Based on observations, interviews, record review, it was determined the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #72) of 27 sampled residents who were reviewed for MDS assessment accuracy. Specifically, the facility failed to ensure information regarding a resident's diagnosis reflected the resident's current condition. Findings include: A review of the Clinical Resident Profile, indicated the facility admitted Resident #72 on 11/09/2023 with a diagnosis of pneumonia. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2024, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident #72 had moderate cognitive impairment. Section I, subsection I2000, indicated an active diagnosis of pneumonia. A review of the Medical Diagnoses, revealed Resident #72 had a principal diagnosis of pneumonia, dated 10/31/2023. A review of a physician appointment dated 12/19/2023, indicated the reason for the visit was a nursing home follow-up and recent hospitalization for pneumonia and dementia care. A review of a physician appointment dated 07/08/2024, indicated the reason for the visit was a 6 week follow up nursing home visit for mental evaluation. A review of a physician appointment dated 09/04/2024, indicated the reason for the visit was a 6 week follow up nursing home visit for mental evaluation. A review of Resident #72's plan of care, with a target date of 11/06/2024, did not reveal a current focus, goal, or interventions for a respiratory infection. During an interview on 09/27/2024 at 1:33 PM, the MDS/Care Plan (CP) Coordinator stated MDS assessments are performed within 7 days, the look back period, of the ARD, and is responsible to accurately complete sections of the MDS, including Section I, to ensure residents are treated correctly. The MDS/CP Coordinator stated Resident #72's 08/19/2024 MDS assessment was completed in person in Resident #72's room, the day before. The MDS/CP Coordinator stated the last 7 days of orders were reviewed to determine the current diagnoses and changes were made at that time. The MDS/CP Coordinator stated Resident #72 was not receiving medication for pneumonia and did not have a current infection during the look back period, and the pneumonia diagnosis should have been resolved. The MDS/CP Coordinator stated there was no policy or procedure for completing a care plan or MDS and just reviewed certain things like activities and went section by section and looked up information needed and updated the care plan with new information. During an interview on 09/27/2024 at 1:55 PM, the Director of Nursing (DON) stated the nurses were responsible for assessments and the expectation is the assessment be completed in a timely manner, should be correct at the time it is done, at the time the nurse sees the resident. During an interview on 09/27/2024 at 1:50 PM, the Administrator stated the care plans and the MDS are completed in the first 24 hours. The nurse completes the assessment and the MDS Coordinator reviews and completes the MDS, after the review of the initial assessment, following the policy and procedure. During an interview on 09/27/2024 at 2:07 PM, Consultant #2 advised they do not have a policy and procedure for the MDS, the RAI Manual is used.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure an accurate care plan for 1 (Resident #50) of 27 sampled residents who were reviewed for a comprehensive care plan. Findings include: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, dated 03/2022, indicated each resident would have a care plan developed and implemented to meet their needs, no more than 21 days after admission, and include identification of care needs and objectives to meet the resident's highest physical, mental and psychosocial well-being. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Resident #50 did not exhibit mood disorders or behaviors; had active diagnoses that included mental health and stress disorders involving depression, mania, hallucinations, delusions, restlessness, and decision-making ability; and was receiving psychotropic medication. A review of the care plan with an admission date of 08/12/2024 and revision date of 08/18/2024, did not address Resident #50's diagnoses that included mental health and stress disorders involving depression, mania, hallucinations, delusions, restlessness, and decision-making ability. A review of the Order Summary Report, revealed Resident #50 was to be monitored for psychotropic drug side effects and was receiving psychotropic medications, with a start date of 08/12/2024. A review of Medication Administration Record [MAR], revealed Resident #50 had twice daily monitoring for antianxiety, antidepressant, and antipsychotic medications, with a start date of 08/12/2024. A review of admission Assessment, with an effective date of 8/12/2024, revealed Resident #50 had admitting diagnoses that included anxiety, depression, bipolar disorder, and schizophrenia; and was receiving antianxiety medications. During an interview on 09/27/2024 at 1:16 PM, the MDS/CP Coordinator stated care plans were done as part of the Minimum Data Set (MDS) on admission. The MDS/CP Coordinator stated at the time of admission the nurse was responsible for ensuring the initial assessment was completed accurately. The MDS/CP Coordinator stated there was no policy or procedure for completing the care plan or MDS, and reviewed certain things, section by section of the MDS and used resources to prepare Resident #50's care plan, that included review of the assessment for identified issues, meeting with the resident, speaking with the nurses and certified nursing assistants (CNAs), reviewing daily reports, past and present diagnoses, and if something was new, the care plan was updated. The MDS/CP Coordinator stated it was important for Resident #50's care plan to be accurate and reflect their needs to receive the most beneficial help to remain healthy, comfortable, be able to return home, or remain in the facility. During an interview on 09/27/2024 at 1:50 PM, the Administrator stated the care plans and MDS were done in the first 24 hours. The nurse completed the assessment and the MDS Coordinator reviewed and completed the MDS, after reviewing the initial assessment following the policy and procedure. During an interview on 09/27/2024 at 1:58 PM, the Director of Nursing (DON) stated the nurse should complete the admission assessment completely and accurately based on what the medications and abilities were when the resident came through the door because it helps the CNAs in knowing how care is provided to the resident.

