The Administrator stated. I immediately went to kitchen and told them to dump the cereal and refill and cover them. Dump, reload and cover. Those were my words. 25. The facility policy titled, Food Preparation, provided by the Administrator on 06/01/22 at 8:52 AM, did not address food was to be prepared in sanitary conditions. 26. The facility policy titled, Handling, Serving and Transporting Foods, provided by the Administrator on 06/01/22 at 8:52 AM documented, .Foods will be presented attractively, under sanitary conditions . 21. The facility policy titled, Safety & Sanitation Ware Washing (Dish Machine), provided by the Administrator on 06/02/22 at 8:58 AM documented, .Objective: Participants will know the correct procedure for using, maintaining, and monitoring the dish machine . The Director of Food and Nutrition Services should review the product requirements to determine the correct ppms for the sanitizer . The requirements for the machine must be met before washing/sanitizing the dishes. Follow the manufacturer's directions for checking the temperature and sanitizer. Contact the Director of Food and Nutrition Services or maintenance if it is not working properly . 27. The facility policy titled, Safety & Sanitation Cleaning and Care for Equipment, provided by the Administrator on 06/02/22 at 8:58 AM documented, Objective: Participants will know how to clean and care for equipment.

Based on observation, record review, and interview, the facility failed to ensure the maintenance of an effective pest control program to maintain a facility free of insects/pests The findings are: 1. On 05/30/22 at 10:22 AM, during initial tour of kitchen with Dietary Staff (DS) #1 the following observations were made: 2. On 05/30/22 at 10:41 AM, in the Dry Storage Room flies were on the potatoes, boxes of food, the walls, and the ceiling. 3. On 05/30/22 at 11:17 AM, a fly landed on the edge of a pan of cherry crumble dessert was sitting on the counter next to the steam table. Flies were also on the walls, the ceiling, the prep table, and the lids of items on steam table. 4. On 05/30/22 at 1:26 PM, Resident #27 was walking in hall. He stopped to show the surveyor his notebook of how many flies he had killed. He stated, I've killed eight hundred and five flies. He then pointed at his notebook that he had written from the number 1 to 805 in his notebook pages. He stated, .They call me the Fly man. I kill every fly I see, and when I get one thousand, they are going to get me a banana milkshake . a. On 5/31/22 at 3:46 PM, Resident #27 was in the lobby. He was holding a fly swatter with a dead fly on it. He stated to the Greeting Host, I've killed another fly. The Greeting Host lifted a trash can up and Resident #27 tapped the dead fly into the can. He then asked the Greeting Host for a pen. He stated, I need to write this down .I am up to eight hundred and twenty-eight that I have killed. He showed me his notebook and he had written 805, 806 all the way to 828 since the surveyor had been shown the notebook at 1:26 PM on 5/30/22. He stated again, They are going to get me a banana milkshake when I kill one thousand flies . b. On 6/1/22 at 8:50 AM, the Director of Nursing (DON) stated, He [Resident #27] calls himself the fly man. He killed one [fly] in my office this morning. He keeps up with them in his book . 5. On 05/30/22 at 1:40 PM, Resident #2 was in his room with a fly swat on his bedside table. He was asked, Do you have problems with flies? He stated, I've got a couple that bother me . A fly landed on the surveyor's laptop and was flying around resident's rooms. The Surveyor had to swat it away several times for it to leave the area. 6. On 05/30/22 at 1:46 PM, observe the Occupational Therapist (OT) #1 was bringing Resident #38 back to his room in a wheelchair. A fly was in the resident's room. The resident was asked, Is that a fly? OT #1 stated, There seems to be a fly in here every time I am in here. Resident #38 was asked, Are you bothered by flies? He stated, Yes, quite a few. He was asked, Have you reported it to anyone? He stated, Yes, I think it was an aide or maybe the nurse . 7. On 05/31/22 at 7:39 AM, a trash can and a large trash disposal container area located behind the building were organized stacks of garbage from a remodel and flies. 8. On 05/31/22 at 11:02 AM, the DM had two fly swatters, one in each hand, killing flies around kitchen and they were falling on floor. DS #1 was sweeping up dead flies with a broom. 9. On 05/31/22 at 11:14 AM, DS #3 took pureed bread rolls to the stove to reheat. While the surveyor was waiting for DS #3 to check the temperature of the pureed rolls, six flies landed at different moments in barbeque sauce that was in a metal bowl not covered on the prep table, under the hanging pans and on scoops. 10. On 05/31/22 at 11:33 AM, the DM left the kitchen and left two pans of meatloaf uncovered on the prep table. Surveyor observed 2 flies land on the meatloaf. 11. On 05/31/22 at 11:35 AM, Surveyor observed more than 30 flies on the clean scoops, utensils, and pots hanging above the prep table. 12. On 05/31/22 at 11:55 AM, DS #1 left covering off of the bread rolls on the steam table after retrieving rolls to make a new batch of roll puree Flies were landing on the cover of the bread roll pan. 13. On 06/02/22 at 7:03 AM, when the Surveyor entered the kitchen there were various types of cereal in bowls on the carts about to be given to the Certified Nursing Assistants to be served to the residents. There were 6 flies climbing on the bowls. On the steam table were food items (eggs, sausage, biscuits) that were not covered and flies were landing on the food. DS #3 and DS #5 were asked if the food was ready to be served and DS #3 stated it was. 14. The (Company) Commercial General Pest Control statements from 12/27/21 to 05/23/22 provided by the Administrator on 06/01/22 at 7:45 AM documented, .roaches . and spiders . were the targeted pests for monthly treatments . and the kitchen was the general service point. Flies were not listed.