Based on observations, interviews, record review, and policy review, it was determined that the facility failed to properly store oxygen canisters while not in use for 1 (Resident #53) of 4 residents reviewed for accidents. The findings include: A review of the Medical Diagnosis Report indicated Resident #53 was admitted to the facility with diagnoses which included chronic respiratory failure, with low oxygen levels, and chronic obstructive pulmonary disease (COPD). A review of the quarterly Minimum Data Set, with an Assessment Reference Date of 04/21/2025, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #53 ' s Care Plan, revised 08/21/2024, revealed Resident #53 received oxygen therapy related to COPD, and was a smoker. Interventions included to instruct the resident about facility policy and safety concerns. The care plan did not indicate the resident was non-compliant with instruction related to receiving oxygen therapy. During an observation on 06/02/2025 at 3:45 PM, Resident #53 ' s oxygen tank was noted to be stored in the middle of the floor, near the foot of the bed, and Resident #53 was resting in a recliner at the bedside. During an observation on 06/02/2025 at 4:42 PM, Resident #53 ' s oxygen tank remained sitting on the floor at the foot of the bed with no rolling cart or device present in the room to secure the tank and ensure safety. During an interview on 06/05/2025 at 8:52 AM, Certified Nursing Assistant (CNA) #7 indicated she was familiar with Resident #53 and was aware the resident wore oxygen. CNA #7 stated if there was an oxygen tank found sitting on the floor, they would pick it up and put it on Resident #53 ' s wheelchair. During an interview on 06/05/2025 at 9:02 AM, Licensed Practical Nurse (LPN) #8 indicated she was familiar with Resident #53. LPN #8 indicated Resident #53 normally wore oxygen and carried the oxygen tank between the resident ' s legs while in a wheelchair. LPN #8 indicated it was inappropriate to store and carry oxygen tanks this way. During an interview on 06/05/2025 at 9:08 AM, the Director of Nursing (DON) indicated she was familiar with Resident #53 and was aware the resident wore oxygen. The DON indicated it was not appropriate to store oxygen tanks on the floor, without being in a holder, because they may explode if tipped over. The DON provided education to staff on this day, 06/05/2025. The training was reviewed and the DON indicated education was provided to Resident #53 by the Administrator. During an interview on 06/05/2025 at 9:15 AM, the Administrator indicated oxygen cylinders were to be stored and contained in the metal oxygen racks, so they would not tip over. The Administrator indicated oxygen tanks may explode, if tipped over. A review of an Oxygen Administration policy, dated 10/2010, indicated to check the mask, tank, humidifying bottle, and other components to be sure they are in good working order and fastened to a stand. A review of the NFPA 99, Health Care Facilities Code, revealed in Chapter 11, Gas Equipment, 11.3.3.3 When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders, and 11.3.3.4 Individual small-size (A, B, D, or E) cylinders available for immediate use in patient care areas shall not be considered to be in storage.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication was not left at the bedside for one of one observation and the facility failed to ensure insulins and antianxiety medications were stored at manufacturer recommended temperature for one of one observation of medication storage. The findings include: 1. During an observation on 06/02/2025 at 1:02 PM, a medication cup containing a clumpy white powdery substance was observed on Resident #48's over-bed table. Licensed Practical Nurse (LPN) #8 stated, Resident #48 would have to be asked because LPN #8 did not know what was in the medication cup. LPN #8 left the room, with the medication cup still at the bedside. a. A review of Medical Diagnosis revealed Resident #48 was admitted to the facility with diagnoses which included stroke, heart dysrhythmia, and heart failure. b. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/14/2025, indicated Resident #48 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact and that Resident #48 had skin tears. c. During an interview on 06/02/2025 at 1:19 PM, LPN #8 revealed Resident #48 could not identify the substance in the medication cup, and the Director of Nursing (DON) or the Pharmacist would need to identify the medication. d. During an interview on 06/02/2025 at 2:45 PM, the DON stated the Pharmacist confirmed the medication cup contained an antifungal powder, but did not know which resident it was intended for. The DON also stated staff were not supposed to leave medication at the bedside. The DON stated, Nurses are responsible, because they pass medications to the residents and it is a safety issue. The DON indicated medications were not to be left at the bedside because some residents wander in the building, and they could take the medication the wrong way. e. During an interview on 06/02/2025 at 5:14 PM, Resident #48 stated I came back from breakfast and found a medication cup at the bedside and said to myself what the [expletive] is that. Resident #48 indicated they did not know what the medication cup of white substance was or where it came from, and they had no need for the medication. f. During an interview on 06/04/2025 at 1:00 PM, the Medical Director (MD) stated, You cannot leave medications at the bedside, because you must know how much residents take. There must be supervision in terms of administering the medications. Some residents have the capability of self-administering their own medications but there are medications that must be monitored if the medication has been taken. g. During an interview on 06/04/2025 at 3:05 PM, the Administrator confirmed Resident #48 had a cup of antifungal medication at the bedside and revealed that staff were expected not to leave medication at the bedside. Medication has to be given with nursing in the room. The Administrator indicated training will be completed. The Administrator and the DON indicated there were no residents with self-administration rights. h. A review of a policy titled Self-Administration of Medication, dated 10/27/2017, revealed the interdisciplinary team had to assess residents to determine if residents were cognitively intact and physically able to be responsible for taking a self-administered medication. This policy also indicated bedside storage could only be done when there was no risk to the residents. i. A review of a training, dated 06/02/2025, revealed medications must be stored properly according to policies and procedures. Medications should never be left at the bedside; all medications are to be given before leaving resident rooms. 2. During an observation on 06/04/2025 at 9:23 AM, LPN #8 opened a tall white refrigerator in the medication room and said, The thermometer says 24 degrees. LPN #8 confirmed three bottles of antianxiety medication were in the narcotic box for 300/400 halls. She then read from a bottle, to store at 36-46 degrees Fahrenheit. LPN #8 confirmed the temperature was not in the recommended range. LPN #8 stated they would have to ask the DON who was responsible for checking refrigerator temperatures. a. During a concurrent observation and interview on 06/04/2025 at 9:30 AM, the DON came to the medication room and confirmed that 24 degrees was too cold for the narcotic refrigerator and read the medication ' s recommended storage temperature of 36-46 degrees Fahrenheit. The DON revealed housekeeping was responsible for refrigerator temperatures. b. A review of temperature logs from May indicated the refrigerator temperatures were 28-33 degrees. LPN #8 provided a copy of the June temperature log, and for the first two days of June, it was indicated the refrigerator temperatures were 32 degrees. c. During an interview on 06/04/25 at 10:06 AM, the DON provided the temperature log for May 2025 and read the temperatures for the large white refrigerators ranged from 28-33 degrees. The June log revealed the refrigerator temperature as 32 degrees. The DON said staff did not notify administration that the refrigerator had been out of range the entire month. She also stated housekeeping was responsible for recording the temperatures of the locked medication room refrigerator. d. During an interview on 06/04/2025 at 10:22 AM, the Administrator stated that the DON told the Administrator there was an issue with the refrigerator being 24 degrees and they would be training staff. The Administrator confirmed the process was housekeeping was responsible for documenting refrigerator temperatures, and administration was not notified the refrigerator was too cold. e. During an interview on 06/04/2025 at 1:00 PM, the MD stated medications are to be stored at the right temperatures. The medication needs to be discarded, and a refrigerator needs to be put in place, that is accurate. There is a pharmacist that looks at refrigerator temperatures and they should have taken care of this issue. There are conditions that the medications have to be stored at. f. A review of a policy titled Medication Storage in the Facility dated 10/27/2017, revealed medications requiring room temperature storage are kept in the range 59-77 degrees Fahrenheit and refrigerated medications stored at 36-46 degrees Fahrenheit. The facility is responsible for having a temperature log in the medication storage area. g. A review of Consultant Pharmacist Monthly QA Report for May 2025, indicated the medication room refrigerator was 32 degrees, and the recommended temperature was 36-46 degrees Fahrenheit. The facility was instructed to adjust and monitor the refrigerator temperature. Medication supply should only be accessible to licensed nursing and pharmacy staff. Medication room, carts and medication supply should be locked when unattended.