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to include a cognitively impaired resident's representative in the care plan meetings for 1 (Resident #5) of 28 residents reviewed for development of comprehensive care plans. Findings include: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022 indicated that the interdisciplinary team (IDT) in conjunction with the resident or the resident's representative develops and implements the comprehensive care plan. As part of their resident's rights person-centered comprehensive care plans allow for resident or resident's representative participation in planning, resident goal and outcome setting, type, frequency, and duration of care, as well as request meetings, revision, and services. Notification of care plan meetings are provided in advance. Documentation in the resident's Electronic Health Record (EHR) should include steps taken to include the resident or resident's representative or an explanation of why it is not practicable for them to be included in the process. Comprehensive care plans are completed at admission, annually, and with a significant change in status. A review of the electronic health record (EHR) indicated the facility admitted Resident #5 with diagnoses that included senile degeneration of the brain, dementia, psychotic disturbances, and behavioral disturbances. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2024 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. The quarterly MDS with an ARD of 06/13/2024 revealed Resident #5 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. The significant change MDS with an ARD of 08/20/2024 revealed Resident #5 had a BIMS score of 8 which indicated the resident had moderate cognitive impairment. A review of Resident #5's care plan, revised on 09/09/2024, revealed the resident and the family will receive the support needed to successfully transition into a long-term care. Interventions included emotional support, but no mention was made to include resident or resident's representative in the care planning process. Goal and interventions were initiated on 03/08/204 and revised on 08/09/2024, following the care plan meetings without the resident or the resident's representative. During an interview on 09/25/2024 at 09:31 AM, Resident #5 ' s Power of Attorney (POA) stated there is a lot of confusion about the long-term care process which included expectations of the family and the facility. The POA expressed lack of communication of medication changes, fall prevention, and notification process; failed attempts to reach the Social Services Director (SSD) on the phone, and the office door was never open and the POA had no knowledge of what a care plan meeting was and had never been to one. During an interview on 09/27/2024 at 1:12 PM, the Minimum Data Set Coordinator/Care Plan Coordinator (MDS/CP Coordinator) stated regarding the notification of the care plan meeting process is they first develop next month's care plan list which is then given to the Social Services Director (SSD) about a week before the beginning of the month. The SSD then sends out a letter to the residents or their representatives. The MDS/CP Coordinator stated the SSD does all communication with the residents and their representatives and denies any knowledge of any documentation process by the SSD. The MDS/CP Coordinator stated the care plan meeting concerns were documented on paper and signed by all attendees then handed over to the SSD. During an interview on 09/27/2024 at 2:35 PM, the SSD stated the process for the resident representative's notification of a care plan meeting was an initial phone call the month prior to the meeting to ensure availability. If the SSD was unable to reach the representative, a letter was mailed out with the information. The SSD stated the initial phone call to Resident #5's POA resulted in a voicemail, with no verbal contact ever made. The SSD stated she did not document the attempt in the resident's EHR because they often forgot to chart. The SSD denied ever mailing a care plan notification letter to Resident #5's POA because she forgot. The SSD stated the care plan meeting notes were not available in the EHR because they were on paper in the SSD's Office and Resident #5's POA had never been to a care plan meeting, and it had never been discussed with the POA by the SSD.