Based on interviews, observations, record review, and facility policy review, the facility failed to ensure chemical solutions were available to effectively clean and sanitize dishware and kitchen equipment; failed to store, prepare, distribute and serve food in accordance with professional standards of safety; failed to ensure dietary staff washed their hands following the removal of gloves and between task during meal preparation; failed to ensure food preparation surfaces were cleaned and sanitized using a sanitizing solution; failed to ensure equipment was clean and sanitized between uses; and failed to ensure the dietary staff cleaned and sanitized the test thermometer between testing the temperatures of food items on the steamtable. A total of 89 residents received meals from the kitchen and were at risk of contracting a food borne pathogen with the potential of causing gastrointestinal illnesses. The findings are: 1. During an observation and interview on 06/02/2025 at 01:15 PM, the Dietary Consultant stated the dishwasher was a low temp dish machine. This surveyor noted the temperature on the dish machine had a temperature reading of 140 degrees Fahrenheit (F) on the final cycle. The dish machine did not reach a temperature higher than 140 degrees F. Dietary Aide (DA) #1 tested the water, utilizing a test strip, in the dishwasher following the sanitizing cycle. The pH test strips did not change colors. DA #1 stated the pH strip was clear because the sanitizing solution bucket was empty and the facility did not have any sanitizer available. DA #1 said they had been out of sanitizer chemicals since yesterday, 06/01/2025, and the chemical vendor was scheduled to bring the facility a supply of chemicals on 06/03/2025. DA #1 checked the sanitizer in the three-compartment sink by dipping a pH test strip in the sanitizer sink of water and stated the pH strip did not change colors because the facility did not have any sanitizer available for the sink. This surveyor observed there was no sanitizer bucket below the sink and the hose for the sanitizer bucket was lying on top of the soap bucket. The sanitizer bucket of the dishwasher was noted to be empty. This surveyor observed the clipboard of the logs, for documentation regarding the temperatures and parts per million (PPM) solutions. The clipboard did not have a June log for the staff to document the dishwasher temperatures or PPM readings. The Dietary Manager stated, I haven't had the time to change the logs. The Dietary Consultant removed the May log, which had only one temperature logged for May 1, 2025, of 200 degrees Fahrenheit under the wash temperature, no other temperatures or PPM were logged for the remainder of May and added a new log for June A. On 06/02/2025, DA #2 provided a written statement that she had worked the day of Sunday, 06/01/2025, and there was no sanitizer in the bucket at that time. B. During an interview on 06/02/2025 at 01:49 PM, DA #2 stated the bucket used to provide sanitizing chemicals for the kitchen ' s dishwashing sink had been gone from the sink for four to five days. DA #2 said she had asked DA #3 four to five days ago if there was any sanitizer in the storage, and he had told her no. C. During an interview on 06/02/2025 at 01:52 PM, the Certified Dietary Manager (CDM) said she knew on Friday, 05/30/2025, that they were running out of the sanitizer and would not make it until the next delivery on 06/03/2025. She stated the chemical vendor representative had been at the facility on 06/02/2025 and checked the chemicals and told her they were out, and the chemicals would be delivered the following morning. The CDM then stated, I guess I need to call him back out here. The CDM said the process for ordering chemicals was to order every Monday for Tuesday deliveries. The CDM said she had not ordered last week because the staff told her not to order because they had enough and there was no room in the storage closet. The CDM said she should have checked herself. The CDM said the last order was on 05/13/2025. The CDM said she was responsible for ensuring the chemicals were ordered and the administrator approved the orders. The CDM said the dishwasher staff working should log the temperatures and PPMs on the logs that day. D. During an interview on 06/02/2025 at 03:45 PM, the CDM told this surveyor that there were no logs indicating the sanitizing solution had been monitored for the 3-compartment sink for April or May of 2025. E. During an interview on 06/02/2028 at 05:40 PM, the CDM reported she is responsible for ensuring the logs were completed and the dishwasher staff was responsible for logging the temperatures and PPMs. F. On 06/03/2025 at 08:32 AM, the Administrator said checking the temperatures and sanitizing was important for the safety of our residents, and if they were not done it would be potentially dangerous for the residents. The Administrator said if the chemical readings were too high it would be dangerous for whatever chemicals could do to you. G. On 06/04/2025 at 01:00 PM the Medical Director said he was aware of the monitoring of the issues identified. He said they were monitoring symptoms for gastro issues. He stated he had provided directions for the staff. He said his concerns were to monitor the residents to see if there were any symptoms linked to it. He stated they have protocols in place to ensure it did not happen again. H. On 06/04/2025 at 05:15 PM, the CDM provided temperature logs for the 3-compartment sink and dishwasher covering the months of February 2025 - June 2025. They revealed, Three Compartment Sink: Parts Per Million PPM should be between 150-400, allow 5 to 10 seconds to develop then compare the color to the chart. Wash sink 110 degrees. Rinse sink 110 degrees, Sanitizer Sink 65 - 70 degrees. a. February 2025 log: no temperatures or PPMs were logged for the breakfast meal for the days 18 - 27; No lunch temperatures or PPMs were logged for the days 18 and 19, 25 - 28; dinner days 18 and 19, 25 - 28. b. March log: no temperatures or PPMs were logged for breakfast for the days 1 - 5, 7 - 31; No temperatures were logged for lunch for days 4 - 5, 11 - 12; 17 - 19; 23 - 31; no temperatures were logged for dinner for days 8 - 9, 11 - 12, 17 - 19, 22 - 31. c. April 2025: log: no wash temperature or sanitizer or PPM was logged for day 1, no temperatures or PPMs were logged for breakfast for days 18 - 30, on day 17 breakfast log had a 4 on the sanitizer and no PPM was logged, lunch temperatures or PPMs were logged for days 17 - 30, no dinner temperature or PPMs were logged for days 17 - 30. d. May 2025: a wash temperature of 200 was logged for breakfast on day 1, no other temperatures were logged. I. Temperature logs for the dishwasher for the months of February-June 2025 indicated, Low Temperature Dishwasher Temperatures must be 120 degrees - 150 degrees or rewashed. a. February 2025: no temperatures or PPM was logged for days 18 - 19. No lunch temperatures or PPMs were logged for days 18 - 19, 25 - 28, no temperatures or PPMs were logged for days 18 - 19. 24 - 28. b. March 2025: no temperatures or PPMs were logged for days 1-5, 7-12, 14-31; breakfast day 6 and 13 did not have a rinse temperature logged, no lunch temperatures or PPMs were logged for days 4-5, 11-12, 17-18, 23-31, no dinner temperatures or PPMs were logged for days 4-5, 11-12, 17-18, 23-31; day 17 no wash temperature or PPM was logged for supper. c. April 2025 Sheet 1: no temperature or PPMs were logged for days 4, 9 - 10, no lunch temperatures or PPMS were logged for days 4, 9 - 10, no supper temperatures or PPMs were logged for days 1, 3 - 6, 13 - 17, 21, 25, 29. April 2025 sheet 2: lines drawn through days 1 - 4 with a note in the comments that appears to state, Dishwasher out of work. No breakfast temperatures or PPMs logged for day 16, day 24 - 25, day 19; no lunch temperatures or PPMs were logged for days 5, 16, 18, 25; no supper temperatures or PPMs were logged for days 6 - 7, 15 - 16, 18, 25, 27. d. May 2025: no temperatures or PPMs were logged for days 16 and 30, no lunch temperatures or PPMs were logged for days 28 and 30. J. A review of the chemical vendor report reflects the vendor was at the facility on 06/02/2025 at 08:37 AM. The report summary indicates the kitchen equipment was working fine, and the results were good. The report indicated the facility needed to order sanitizers because they were empty. The Chemical Sanitation report reflected a rating of 0 PPM for the dish machine sanitizer and the 3-compartment sink sanitizer. The report had two photos, one photo of the sanitizer hose lying on top of the soap dispenser bucket with a note stating Food contact surface sanitizer has a rating of 0 PPMs. The other photo of the empty dish machine bucket stating sanitizer is empty. K. A Food Facts information sheet retrieved from the website of the United States Food and Drug Administration states Know the Symptoms. Consuming dangerous foodborne bacteria will usually cause illness within 1 to 3 days of eating the contaminated food. However, sickness can also occur within 20 minutes or up to 6 weeks later. Symptoms of foodborne illness can include vomiting, diarrhea, and abdominal pain - flu-like symptoms, such as fever, headache, and body ache. L. A policy titled, Dishwashing Machine Use, indicated .Dishwashing machine chemical sanitizer concentrations and contact times will be as follows .Quaternary Ammonium 150 - 200 PPM Per manufacturer's instructions .The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle .If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of the dishwashing machine immediately until temperatures or PPM are adjusted. M. A policy titled, Sanitization, indicated, The food service area shall be maintained in a clean and sanitary manner .All equipment, food contact surfaces and utensil shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 4. Sanitizing of environmental surfaces must be performed with one of the following solutions .b. 150-200 ppm quaternary ammonium compound (QAC) .Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if the solution becomes cloudy or visibly dirty .Manual washing and sanitizing will employ a three-step process for washing rinsing and sanitizing: .Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions may consist of .Quaternary ammonium compound 150 - 200 ppm for time designated by the manufacturer. 2. During an observation on 06/03/2025 at 10:35 AM, DA #4, put a pair of gloves on without washing his hands, he then took a pan of brownies from the rolling cart and sat the pan on the preparation table. He took a knife and cut the brownies. DA #4 removed his gloves, then retrieved a sleeve of lids for the bowls. He put the sleeve of lids back and put on a pair of gloves without washing his hands between these tasks. A. During an observation and interview on 06/03/2025 at 10:45 AM, DA #4 retrieved a food scale from the storage rack and weighed powdered sugar in a large bowl. This surveyor noticed a yellowish substance on the side and top of the scale. DA #4 stated the substance appeared to be dried egg yolk but could be any food item. DA #4 said it should have been cleaned prior to storing on the racks because it could cause food contamination and food borne diseases on whatever touches it. DA #4 wiped the scale off with a hot washcloth and placed it on the storage shelf. He then wiped down the preparation table with hot water he retrieved from the hot water spicket on the coffee maker. This surveyor asked DA #4 what he used to sanitize the table. DA #4 said they did have a bottle with sanitizer in it, but he had not seen it today, so he used hot water. B. During an interview on 06/03/2025 at 11:00 AM, DA #3 said he did not know where the sanitizer spray bottle was, so he had used the sanitizer in the 3-compartment sink to wet his cloth and clean his area. C. On 06/03/2025 at 12:00 PM, DA #3 placed the food on the serving line in the dining room. DA #3 then began to test the temperatures of the food items. DA #3 tested meatloaf, cream lima beans, cream potatoes. This surveyor noted DA #3 had a white paper towel in his hand. DA #3 said they did not have any alcohol wipes, so he had cleaned the thermometer with a paper towel. DA #3 said he had used the last alcohol wipe at the breakfast meal. He said the purpose of the alcohol wipe is to kill the bacteria from switching over from one item to another. 3. During an observation of the facility ' s pantry on 06/02/2025 at 11:15 AM, this survey was accompanied by the CDM and the Dietary Consultant when the following were identified: A. Three 16-ounce packages of marshmallows had a received date of 12/24 written on the package. The packages did not have a use by date or expiration date. B. A box of 76 packets of steak sauce expired 02/24/2025. C. One opened 5-pound bag of pancake mix had been opened and did not contain an open date, use by date, or expiration date. D. A gallon package of powdered fruit drink mix contained a received by date of 04/22/2025 but did not have an expiration date on the package. E. Two 100 count boxes of tea bags did not contain any dates on them. F. One 16-ounce (oz) package of plain potato chips, expiration date of 03/31/2025. G. One 40-oz package of elbow pasta had been opened and did not contain an open date, use by date or expiration date. H. Two 40-oz packages of spaghetti noodles did not have a received date, expiration date or use by date. I. One opened 40-oz package of spaghetti noodles did not have an open date, expiration date or use by date. J. One opened package of lemon gelatin, not sealed, did not contain an open date, an expiration date or a use by date. K. Seven 24-oz packages of lime gelatin did not have a received date, expiration date or best by date. L. One #10 can of pumpkin mix did not have a received date, use by date or expiration date. M. One #10 can of vanilla pudding did not have a received date, use by date or expiration date. N. One #10 can of peaches, one #10 can of tropical fruit, and one #10 can of great northern beans were in the can racks for ready to use foods had dents in the rims of the cans. O. A clear zip bag of unlabeled cereal did not have an open date, use by date, or expiration date. P. Nine 26-oz packages of classic Idaho mashed potatoes did not have a received date, use by date, or expiration date. Q. One package of dried onions did not have a received date, use by date, or expiration date. The only identifying mark on the package was a handwritten note that said onion. 4. On 06/02/2025 at 1:11 PM, this surveyor observed the following spices to be expired in the facility kitchen: A. Ground cloves expired 04/03/2025. B. Ground nutmeg expired 09/27/2023. C. Ground allspice did not have an expiration date or use by date. D. [NAME] leaves expired 04/28/2025. E. Mediterranean style ground oregano expired 06/30/2024. F. Ground cayenne pepper did not have an expiration date or use by date but was received on 06/23/2020. G. Dill weed expired 10/05/2023. H. Rubbed sage did not have an expiration date or use by date 06/16/2024. 5. A policy titled, Food Receiving and Storage, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. Item 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date).

Based on observation, record review, and interview, the facility failed to ensure call lights were kept within reach to allow the residents to summon assistance to accommodate their individual care needs for 1 (Resident #60) of 12 (Residents #5, #12, #15, #20, #23, #24, #25, #39, #41, #46, #58 and #67) sampled residents who were dependent on staff assistance and could utilize the call light system. This failed practice had the potential to affect 62 residents as documented on a list provided by the Administrator on 04/25/23 at 1:50 PM. The findings are: 1. Resident #60 had diagnoses of Cerebral Infarction, Unspecified and Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and required extensive physical assistance of two plus persons with bed mobility and transfer, extensive physical assistance of one person with locomotion on and off the unit, dressing, eating, personal hygiene, was totally dependent of two plus persons with toilet use and was always incontinent of bladder and bowel. a. On 04/24/23 at 11:28 AM, Resident #60 was sitting in his wheelchair with his call light attached to the privacy curtain and out of the resident's reach. The Surveyor asked Certified Nursing Assistant (CNA) #9 if the resident should have his call light in reach. CNA #9 answered, Yes. The Surveyor asked, Why? CNA #9 answered, In case he needs help. b. On 04/26/23 at 3:30 PM, the Surveyor asked the Director of Nursing (DON) if a resident has a call light, where should it be located. The DON stated, Within the resident's reach. The Surveyor asked why, should it be within reach. The DON responded, So they can reach someone if they need help. c. A facility policy and procedure titled, Answering the Call Light, provided by the Administrator on 04/27/23 at 9:24 AM documented, Purpose The purpose of this procedure is to respond to the resident's requests and needs . 4. Be sure that the call light is plugged in at all times . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Deficiency Text Not Available

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 7 residents who received pureed diets, 23 residents who received mechanical soft diets and 58 residents who received regular diets from 1 of 1 kitchen (total census: 86) according to a list provided by the Dietary Supervisor on 04/25/23 The findings are: 1. On 04/24/23 AM, the following observations were made during the lunch meal preparation and meal service: 2. On 04/24/23 at 11:39 AM, Dietary Employee #2 placed 15 servings of cream ranch chicken into a blender and ground. He poured the ground chicken in a pan. He covered the pan with plastic wrap and placed it in the oven to be served to the 23 residents who received mechanical soft diets for lunch. At 1:25 PM, Dietary Employee #2 used a 4 oz spoon to serve half portions of ground chicken to the residents on mechanical soft diets. At 2:07 PM, the Surveyor asked the Dietary Supervisor to weigh the same amount of cream ranch chicken served to the residents for lunch. She did so and it weighed 2.8 ounces. The menu specified for each resident on mechanical soft diets to receive a #8 scoop serving of ground meat (4 oz) and residents on regular diets to receive 4 oz of cream ranch chicken. Residents on regular diets were served 2.8 ounces of cream ranch chicken, instead of 4 ounces of chicken. 3. On 04/24/23 at 1:20 PM, residents on pureed diets were served pureed cream ranch chicken, pureed English peas and pureed dessert. There was no pureed bread prepared and served to the residents on pureed diets. The menu specified for each resident on pureed diets to receive a #16 scoop of pureed bread. 4. On 04/24/23 at 2:09 PM, the Surveyor asked Dietary Employee #2, How many serving of cream ranch chicken did you prepare? He stated, I did 15 servings of chicken. The Surveyor asked, How many residents do you have on mechanical soft diets? He stated, About 22 residents and I should have done more than 15 servings. The Surveyor asked why the residents on pureed diets did not receive bread. He stated, I forgot.

Based on observation, interview, and record review, the facility failed to ensure resident's dining space was not infringed upon by other residents to ensure residents were able to have a pleasant dining experience for 1 (Resident # 25) sampled resident and meals for residents at the same dining table in the Main Dining Room were served together to promote dignity and respect for 1 (Resident #62) of 24 (Residents #5, #12, #15, #24, #25, #26, #39, #44, #48, #51, #53, #54, #58, #60, #61, #62, #65, #67, #72, #77, #79, #84, #291 and #342) sampled residents. This failed practice had the potential to affect 87 residents who had the ability to dine in the Main Dining Room as documented on the Census and Conditions of Residents provided by the Administrator on 04/24/23 at 11:52 AM. The findings are: 1. Resident #25 had diagnoses of Vitamin D Deficiency, Unspecified and Unspecified Severe Protein-Calories Malnutrition. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was independent after setup for eating. a. A Physician Order dated 01/10/22 documented, Regular diet, Regular texture, Regular consistency . b. A Care Plan with a revision date of 04/04/23 documented, The resident has potential for unplanned/unexpected weight loss r/t [related to] RECENT DECLINE IN FUNCTION, RECOVERED FROM COVID19 . Honor preferences . Serve diet as ordered- Regular diet, regular texture, Regular consistency . c. On 04/24/23 at 12:55 PM, Resident #25 was seated at a corner table in the Main Dining Room by herself when Resident #20 was observed being pushed in his wheelchair by Licensed Practical Nurse (LPN) #5 and seated at the same table. At 1:00 PM, both residents lunch trays were brought to the table and set up in front of the residents. Resident #20 picked up Resident #25's meal ticket, showing it to her, talking to her, picking up her tea glass and moving it around on the table and touching Resident #25's plate of cornbread. Resident #25 was turning her head and not talking to Resident #20. Resident #25 had not eaten any of her food. The Surveyor asked if she was going to eat her lunch. She stated, No, I don't want it after someone else has touched it. At 1:30 PM, the Activity Director walked through the Dining Room. The Surveyor asked the Activity Director if she would watch the interaction between the 2 residents. The Activity Director had Licensed Practical Nurse (LPN) #5 move Resident #20 to another table. The Activity Director asked Resident #25 if she would like something else to eat. Resident #25 stated, Yes. At 1:45 PM, another plate with a corndog and french fries was brought to Resident #25. The Surveyor asked the Activity Director if Resident #20 usually sat at Resident #25's table. She stated, Sometimes. There has never been any problems before. d. On 04/24/23 at 2:00 PM, LPN #5 was sitting at a Dining Room table with Resident #20. The Surveyor asked LPN #5 if Resident #20 usually sits at Resident #25's table. He stated, I moved him over there because there was an issue at the other table where he was seated. I could tell that [Resident #20] was upset and I was hoping to avoid any incidents. [Resident #20] has sat over there at Resident #25's table before and there has never been an issue. The Surveyor asked would you consider this a dignity issue. He stated, Yes, I guess so. e. On 04/27/23 at 11:44 AM, the Surveyor asked the Director of Nurses (DON) if having someone evade your space and touch your plate and glass during a meal would be a dignity issue. She stated, Yes and cross contamination issue. 2. Resident #62 had diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Significant Change MDS with an ARD of 04/03/23 documented the resident scored 4 (0-7 indicates severely cognitively impaired) on a BIMS and was independent after setup for eating. a. A Care Plan with a revision date of 11/08/19 documented, The resident has an ADL [activities of daily living] self-care performance deficit r/t cognitive deficits . Encourage resident to attend meals in the dining room . EATING: The resident is able to feed self after tray setup . b. A Physicians Order dated 04/25/22 documented, NAS (No Added Salt) diet, Regular texture, Regular consistency . c. A Care Plan with revision date 02/09/23 documented, The resident has POTENTIAL FOR unplanned/unexpected weight loss r/t cognitive deficits, and is at risk for weight fluctuations r/t diuretic drug therapy . 1800 CC [cubic centimeter] FLUID RESTRICTION . d. On 04/24/23 at 1:00 PM, Resident #62 sat down at the Dining Room table with Resident #25 and Resident #20 as their lunch trays were delivered and setup. At 1:19 PM, all residents seated in the Main Dining Room had received their lunch except Resident #62. At 1:21 PM, a Certified Nursing Assistant (CNA) was observed bringing Resident #62's lunch meal and setting it up. There was nothing on his tray to drink. The Activity Director came by their table and the Surveyor asked why he didn't have anything to drink on his tray. She stated, He is on fluid restriction. At 1:35 PM, Resident #20 took Resident #62's plate from across the table and ate Resident #62's corndog and french fries. The Surveyor notified the Activity Director. The Activity Director asked LPN #5 to please move Resident #20 to another table and told Resident #62 she would bring him and Resident #25 another plate. At 1:45 PM, both Resident #62 and Resident v#25 were brought another plate. e. On 04/27/23 at 11:44 AM, the Surveyor asked the DON if being the only one in the Dining Room without a meal while other residents were eating would be a dignity issue. She stated, Yes. 3. A facility policy and procedure titled, Quality of Life - Dignity, provided by the Administrator on 04/25/23 at 1:50 PM documented, .Policy and Interpretation and Implementation . 6. Residents' private space and property shall be respected at all times . 4. A facility policy and procedure titled, Meal Service, provided by the DON on 04/28/23 at 8:19 AM documented, Basic Responsibility: Licensed Nurse and Nursing Assistant . Purpose 1. To serve well-balanced, attractive meals to all residents . NOTE: .A tray sequence may be used in dining rooms so all residents at a table are served at the same time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) was completed accurately related to an indwelling foley catheter for 1 (Resident #54) and a Discharge MDS for 1 (Resident #88) of 24 (Residents #5, #12, #15, #24, #25, #26, #39, #44, #48, #51, #53, #54, #58, #60, #61, #62, #65, #67, #72, #77, #79, #84, #291 and #342) sampled residents whose MDS's were reviewed. The findings are: 1. Resident #54 had diagnoses of Dementia, Respiratory Failure, Pneumonia, Retention of Urine, and Staphylococcus. The Significant Change MDS with an Assessment Reference Date (ARD) of 02/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons for toilet use, had an indwelling catheter and was always incontinent of bladder. a. A Physicians Order dated of 02/13/23 documented, Foley catheter 16 fr [french] 30 cc [cubic centimeters] . b. The Care Plan with a revision date of 01/04/23 documented, ADL [activities of daily living] self-care performance deficit r/t [related to] weakness/decline in function . has an indwelling foley catheter for bladder management . is dependent on staff for care of catheter . c. On 04/26/23 at 9:37 AM, the Surveyor asked the MDS Coordinator why Resident #54's Significant Change MDS with an ARD of 02/20/23 documented always incontinent of bladder if Resident #54 has an order for a Foley catheter dated 02/13/23. The MDS Coordinator replied, It's a coding error and we will correct that. The Surveyor asked the MDS Coordinator why the MDS assessments should be correct. The MDS Coordinator replied, It paints an accurate picture so appropriate care is provided. 2. Resident #88 was discharged on 02/20/23 and had diagnoses of Unspecified Dementia and Fracture of Unspecified part of Neck of Right Femur. The Discharge Return Anticipated MDS with an ARD of 02/20/23 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). a. A Nursing Note dated 02/20/23 at 2:59 AM documented, .Resident noted with slight mental change in status . Spoke with . POAS [Power of Attorneys] and agreed to allow this nurse to send to [Hospital] ER [Emergency Room] for evaluation. Resident had stated she wanted to go get checked, that she just didn't feel well. EMS [Emergency Medical Services] notified and transported to [Hospital] ER at this time . b. A Nursing Note dated 02/20/23 at 8:06 AM documented, .Called [Hospital] ER and was informed that resident was to be admitted to Hospice. Called [POA] [Name] and was informed that resident was to be admitted to 5th floor hospice at [Hospital]. Daughter stated that resident was in kidney failure and had infection and they were waiting on nurse for admission to hospice . c. On 04/26/23 at 1:24 PM, the Surveyor asked the MDS Coordinator when Discharge MDS's were completed. The MDS Coordinator stated, We try to usually by the next business day. The Surveyor asked where Resident #88 was discharged to. The MDS Coordinator stated, She was return anticipated. She went from us to the ER and then the ER admitted her. The Surveyor asked when the resident was considered discharged . The MDS Coordinator stated, When they admit. Hers should have been discharge return not anticipated. That information was available. Thanks for letting me know. 3. On 04/26/23 at 9:37 AM, the Surveyor asked the MDS Coordinator what guidelines do you go by. The MDS Coordinator replied, We use the RAI [Resident Assessment Instrument] manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure an updated determination evaluation and review was received after the 60 day expiration date for a resident with a mental disorder diagnosis to ensure the resident received care and services in the most integrated setting appropriate to their needs for 1 (Resident #72) of 23 (Residents #5, #10, #12, #15, #20, #25, #32, #39, #46, #48, #49, #53, #54, #58, #60, #61, #63, #65, #67, #72, #79, #86 and #342) sampled residents with serious mental disorders as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 04/27/23 at 3:38 PM. The findings are: 1.Resident #72 was admitted to the facility on [DATE] and had a diagnosis of Post-Traumatic Stress Disorder. The Quarterly MDS with an Assessment Reference Date (ARD) of 02/13/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received an antipsychotic medication 7 of the 7 day look back period. a. The Electronic Health Record contained a (State Designated Professional Associates) letter dated [DATE]. The letter documented, .Has been approved for 60 days . Please contact [State Designated Professional Associates] with admission Date once client admits to your facility . b. The Electronic Health Record contained a (State Designated Professional Associates) letter dated [DATE]. The letter documented, .Has been approved for 30 days . Please contact [State Designated Professional Associates] with admission Date once client admits to your facility . c. On 04/26/23 at 3:28 PM, the Surveyor asked the Administrator for a copy of Resident #72's Preadmission Screening and Resident Review (PASSAR) II. She said the only PASSARs they have is from 03/03/21, for 60 days and 08/17/21, for 30 days, they're both for admission to the nursing home. She had contacted [State Designated Professional Associates] today and a new packet for a PASSAR 1 had been filled out and faxed back to them. d. On 04/26/23 at 3:40 PM, the Surveyor asked the Director of Nursing (DON) if she knew what a PASSAR was. The DON said she did not know, and they were trying to explain that to her today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on observation, interview, and record review, the facility failed to ensure residents' who had a new service or level of care ordered or provided, individualized Care Plans were updated to ensure appropriate care was received for 4 (Residents #54, #61, #72 and #79) of 24 (Residents #5, #12, #15, #24, #25, #26, #39, #44, #48, #51, #53, #54, #58, #60, #61, #62, #65, #67, #72, #77, #79, #84, #291 and #342) sampled residents whose Care Plans were reviewed. This failed practice had the potential to affect 87 residents as documented on the Census and Conditions of Residents provided by the Administrator on 04/24/23 at 11:52 AM. The findings are: 1. Resident #54 had diagnoses of Dementia, Respiratory Failure, Pneumonia, Retention of Urine, and Staphylococcus. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons for toilet use, had an indwelling catheter and was always incontinent of bladder. a. A Physicians Order dated of 02/12/23 documented, May flush Foley catheter with 60 cc of Normal Saline PRN [as needed] d/t [due to] occlusion every 8 hours as needed . b. A Physicians Order dated 02/12/23 documented, May have foley catheter change monthly on the 16th every day shift starting on the 16th and ending on the 16th every month . c. A Physicians Order dated of 02/13/23 documented, Foley catheter 16 fr [french] 30 cc [cubic centimeters] . d. The Care Plan with a revision date of 01/4/23 documented, .ADL [activities of daily living] self-care performance deficit r/t [related to] weakness/decline in function . has an indwelling foley catheter for bladder management . is dependent on staff for care of catheter . The Care Plan was not revised to reflect the accuracy and interventions for an indwelling foley catheter. e. On 04/26/23 at 9:02 AM, the Surveyor asked the MDS Coordinator why should indwelling foley catheters be care planned. The MDS Coordinator replied, So everybody is aware of what to watch out for. The Surveyor asked who was responsible for updating the Care Plans. The MDS Coordinator, Me and my partner. 2. Resident #61 had diagnoses of Parkinson's Disease and Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Annual MDS with and ARD of 04/17/23 documented the resident scored 14 (13 to 15 indicates cognitively intact) on a BIMS and required limited physical assistance of one person for personal hygiene and limited physical assistance with transfer only for bathing. a. The Care Plan with a revision date of 07/05/23 documented, .has an ADL self-care performance deficit . BATHING/SHOWERING: The resident requires limited assistance x [times] 1 staff with bathing/showering as scheduled and as necessary . PERSONAL HYGIENE: The resident requires limited assistance x 1 staff with personal hygiene and oral care . The Care Plan does not address the refusal of bathing, showers, or removal of facial hair. b. On 04/25/23 at 9:32 AM, Resident #61 was lying in bed with chin hair ¾ inches long. c. On 04/27/23 at 11:23 AM, Resident #61 was lying in bed. The Surveyor asked how much assistance she needed for showers/bathing and personal grooming. She stated, Well, I try to do as much for myself as I can, but I'm afraid I will fall, so I have someone in there with me at all times. I wash myself but they scrub my hair real good. The Surveyor asked if she received help with removal of facial hair in the shower. She stated, They ask me if they can shave it, but I don't like their razors. d. On 04/27/23 at 11:40 AM, the Surveyor asked Certified Nursing Assistant (CNA) #11 if Resident #61 ever refused showers/bathing. She stated, Sometimes but not often. The Surveyor asked if Resident #61 refused the removal of facial hair. She stated, Yes, she doesn't like the razors that we use. e. On 04/27/23 at 11:47 AM, the Surveyor asked the Director of Nursing (DON) if she was familiar with Resident #61. She stated, Yes. The Surveyor asked if Resident #61 ever refused showers or care such as facial hair removal. She stated, She does refuse care at times. The Surveyor asked if the Care Plan should include refusal of care. She stated, Yes. 3. Resident #72 had diagnoses of Other Spondylosis with Radiculopathy and Lumbar Region to Muscle Wasting and Atrophy, not Elsewhere Classified, Multiple Sites. The Quarterly MDS with an ARD of 02/13/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and had functional limitation in range of motion (ROM) to both the upper and lower extremities. a. A Physicians Order dated on 02/03/23 documented, RNA [Restorative Nursing Assistant] RNP [Restorative Nursing Program]- Bar Splints to BUE [Bilateral Upper Extremities] hands with PROM [Passive Range of Motion]/Joint mobility and sustained stretches X10 X10 Seconds. Splints to be donned by RNA X 2 hours to tolerance one time only . for 12 weeks . b. A Physicians Order dated on 02/03/23 documented, RNA RNP-Pegs -Have patient place and pull X 15 pegs to patient tolerance 3X/week to promote FM [fine motor] coordination for 12 weeks . c. As of 04/24/23 at 3:42 PM, the Care Plan did not address limited range of motion or use of Bar splints and PEGS. d. On 04/25/23 at 9:13 AM, the Surveyor asked Licensed Practical Nurse (LPN) #6 about Resident #72's Physician Order concerning her bilateral hand splints and if she was wearing them for her contractures. LPN #6 stated, She had splints, but she broke out in sores between her fingers. They were going to test her this week and see if she can resume wearing the splints. 4. Resident #79 had diagnoses of Chronic Diastolic (Congestive) Heart Failure and Acute and Chronic Respiratory Failure with Hypoxia. The Significant Change MDS with an ARD of 03/27/23 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a BIMS and received oxygen therapy. a. A Physicians Order dated 03/20/23 documented, Change 02 tubing and bottle Q [every] Friday night . b. A Physician Order dated of 04/24/23 documented, May wear O2 [oxygen] at 2L/NC [liters via nasal cannula] for SOB [shortness of breath] as needed . c. The Care Plan with a revision date of 04/12/23 did not address oxygen therapy. d. On 04/26/23 at 9:37 AM, the Surveyor asked the MDS Coordinator why Resident #79's oxygen was not care planned. The MDS Coordinator replied, I can't tell you why it's not, but I'll look to make sure. If it's not, it's being put in right now. e. On 04/26/23 at 10:37 AM, the Surveyor asked the Infection Control Prevention (ICP) why oxygen should be care planned. The ICP replied, So we all know their plan of care. f. On 04/27/23 at 10:23 AM, the Surveyor asked the DON why oxygen should be care planned. The DON replied, The Care Plan is accessible to all staff and tells you how to take care of the resident with interventions. g. On 04/27/23 at 10:54 AM, the Surveyor asked the Administrator why oxygen should be care planned. The Administrator replied, So we ensure they are receiving adequate care. 5. The facility policy titled, Care Plans - Comprehensive, provided by the Administrator on 04/25/23 at 1:50 PM documented, .3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk facts factors associated with identified problems. c. Build on resident's strengths. d. Reflect the resident's expressed wishes regarding care and treatment goals. e. Reflect treatment goals, timetables, and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. g. Aid in preventing or reducing declines in the residential's functional status and/or functional levels. h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program and; i. Reflect currently recognized standards of practice for problem areas and conditions . 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .

Based on observation, interview, and record review, the facility failed to ensure residents with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, as evidenced by failure to ensure physician ordered interventions were consistently implemented to promote healing and prevent new ulcers from developing for 1 (Resident #84) of 3 (Residents #5, #54 and #84) sampled residents who had pressure ulcer. This failed practice had the potential to affect 5 residents according to a list provided by the Director of Nursing (DON) on 04/25/23 at 2:11 PM. The findings are: 1. Resident #84 had diagnoses of Alzheimer Disease, Acute Respiratory Failure with Hypoxia, and Chronic Kidney Disease, Stage 3. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/23 documented the resident scored 4 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was at risk for developing pressure ulcers/injuries, had one or more unhealed pressure ulcers/injuries and required a pressure reducing device for his chair; turning/repositioning program; nutrition or hydration intervention to manage skin problems and pressure ulcer/injury care. a. The Care Plan with a revision date of 01/30/23 documented, The resident has potential for pressure ulcer development r/t [related to] limited mobility d/t [due to] hx [history] of Stroke, some incontinence . Follow facility policies/protocols for the prevention/treatment of skin breakdown . b. A Physicians Order dated 04/10/23 documented, Float bilat [bilateral] heels in bed with pillows to offload every shift . c. A Physicians Order dated 04/11/23 documented, Apply skin prep to left heel unstageable pressure daily and offload every day shift for 14 Days . d. On 04/24/23 at 2:35 PM, Resident #84 was lying on top of the bedspread covered with a blanket, on a regular mattress. No pillow(s) were under his lower legs and his left heel was on the mattress. e. On 04/24/23 at 3:14 PM, Resident #84 was lying on top of the bedspread covered with a blanket, on a regular mattress. No pillow(s) were under his lower legs and his left heel was on the mattress. f. On 04/24/23 at 3:56 PM, Resident #84 was lying on top of the bedspread covered with a blanket, on a regular mattress. No pillow(s) were under his lower legs and his left heel was on the mattress. g. On 04/25/23 at 1:44 PM, Resident #84 lying on top of the bedspread covered with a blanket, on a regular mattress. No pillow(s) were under his lower legs and his left heel was on the mattress. h. On 04/25/23 at 2:55 PM, the Surveyor watched the Treatment Nurse provide wound care to Resident #84 with no negative findings. i. On 04/26/23 at 9:03 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 why Resident #84's heels were to be floated. LPN #2 replied, To keep breakdown from happening. The Surveyor asked who was responsible for ensuring Physician Orders were followed related to the floating of Resident #84's heels. LPN #2 replied, The nurse. j. On 04/26/23 at 10:37 AM, the Surveyor asked the Infection Control Prevention (ICP) why Resident #84's heels were to be floated. The ICP replied, To reduce pressure. The Surveyor asked who was responsible for ensuring Physician Orders were followed related to the floating of Resident #84's heels. The ICP replied, Nurses and the CNAs [Certified Nursing Assistant] . k. On 04/27/23 at 10:23 AM, the Surveyor asked the Director of Nursing (DON) why Resident #84's heels were to be floated. The DON replied, To prevent pressure ulcers and breakdown of the heels. The Surveyor asked who was responsible for ensuring Physician Orders were followed related to the floating of Resident #84's heels. The DON replied, Nurses ensure, the nursing staff. The Surveyor asked why the Physician Orders should be followed. The DON replied, To provide the best care. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to the concerns found during this survey? The DON replied, I expect them to follow them 100%. l. On 04/27/2023 at 10:54 AM, the Surveyor asked the Administrator why Resident #84's heels were to be floated. The Administrator replied, To prevent pressure. The Surveyor asked who was responsible for ensuring Physician Orders were followed related to the floating of Resident #84's heels. The Administrator replied, The CNAs and nurses. The Surveyor asked why the Physician Orders should be followed. The Administrator replied, To ensure we're providing adequate care. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the CMS guidelines related to the concerns found during this survey? The Administrator replied, I expect they follow the rules. m. A facility policy titled, Prevention of Pressure Ulcers, provided by the Administrator on 04/25/23 at 1:50 PM documented, Purpose The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Preparation Review the resident's care plan to assess for any special needs of the resident. General Guidelines . 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 3.If pressure ulcers are not treated when discovered, they quickly get larger . 4. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin . 5. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident . Interventions and Preventive Measures: General11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate .

Based on observation, interview, and record review, the facility failed to ensure residents with suprapubic/indwelling foley catheters received care and treatment in accordance with professional standards of nursing practices for 2 (Residents #54 and #79) of 3 (Residents #42, #54 and #79) sampled residents, as evidenced by failure to ensure the indwelling foley catheter drainage bag and tubing was contained and off the floor for Resident #79; and failed to ensure Residents #54's indwelling foley catheter/tubing/anti-reflux chamber were free of sediment to prevent cross contamination and possible infections. This failed practice had the potential to affect 6 residents according to a list provided by the Administrator on 04/25/23 at 1:50 PM. The findings are: 1. Resident #54 had diagnoses of Dementia, Respiratory Failure, Pneumonia, Retention of Urine, and Staphylococcus. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. The Care Plan with a revision date of 01/04/23 documented, .ADL [activities of daily living] self-care performance deficit r/t [related to] weakness/decline in function . has an indwelling foley catheter for bladder management . is dependent on staff for care of catheter . b. A Physicians Order dated of 02/12/23 documented, May flush Foley catheter with 60 cc of Normal Saline PRN [as needed] d/t [due to] occlusion every 8 hours as needed . c. A Physicians Order dated 02/12/23 documented, May have foley catheter change monthly on the 16th every day shift starting on the 16th and ending on the 16th every month . d. A Physicians Order dated of 02/13/23 documented, Foley catheter 16 fr [french] 30 cc [cubic centimeters] . e. On 04/24/23 at 11:42 AM, Resident #54 was lying in bed. An foley catheter bag was attached to bed frame. The foley catheter tubing contained a white/yellow sediment. The anti-reflux chamber was crusted with white/yellow sediment. f. On 04/25/23 at 9:22 AM, Resident #54 was lying in bed. A foley catheter bag was attached to the bed frame. The foley catheter tubing contained a white/yellow sediment. The anti-reflux chamber was crusted with white/yellow sediment. g. On 04/26/23 at 10:25 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 why should indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. LPN #3 replied, Sediment can be a sign of occlusion and it could lead to infection. The Surveyor asked who was responsible for ensuring Resident #54's indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. LPN #3 replied, The nurse. h. On 04/26/23 at 10:37 AM, the Surveyor asked the Infection Control Prevention (ICP) why should indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. The ICP replied, To allow proper drainage. The Surveyor asked who was responsible for ensuring Resident #54's indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. The ICP replied, The nurse. i. On 04/27/23 at 10:23 AM, the Surveyor asked the Director of Nursing (DON) why should indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. The DON replied, Infection control. The Surveyor asked who was responsible for ensuring Resident #54's indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. The DON replied, The charge nurse. j. On 04/27/23 at 10:54 AM, the Surveyor asked the Administrator why should indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. The Administrator replied, Infection risk. The Surveyor asked who was responsible for ensuring Resident #54's indwelling foley catheter tubing and the anti-reflux chamber be free of white/yellow sediment. The Administrator replied, The nurse. 2. Resident #79 had diagnoses of Urinary Tract Infection, Heart Failure and Dementia. The Significant Change MDS with an ARD of 03/27/23 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a BIMS and had an indwelling catheter. a. A Physicians Order dated 03/17/23 documented, Foley - change foley cath [catheter] . every day shift on the 14th and ending on the 14th every month . b. The Care Plan with a revision date of 03/30/23 documented, .has an ADL [activity of daily living] self-care performance deficit r/t [related to] Confusion, Dementia, weakness . has an indwelling foley catheter . c. On 04/25/23 at 1:08 PM, Resident #79 was lying in bed. An indwelling foley catheter bag was lying in the floor on the left side of the bed. d. On 04/25/2023 at 1:21 PM, Resident #79 was lying in bed. An indwelling foley catheter bag was lying in the floor on the left side of the bed. e. On 04/25/23 at 1:23 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4 why a resident's indwelling foley catheter should not be in the floor. CNA #4 replied, Bacteria. The Surveyor asked how should a resident's indwelling foley catheter be positioned when the residents are in the bed. CNA #4 replied, On the rail of the bed, not touching the floor. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheters were not in the floor. CNA #4 replied, The CNAs. The Surveyor asked have you been trained on how to care for residents with indwelling foley catheters. CNA #4, replied, Yes. f. On 04/25/23 at 01:24 PM, the Surveyor asked CNA #5 why a resident's indwelling foley catheter should not be in the floor. CNA #5 replied, Risk of infection. The Surveyor asked how should a resident's indwelling foley catheter be positioned when the residents are in the bed. CNA #5 replied, On the bedside rail, not touching the floor. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheter were not in the floor. CNA #5 replied, The CNA's. The Surveyor asked, Have you been trained on how to care for residents with indwelling foley catheters? CNA #5 replied, Yes. g. On 4/25/2023 at 01:26 PM, the Surveyor asked CNA #6 why a resident's indwelling foley catheter should not be in the floor. CNA #6 replied, Bacteria, the risk of infection, and it should be lower than the bladder for proper flow. The Surveyor asked how a resident's indwelling foley catheter should be positioned when the residents are in the bed. CNA #6 replied, On the bed rail. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheter were not in the floor. CNA #6 replied, CNAs. The Surveyor asked, Have you been trained on how to care for residents with indwelling foley catheters? CNA #6 replied, Yes. h. On 4/26/2023 at 09:02 AM, the Surveyor asked the MDS Coordinator why a resident's indwelling foley catheter should not be in the floor. The MDS Coordinator replied, Infection, they could pull them out. The Surveyor asked where a resident's indwelling foley catheter should be positioned when the resident is in the bed. The MDS Coordinator replied, Never in the floor. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheters were not in the floor. The MDS Coordinator replied, Everybody. The Surveyor asked have staff been trained in foley catheter care and positioning. The MDS Coordinator replied, Yes. i. On 04/26/23 at 9:03 AM, the Surveyor asked LPN #2 why a resident's indwelling foley catheter should not be in the floor. LPN #2 replied, Infection. The Surveyor asked where a resident's indwelling foley catheter should be positioned when the resident is in the bed. LPN #2 replied, Below the bladder, on the bed rail. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheters were not in the floor. LPN #2 replied, Everybody. The Surveyor asked have staff been trained in foley catheter care and positioning. LPN #2 replied, Yes. j. On 4/26/2023 at 10:37 AM, the Surveyor asked the (ICP) why a resident's indwelling foley catheter should not be in the floor. The ICP replied, Risk of infections. The Surveyor asked where a resident's indwelling foley catheter should be positioned when the resident is in the bed. The ICP replied, Not in the floor. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheters were not in the floor. The ICP replied, All nursing staff. The Surveyor asked have staff been trained in foley catheter care and positioning. The ICP replied, Yes. k. On 04/27/23 at 10:23 AM, the Surveyor asked the DON why a resident's indwelling foley catheter should not be in the floor. The DON replied, It's infection control. The Surveyor asked where a resident's indwelling foley catheter should be positioned when the resident is in the bed. The DON replied, Below the bladder. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheters were not in the floor. The DON replied, Nursing staff. The Surveyor asked have staff been trained in foley catheter care and positioning. The DON replied, Yes. The Surveyor asked. What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to the concerns found during this survey? The DON replied, I expect them to follow them 100%. l. On 04/27/23 at 10:54 AM, the Surveyor asked the Administrator why a resident's indwelling foley catheter should not be in the floor. The Administrator replied, Risk of infection. The Surveyor asked where a resident's indwelling foley catheter should be positioned when the resident is in the bed. The Administrator replied, Hung on the bed rail. The Surveyor asked who was responsible for ensuring the residents indwelling foley catheters were not in the floor. The Administrator replied, CNAs and nurses. The Surveyor asked have staff been trained in foley catheter care and positioning. The Administrator replied, Yes. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the CMS guidelines related to the concerns found during this survey? The Administrator replied, I expect they follow the rules. 3. A facility policy titled, Catheter Care, Urinary, provided by the Administrator on 04/25/23 at 1:50 PM documented, Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections . Maintaining Unobstructed Urine Flow 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . Infection Control b. Be sure the catheter tubing and drainage bag are kept off the floor . Changing Catheters 1.it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . Managing Obstruction 1. If the catheter material is contributing to obstruction, notify the physician and change the catheter if instructed to do so. 2. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction .

Based on observation, record review, and interview, the facility failed to ensure Oxygen (O2) was running at the prescribed rate as ordered by the physician and the humidifier and tubing were dated and properly stored in a closed bag or container when not in use, to prevent potential cross contamination that could result in respiratory infections for 5 (Residents #24, #54, #67, #79 and #84) of 11 (Residents #5, #12, #24, #25, #26, #41, #54 #67, #79, #84 and #342 ) sampled residents who required O2. This failed practice had the potential to affect 21 residents who required O2 according to a list provided by the Administrator on 04/27/23 at 1:05 PM. The findings are: 1. Resident #24 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure with Hypercapnia. The Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 03/14/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. A Physicians Order with a start date of 03/10/23 documented, change and date oxygen water bottle and tubing q [every] week on 11-7 [11:00 PM to 7:00 AM shift] . b. A Physicians Order with a start date of 04/24/23 documented, may have O2 at 2.5 liters/minute] via n/c [nasal cannula] for sob [shortness of breath] prn [as needed] . c. A Care Plan with revision date of 04/03/23 documented, .has a Dx [diagnosis] of COPD, Chronic Respiratory Failure, and is at risk for complications . Oxygen Settings: O2 via nasal canula per orders . d. On 04/24/23 at 11:27 AM, Resident #24 was lying in bed at a 90-degree angle. An oxygen concentrator was in the room running at 4 to 4.5 liters per minute through a nasal cannula. The oxygen tubing is not dated. e. On 04/24/23 at 2:58 PM, the Surveyor asked the Director of Nursing (DON), How many liters of oxygen is Resident #24 receiving. She stated, She is on between four and five. The Surveyor asked how many liters were ordered. The DON stated, I don't know. The Surveyor asked should the oxygen tubing be dated. The DON stated, Yes. f. On 04/25/23 at 9:02 AM, Resident #24 was sitting in a wheelchair. The Surveyor asked her if she uses O2. Resident #24 stated she does not use O2 when sitting up in her chair. 2. Resident #54 had diagnoses of Dementia, Respiratory Failure and Pneumonia. The Significant Change MDS with an ARD of 02/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and received oxygen therapy. a. A Care Plan with a revision date of 01/04/23 documented, . COPD/ chronic resp [respiratory] failure . and recent pneumonia with risk for complications . Oxygen Setting: O2 via nasal cannula per orders . b. A Physicians Order dated 02/12/23 documented, May have 02 @ [at] 4 l/m (liters per minute) via n/c prn . c. A Physicians Order dated 02/12/23 documented, Change and date O2 tubing and water bottle Q week on 11-7 every night shift every Fri [Friday] . d. On 04/24/23 at 11:41 AM, Resident #54 was lying in bed receiving oxygen at 4.5 liters per minute via nasal cannula. The oxygen tubing and humidifier bottle were not dated. 3. Resident #67 had diagnoses of Pneumonia, Unspecified Organism and Chronic Respiratory Failure with Hypoxia. The admission MDS with an ARD of 04/06/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and received oxygen therapy. a. A Care plan with a revision date of 04/10/23 documented, The resident has altered respiratory status/difficulty breathing r/t [related to] Anxiety, Chronic Resp Failure . Oxygen Settings: O2 via nasal canula per orders. b. A Physicians Order dated 04/24/23 documented, May wear O2 at 2L/NC [liters per nasal cannula] every shift. c. A Physicians Order dated 04/24/23 documented, Change and date O2 tubing every night shift every Fri . d. On 04/24/23 at 11:48 AM, Resident #67 was lying in bed receiving O2 via NC at 3.5 liters. The O2 tubing was not dated, and no storage bag was present. e. On 04/24/23 at 2:55 PM, the Surveyor asked the Director of Nursing (DON), How many liters of oxygen is [Resident #67] receiving? She stated, Three and a half liters. The Surveyor asked, Do you know how many liters of oxygen are ordered for [Resident #67]? She stated, I do not. The Surveyor asked, Should the oxygen tubing be dated? She stated, Yes. The Surveyor asked, Should there be a storage bag present? She stated, Yes. 4. Resident #79 had diagnoses of Chronic Diastolic (Congestive) Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia and Dementia. The Significant Change MDS with an ARD of 03/27/23 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a BIMS and received oxygen therapy. a. A Physicians Order dated 03/20/23 documented, Change O2 tubing and bottle Q Friday Night every night shift every Fri . b. The Care Plan with a revision date of 04/24/23 did not address oxygen therapy. c. A Physicians Order dated of 04/24/23 documented, May wear O2 at 2L/NC for SOB as needed . d. On 04/24/23 at 12:11 PM, Resident #79 was lying in bed with her eyes closed. An oxygen concentrator was running at 1.5 liters per minute. The O2 tubing was not dated, the humidification bottle was dated 04/17/23 and there was no storage bag present. e. On 04/24/23 at 3:00 PM, the Surveyor asked the DON, How many liters of oxygen is [Resident #79] receiving? The DON replied, One and a half. The Surveyor asked how many liters were ordered. The DON replied, I don't know. The Surveyor asked what the date was on the humidification bottle. The DON replied, April 17th. The Surveyor asked when the humidification bottle should be changed. The DON replied, At least within the last seven days. The Surveyor asked if the oxygen tubing should be dated. The DON replied, Yes, it should. The Surveyor asked if a storage bag should be present. The DON replied, Yes. 5. Resident #84 had diagnoses of Alzheimer Disease, Acute Respiratory Failure with Hypoxia, and Chronic Kidney Disease, Stage 3. The Medicare 5-Day MDS with an ARD of 03/03/23 documented the resident scored 4 (0-7 indicates severely cognitively impaired) on a BIMS and received oxygen therapy. a. A Physicians Order dated of 04/10/23 documented, May have 02 @ 3 liters/minute via NC PRN SOB . b. A Physicians Order dated of 04/10/23 documented, Change and date 02 water bottle and tubing Q week on 11-7 every night shift every Fri . c. A Care Plan with a revision date of 01/30/23 documented, The resident has potential for altered respiratory status/difficulty breathing . Administer medication/puffers as ordered . The Care Plan does not address oxygen therapy. d. On 04/24/23 at 2:34 PM, Resident #84 was lying in bed receiving oxygen at 3 liters per minute via nasal cannula. The humidifier bottle was empty. e. On 04/24/23 at 3:14 PM, Resident #84 was lying in bed receiving oxygen at 3 liters per minute via nasal cannula. The humidifier bottle was empty. 6. On 04/26/23 at 9:02 AM, the Surveyor asked the MDS Coordinator why residents should receive oxygen therapy as prescribed by the Physician. The MDS Coordinator replied, To prevent further complications and we should follow Physician Orders. The Surveyor asked who was responsible for ensuring a resident's oxygen was administered per the Physician Orders. The MDS Coordinator replied, The nurse. The Surveyor asked why the oxygen humidifier bottle should have water in it and the tubing/water bottle be dated. The MDS Coordinator replied, Comfort. The Surveyor asked who was responsible for ensuring the oxygen water bottles/tubing were changed/dated. The MDS Coordinator replied, The nurse. The Surveyor asked who was responsible for ensuring the oxygen humidifier bottles had water in them while the oxygen was running. The MDS Coordinator replied, The nurse. 7. On 04/26/23 at 9:03 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 why residents should receive oxygen therapy as prescribed by the Physician. LPN #2 replied, Comfort. The Surveyor asked who was responsible for ensuring a resident's oxygen was administered per the Physician Orders. LPN #2 replied, The nurse. The Surveyor asked why the oxygen humidifier bottle should have water in it and the tubing/water bottle be dated. LPN #2 replied, Infection, dry nasal passages. The Surveyor asked who was responsible for ensuring the oxygen water bottles/tubing were changed/dated. LPN #2 replied, The nurse. The Surveyor asked who was responsible for ensuring the oxygen humidifier bottles had water in them while the oxygen was running. LPN #2 replied, The nurse. 8. On 4/26/2023 at 10:37 AM, the Surveyor asked the Infection Control Prevention (ICP) why residents should receive oxygen therapy as prescribed by the Physician. The ICP replied, We don't want to give them more and we don't want to give them less. The Surveyor asked who was responsible for ensuring a resident's oxygen was administered per the Physician Orders. The ICP replied, The nurse. The Surveyor asked why the oxygen humidifier bottle should have water in it and the tubing/water bottle be dated. The ICP replied, It provides humidity, so they don't dry out, so we are in compliance with changing it out weekly. The Surveyor asked who was responsible for ensuring the oxygen water bottles/tubing were changed/dated. The ICP replied, The nurses. The Surveyor asked who was responsible for ensuring the oxygen humidifier bottles had water in them while the oxygen was running. The ICP replied, The nurse. 9. On 04/27/23 at 10:23 AM, the Surveyor asked the Director of Nursing (DON) why residents should receive oxygen therapy as prescribed by the Physician. The DON replied, To make sure the oxygen is in the range it's supposed to be in. The Surveyor asked who was responsible for ensuring the resident's oxygen is administered per the Physician Orders. The DON replied, The Charge Nurse. The Surveyor asked why the oxygen humidifier bottle should have water in it and the tubing/water bottle be dated. The DON replied, To make sure we're not using something too old. The Surveyor asked who was responsible for ensuring the oxygen water bottles/tubing were changed/dated. The DON replied, The Charge Nurse. The Surveyor asked who was responsible for ensuring the oxygen humidifier bottles had water in them while the oxygen was running. The DON replied, The nurse. The Surveyor asked why Physician Orders should be followed. The DON replied, To provide the best care. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to the concerns found during this survey? The DON replied, I expect them to follow them 100%. 10. On 04/27/23 at 10:54 AM, the Surveyor asked the Administrator why residents should receive oxygen therapy as prescribed by the Physician. The Administrator replied, So they're sats [saturation] don't drop and they can breathe. We don't want to over give it either. The Surveyor asked who was responsible for ensuring the resident's oxygen is administered per the Physician Orders. The Administrator replied, The nurse. The Surveyor asked why the oxygen humidifier bottle should have water in it and the tubing/water bottle be dated. The Administrator replied, To keep them from drying out, and it's to prevent infection control. The Surveyor asked who was responsible for ensuring the oxygen humidifier bottles had water in them while the oxygen was running. The Administrator replied, The nurse. The Surveyor asked why Physician Orders should be followed. The Administrator replied, To ensure we're providing adequate care. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the CMS guidelines related to the concerns found during this survey. The Administrator replied, I expect they follow the rules. 11. A facility policy named, Oxygen Administration, provided by the Administrator on 04/25/23 at 1:50 PM documented, . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation . l. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan . Steps in the Procedure 9. Place appropriate oxygen device on the resident . 10. Adjust the oxygen delivery so that it is comfortable for the resident and the proper flow of oxygen is being administered . 12. Check the mask, tank, humidifying jar, etc. [etcetera], to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through . 14. Periodically re-check water level in humidifying jar .

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 7 residents who received pureed diets as documented on the List Dietary Supervisor provided by the Food Service Supervisor on 04/25/23 at 9:21 AM. The findings are: 1. On 04/24/23 at 11:49 AM, Dietary Employee #2 placed 10 servings of cream ranch chicken breast into a blender, added thickener and pureed. She poured the pureed meat in a pan. She covered the pan with plastic wrap and placed it in the oven to serve to 7 residents who required pureed diets. The consistency of the pureed meat was gritty, not smooth, and it was dried. At 1:20 PM, the Surveyor asked Dietary Employee #2 to describe the consistency of the pureed meat and pureed dessert. She stated, Pureed meat could have been pureed a little more. It has piece of meat in it. Pureed dessert has lumps. A little more liquid on both pureed food items would have made them smoother. At 1:58 PM, the Surveyor asked Certified Nursing Assistant #3 to describe the consistency of the pureed meat and pureed dessert. She stated, They were both pretty dried. 2. On 04/25/23 at 7:35 AM, the pureed sausage served to the residents on pureed diets was gritty, not smooth, and the pureed biscuit served to the residents on pureed diets had lumps in it. At 7:57 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed sausage and pureed biscuit. She stated, They both needed to be pureed more. We are missing the blender lid seal that goes around the lid. We have ordered a new one and it will be here soon.

3. Resident #291 had diagnoses of Cellulitis of Right Lower Limb, Unspecified Severe Protein-Calorie Malnutrition, Sepsis, Unspecified Organism and Bacteremia. The admission MDS with an ARD of 04/19/23 was currently in progress. a. On 04/25/23 at 2:30 PM, Resident #291 was lying in bed. His bedside table still had his lunch tray on it. He stated, The main thing that upsets me now is the fact that when they deliver my meals, they bring it in, put it on my table there, and start opening up all my stuff. I can open my own stuff and don't particularly want them to put my straws in my drinks. They don't even have on gloves and how do I know if they washed their hands or not. b. On 04/26/23 at 8:05 AM, Resident #291was lying in bed. Certified Nursing Assistant (CNA) #1 brought in Resident #291's breakfast tray and sat it on the bedside table. CNA #1 asked Resident #291 if he would like for her to open his milk. Resident #291 stated, Yes, please. She started to open the milk carton when the Surveyor stopped her. The Surveyor asked CNA #1, What should you do between residents when setting up their meals? She stated, Use hand sanitizer. The Surveyor asked, Did you use alcohol-based hand sanitizer [ABHR] before setting up Resident #291's tray? She stated, No. The Surveyor asked, Why is it important to use ABHR between residents? She stated, To prevent cross contamination. c. On 04/27/23 at 11:48 AM, the Surveyor asked the DON if staff should wash their hands or use ABHR before passing out the resident's meal trays. She stated, Yes. The Surveyor asked, What is the importance of hand hygiene between residents, especially when passing meal trays? She stated, Cross contamination. d. A facility policy titled, Handwashing/Hand Hygiene, provided by the Administrator on 04/25/23 at 1:50 PM documented, .Policy Interpretation and Implementation . 2. All personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors . 7.o. Before and after eating or handling food; p. Before and after assisting a resident with meals . Based on observation, interview, and record review, the facility failed to ensure visitors wore personal protective equipment while visiting a resident on contact isolation for 1 (Resident #54); staff performed hand hygiene and/or changed gloves during incontinent care for 1 (Resident #58); and staff performed hand hygiene before serving/setting up of a meal tray for 1 (Resident #291) of 3 (Residents #54, #58 and #291) sampled residents. This failed practice had the potential to affect 87 residents according to the Census and Conditions of Residents provided by the Administrator on 04/24/23 at 11:52 a.m. The findings are: 1. Resident #54 had diagnoses of Dementia, Respiratory Failure, Pneumonia, and Staphylococcus. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was not on isolation or quarantine for an active infectious disease. a. A Physicians Order dated 04/14/23 documented, Place in contact isolation precautions d/t [due to] STAPH urethra . b. On 04/24/23 at 11:32 AM, Resident #54 was lying in bed. A Contact Isolation sign was on the doors. An isolation bin with personal protective equipment (PPE) was sitting in the hall outside of the resident's room. A visitor was observed from the doorway with no PPE on while in the room. c. On 04/26/23 at 10:25 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 why Resident #54 was on Contact Isolation. LPN #3 replied, Staphylococcus in the wound/catheter drainage. The Surveyor asked what personal protective equipment was worn while in Resident #54's room. LPN #3 replied, Gloves and a gown. The Surveyor asked who was supposed to wear PPE while in Resident #54's room. LPN #3 replied, Everybody. The Surveyor asked if it included visitors. LPN #3 replied, Yes. d. On 04/26/23 at 10:37 AM, the Surveyor asked the Infection Control Prevention (ICP) why Resident #54 was on Contact Isolation. The ICP replied, Staph on the drainage of the urethrae area. The Surveyor asked what PPE was to be worn while in the room. The ICP replied, Gloves and gown for Contact Isolation. The Surveyor asked who was supposed to wear PPE while in Resident #54's room. The ICP replied, Everybody that goes in. The Surveyor asked if it included visitors. The ICP replied, Yes. e. On 04/27/23 at 9:09 AM, the Surveyor asked Certified Nursing Assistant (CNA) #10 why Resident #54 was on Contact Isolation. CNA #10 replied, Staph. The Surveyor asked what PPE was to be worn while in the room. CNA #10 replied, Gloves and a gown. The Surveyor asked who was supposed to wear PPE while in the room. CNA #10 replied, Everybody. The Surveyor asked if it included visitors. CNA #10 replied, Yes. f. On 04/27/23 at 9:10 AM, the Surveyor asked CNA #1 why Resident #54 was on Contact Isolation. CNA #1 replied, Staph. The Surveyor asked what PPE was to be worn while in the room. CNA #1 replied, Gloves and a gown. The Surveyor asked who was supposed to wear PPE while in Resident #54's room. CNA #1 replied, Everybody. The Surveyor asked if it included visitors. CNA #1 replied, Yes. g. A document provided by the Director of Nursing (DON) on 04/27/23 at 9:25 AM titled, .Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multi-drug resistant Organisms (MDROs) documented, .Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room . h. On 04/27/23 at 10:23 AM, the Surveyor asked the DON why Resident #54 was on Contact Isolation. The DON replied, Staph in wound on the peri area. The Surveyor asked what PPE was to be worn while in the room. The DON replied, Gown and gloves. The Surveyor asked who was supposed to wear PPE while in Resident #54's room. The DON replied, Everybody. The Surveyor asked if it included visitors. The DON replied, Yes. The Surveyor asked why PPE was to be worn in Resident #54's room. The DON replied, To prevent the spread of infection. i. On 04/27/23 at 10:54 AM, the Surveyor asked the Administrator why Resident #54 was on Contact Isolation. The Administrator replied, I'm not positive. The Surveyor asked what PPE was to be worn while in Resident #54's room. The Administrator replied, Gown and gloves. The Surveyor asked who was supposed to wear PPE while in the room. The Administrator replied, Anyone who enters the room. The Surveyor asked if it included visitors. The Administrator replied, Yes. The Surveyor asked why PPE was to be worn in Resident #54's room. The Administrator replied, To prevent the spread of infection. j. A facility policy titled, Infection Control Guidelines for All Nursing Procedures , provided by the Administrator on 04/25/23 at 1:50 PM documented, .Purpose To provide guidelines for general infection control while caring for residents . General Guidelines 1. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 2. Transmission-Based Precautions will be used whenever measures more stringent that Standard Precautions are needed to prevent the spread of infection . 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials . 2. Resident #58 had diagnoses of Dementia, Alzheimer's Disease and Kidney Disease. The 5-day MDS with an ARD of 03/18/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS required extensive physical assistance of two plus persons for toilet use and was occasionally incontinent of bladder and frequently incontinent of bowel. a. The Care Plan with a revision date of 05/23/22 documented, .has an ADL [activity of daily living] self-care performance deficit . the resident requires extensive assistance x [times] 2 staff for toileting . b. On 04/24/23 at 11:18 AM, Certified Nursing Assistant (CNA) #8 released the adhesive of the left side of Resident #58's brief. CNA #7 and CNA #8 removed the resident ' s shoes and pants. CNA #7 and CNA #8 did not removed gloves and did not perform hand hygiene. CNA #7 wiped the front of the resident's peri area with 1 wipe on the right side then discarded and continued this process 3 times. CNA #7 wiped the residents buttock containing bowel movement with 1 wipe then discarded and continued this process 3 times. CNA #7 discarded the dirty brief in the trash. CNA #7 placed a clean brief under the resident, the resident rolled onto his side, and CNA #8 pulled the brief up on her side. CNA #7 then pulled the resident's brief up in the front and secured it. CNA #7 did not change her dirty gloves and did not perform hand hygiene before she placed or secured the clean brief. c. On 04/26/23 at 10:25 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 when hand hygiene should be performed after providing incontinent care on a resident who has had a bowel movement. LPN #3 replied, Before and after care. The Surveyor asked when gloves should be changed after performing incontinent care on a resident who has had a bowel movement. LPN #3 replied, If soiled, change them, and wash hands when done with care. The Surveyor asked why dirty gloves should be changed before securing a resident's clean brief. LPN #3 replied, Because of cross contamination. d. On 04/26/23 at 10:37 AM, the Surveyor asked the Infection Control Prevention (ICP) when hand hygiene should be performed after providing incontinent care on a resident who has had a bowel movement. The ICP replied, Before I applied the clean brief. The Surveyor asked when gloves should be changed after performing incontinent care on a resident who has had a bowel movement. The ICP replied, After the dirty and before applying the clean brief or linen. The Surveyor asked why dirty gloves should be changed before securing a resident's clean brief. The ICP replied, It could have bacteria. e. On 04/27/23 at 10:23 AM, the Surveyor asked the Director of Nursing (DON) when hand hygiene should be performed after providing incontinent care on a resident who has had a bowel movement. The DON replied, Before, during, change gloves, and after. The Surveyor asked when gloves should be changed after performing incontinent care on a resident who has had a bowel movement. The DON replied, After done wiping. The Surveyor asked why dirty gloves should be changed before securing a resident's clean brief. The DON replied, It could cause cross contamination. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to the concerns found during this survey? The DON replied, I expect them to follow them 100%. f. On 04/27/23 at 10:54 AM, the Surveyor asked the Administrator when hand hygiene should be performed after providing incontinent care on a resident who has had a bowel movement. The Administrator replied, After you finish cleaning the bowel movement, and before placing the clean brief. The Surveyor asked when gloves should be changed after performing incontinent care on a resident who has had a bowel movement. The Administrator replied, Change gloves after you're done with the dirty, then put on clean gloves before doing clean. The Surveyor asked why dirty gloves should be changed before securing a resident's clean brief. The Administrator replied, Cross contamination. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the CMS guidelines related to the concerns found during this survey? The Administrator replied, I expect they follow the rules. g. A facility policy titled, Handwashing/Hand Hygiene, provided by the Administrator on 04/25/23 at 1:50 PM documented, .This facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. Wash hands with soap . and water for the following situations: a. When hands are visibly soiled . 7. Use an alcohol-based hand rub . or alternatively, soap . and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids . 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] L Based on record review, and interview, the facility failed to ensure education provided to residents/responsible parties regarding the benefits and potential side effects associated with COVID-19 vaccines and the residents/responsible parties' choice was documented in the facility's electronic medical records for 3 (Residents #60, #72 and #86) of 5 (Residents #60, #72, #86, #291 and #342) sampled residents whose immunization records were reviewed for COVID-19 vaccine information to ensure residents were able to make informed decisions as to whether or not to receive the vaccine. The findings are: 1. The Positive Residents and Staff list provided by the Director of Nursing (DON) on 04/24/23 at 3:36 PM documented the facility had 1 resident and 1 staff member test positive for COVID-19 within the last four weeks. 2. On 04/24/23 at 3:36 PM, the Director of Nursing (DON) provided a list of the resident ' s vaccination status. On the list there were 15 residents who had refused the vaccine. Residents #60, #72 and #86 were reviewed. 3. On 04/25/23 at 8:30 PM, Resident immunization records were reviewed with the following results: a. Resident #60 had diagnoses of Parkinson's Disease and Type II Diabetes Mellitus without Complications. Resident #60's Immunization History contained no documentation regarding the COVID-19 immunization. The Medical Record contained no documentation to indicate the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine or documentation of the resident's or representative's decision regarding receiving the vaccination. b. Resident #72 had diagnoses of Adult Failure to Thrive and Chronic Obstructive Pulmonary Disease. Resident #72's Immunization History listed refused regarding the COVID-19 immunization. The Medical Record contained no documentation to indicate the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine or documentation of the resident's or representative's decision regarding receiving the vaccination. c. Resident #86 had diagnoses of Unspecified Dementia and Type II Diabetes Mellitus without Complications. Resident #86's Immunization History contained no documentation regarding the COVID-19 immunization. The Medical Record contained no documentation to indicate the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine or documentation of the resident's or representative's decision regarding receiving the vaccination. 4. On 04/26/23 at 8:35 AM, the Surveyor asked the Infection Control and Preventionist (ICP) if she was responsible for the resident's COVID-19 vaccinations. The ICP stated, No, [DON] handles that. 5. On 04/26/23 at 8:53 AM, the Surveyor asked the DON if she could locate resident education, declinations, or consents for Residents #60, #72 and #86. The DON stated, I'm with you. I don't see any in there for any of them, and they have not received them. The Surveyor asked if education, declinations, or consents should be documented in the Electronic Health Records. The DON stated, Yes ma'am, there should be. The Surveyor asked what the outcome could be if they are not documented. The DON stated, We don't know if they want them, and they could get COVID. 6. The facility policy titled, COVID-19 Vaccine Policies and Procedures , provided by the Administrator on 04/24/23 at 3:38 PM documented, .Purpose Maximizing COVID-19 vaccination rates in the facility will help reduce the risk residents and staff have of contracting and spreading COVID-19 . Responsibility Nursing home leadership is responsible for developing, implementing, and maintaining these policies and procedures . Offering the COVID-I9 Vaccine COVID-19 vaccinations will be offered to all staff and resident's . All staff and residents/representatives will be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including information on the benefits and risks . Documenting COVID-I9 Vaccine, The Facility will maintain documentation for all residents and staff on COVID-19 vaccinations . The information to be documented includes: The staff person, resident or representative was provided the education regarding the benefits and potential risks associated with the COVID-19 vaccine. Whether the staff person, resident/representative consented to the vaccine . reason for refusal . Contraindication Refusal For staff or residents who refuse, the facility will ask that individual to sign a COVID-19 vaccine declination form and main copy of the form .

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure 1 of 1 dietary staff washed their hands before handling clean equipment. These failed practices had the potential to affect 86 residents who received meals from the kitchen (total census: 86) as documented on a list provided by Dietary Supervisor on 04/25/23. The findings are: 1. On 04/24/23 at 11:09 AM, the following observations were made in the walk-in the refrigerator: a. An unsealed open zip lock bag that contained slices of cheese. b. An opened box of cream cheese, the box was not covered and the bag holding the cheese was not sealed. c. There were forty-one cartons of whole milk with an expiration date of 04/22/23. 2. On 04/24/23 at 11:20 AM, the following observations were made in the walk-in freezer: a. An opened box of hamburger patties, the box was not covered or sealed. b. An opened box of corndogs, the box was not covered or sealed. c. An opened box of dinner roll and an opened box of sugar cookies, the boxes were not covered or sealed. d. An opened box of bread sticks, the box was not covered or sealed. 3. On 04/24/23 at 11:33 AM, Dietary Employee (DE) #1 pulled her pants up. Without washing her hands, she picked up glasses by their rims and placed them on the trays to be used for portioning beverages to be served to the residents for lunch. 4. On 04/24/23 at 11:37 AM, DE #2 used tissue papers to wipe off water around the hand washing sink. He picked up a clean blade and attached to the base of the blender, to be used to puree food items to be served to the residents for lunch. 5. On 04/24/23 at11:46 AM, DE #2 used tissue papers to dry off spilled water around the hand washing sink. Without with washing his hands, he picked up a clean blade and attached it to the base of the blender to be used to puree food items to be served to the residents for lunch meal. 6. On 4/24/23 at 12:15 PM, DE #1 used a key to open the janitor's closet and contaminated her hands. As she walked out of the janitor's closet and locked the door, she picked up a clean water heater metal at the tip that goes inside the coffee maker, inserted it, added loose coffee, and brewed. When she was ready to take it to the service area in the dining room kitchenette to serve to the residents for lunch meal, she was stopped immediately and asked what she should have done after touching dirty objects and before handing clean equipment. She stated, I contaminated the water heating metal when I had picked it up from the tip and placed it inside the coffee maker. I will throw that one away and make a new one. 7. On 4/24/23 at 12:16 PM, DE #2 used tissue papers to dry off spilled water around the hand washing sink. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used to puree food items to be served to the residents who had physician order for pureed diets. When he was about to place cauliflower into the blender, he was stopped and asked what should you have done after touching dirty objects and before handing clean equipment? He stated, I should have washed my hands. I will rewash it. 8. On 04/24/23 at 12:50 PM, DE #3 was wearing gloves on her hands. She removed boxes of salad, melon with pineapple, orange and grapes from the walk-in refrigerator and placed them on the counter. Without changing gloves and washing her hands, she picked up clean bowls with her gloved fingers inside the bowls and placed them on the trays. She then, placed mixed fruits inside the bowls to be served to the residents for supper. The Surveyor was asked, What should you have done after touching dirty objects and before handing clean equipment? She stated, I should have removed the gloves and washed my hands. 9. 9. The facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, provided by the Dietary Supervisor on 04/25/23 at 9:21AM documented, .6. Employees must wash their hands: .g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. After engaging in other activities that contaminate the hands .