During an observation on 09/24/2024 at 07:00 AM, Dietary [NAME] #7 used a #30 (1 ounce) black scoop for puree bread, a #20 (1.63 ounce) yellow scoop for puree egg, a #20 yellow scoop for puree sausage, a #16 (2 ounce) blue scoop for scrambled eggs, and a 120 (4 ounce) ladle for oatmeal. Review of the facility's Week 2 Menu stated measurements as follows: 1/4 cup egg. During an interview on 09/24/2024 at 09:00 AM, the Dietary Manager stated that scoop sizes were as follows: #20 yellow scoop equals 1.63 ounces; #16 blue scoop equals 2 ounces. The Dietary Manager stated that the scoop is filled all the way to the top. Following a measurement using the scoops used during the breakfast service, the Dietary Manager stated she was not aware the scoops used were not appropriate for the portions indicated on the facility provided menu. During an interview on 09/24/2024 at 09:00 AM, the Dietary Manager stated that the menus provided for the residents' breakfast service were not followed. The Dietary Manager stated that the facility always serves the same foods for breakfast: sausage, bacon, oatmeal, biscuits, gravy, and eggs. The Dietary Manager stated it was her decision to serve the same breakfast foods each day and to not follow the menus indicated for use during residents' meal services. During an interview on 09/24/2024 at 10:00 AM, the Dietary Manager stated enhanced/fortified foods were prepared by adding extra butter, cheese, and more milk to a selected item. The Dietary Manager stated foods where enhanced/fortified by increasing calories, she did not follow recipes for enhanced/fortified foods. During an interview on 09/25/2024 at 3:24 PM, the Registered Dietician stated that food menus and recipes were written by the food companies. Her job duty is to inspect and approve the menus. When asked how to measure the caloric intake of foods that were to be enhanced/fortified she stated you would measure the calories of the ingredients added to make the foods enhanced/fortified such as fortified milk. The Registered Dietician stated that substitutes or alternatives for foods offered to the residents should be nutritionally equivalent to what the food is replacing. The Registered Dietician stated she was not aware of a house shake prepared by the facility, or any recipe related to the house shake. Residents on enhanced/fortified diets are prescribed these diets as a method of gaining weight. It is important to follow dietary orders as these orders are put into place for a reason, such as to help a resident gain weight. Left over foods should not be used for puree as left over foods can lose nutritional value. Enhanced/fortified milk has added calories to make it enhanced/fortified, vitamins and minerals already in the milk do not make the milk enhanced/fortified. During a record review of the facility provided, Weekly Menus no recipes for enhanced/fortified foods were listed. During an interview on 09/26/2024 at 2:00 PM, the Dietary Manager stated that there were no recipes for enhanced/fortified foods. The Dietary Manager stated that she chooses an item off of the menu and makes that item enhanced/fortified by adding extra calories to it. The Dietary Manager stated she made enhanced/fortified cornbread on 09/24/2024 by adding butter to it. The Dietary Manager stated she did not measure the butter, it was melted and spread on top of the cornbread. The Dietary Manager stated she did not know how many calories she was adding to the foods she made enhanced/fortified. During an interview on 09/26/2024 at 4:47 PM, the Dietary Manager stated an enhanced/fortified recipe for oatmeal and an enhanced/fortified recipe for peanut butter drink were available from previous food service company. The Dietary Manager stated that dietary staff did not have access to recipes for enhanced/fortified oatmeal or peanut butter drink and no recipes were available to dietary staff when preparing enhanced/fortified foods. During an interview on 09/27/2024 at 3:43 PM, Consultant #2 asked the Surveyor if recipes for enhanced/fortified foods obtained from the current food service company would suffice for future use. The Surveyor stated that no recommendations could be made by the surveying team, Consultant #2 should consult with the Registered Dietician for recipe use. Consultant #2 stated that the recipes for enhanced/fortified foods were not available to dietary staff, but if approved by the Registered Dietician would be available for dietary staff for future use. 5. A review of the electronic health record indicated the facility admitted Resident #4 with diagnoses that included dementia, muscle weakness, and cerebral infarction. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated Resident #4 had severe cognitive impairment. A review of Resident #4's Order Summary Report, revealed Resident #4 was ordered to receive enhanced/fortified foods with pureed texture, regular consistency, 2 shakes with meals, high calorie juice with meals, and ice cream with all meals. A review of the Dietary Quarterly report dated 07/14/2024 stated, Resident #4 was to receive fortified foods, house shakes, and high calorie juice. Resident #4 weight loss at the time was 4.87% over six months. A review of Resident #4's meal card, dated 09/25/2024, stated, house shake (add peanut butter, ice cream in red cup with shakes). Indicating the recipe for the blended shake should have contained more than one shake. During a concurrent observation and interview on 09/25/2024 at 1:03 PM, Resident #4 was served a tray of pureed chicken with gravy, pureed bread with gravy, pureed broccoli, 120 milliliters (ML) high calorie juice, pureed peach crisp, 120 ML chocolate ice cream, and a red mug filled with a blended shake. The Dietary Manager (DM) stated the shake was mixed with 1 container of ice cream, 1 carton of the prepackaged shake (house shake per facility), and 1 scoop of peanut butter. The scoop was described as a regular household flatware teaspoon and not a true measured scoop. The DM stated they did have access to the resident's electronic health record and orders. The DM denied knowledge that the meal card order was not clear and acknowledged the blended shake should have contained two cartons of the house shake. The DM stated the resident was not getting the correct supplements per ordered intake. 6. A review of the medical diagnosis in Resident #5's electronic health record indicated the facility admitted Resident #5 with diagnoses that included senile degeneration of the brain, and dementia. A review of Resident #5's Weight Summary, showed on 03/09/2024, an admission weight of 137.8 pounds (lbs.); on 06/07/2024, a weight of 116.2 lbs.; and on 09/05/2024, a weight of 111.4 lbs. Calculated weight loss showed 4.13% over three months and 19.16% significant weight loss over six months. A review of Resident #5's IDT [Interdisciplinary Team] Clinically Unavoidable Weight Loss, dated 04/19/2024, concluded Resident #5's weight loss was unavoidable with an explanation of resident has dementia and refuses care to allow staff to assist with eating. The admission MDS with an ARD of 03/13/2024, revealed Resident #5 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment, required setup and clean-up assistance only for eating, and had no, or unknown weight loss noted. A review of Resident #5's, care plan, revised on 09/10/2024, revealed the resident had experienced a weight loss. Interventions included receiving adequate nutrition as a regular enhanced diet with mechanical soft texture and thin liquids. A review of Resident #5 ' s orders revealed Resident #5 had a regular enhanced diet with regular texture with thin liquids and high calorie juice ordered on 05/31/2024 and modified on 09/06/2024 to mechanical soft texture and added ice cream with lunch and dinner. During a phone interview on 09/25/2024 at 3:24 PM, the Registered Dietician (RD) stated she was not a full-time employee of the facility but rounded as a regional support for the company. The RD denied being present for the facility meetings for significant weight loss, and stated she only approved menus, and the recipes were the responsibility of the Dietary Manager. During an interview on 09/26/2024 at 2:00 PM, the Dietary Manager (DM) stated no fortified recipes existed in the facility. The DM stated they had been trained to add butter, milk, or cheese to a recipe to make it a fortified item. The DM denied any measurements of these items when they were added. The DM's exampled process was melted butter had been brushed on to the top of a pan of cooked cornbread on 09/24/2024 for lunch and the cornbread was now a fortified food item used to serve residents in need of a fortified food ordered for supplemental nutritional support. The DM was found to have no certification or specialized training in nutrition. 2. A review of Resident #27's Order Summary Report, indicated the resident had medical diagnoses of moderate protein-calorie malnutrition, morbid (severe) obesity due to excess calories, unspecified dementia with other behavioral disturbance, and cancer of the cervix and uterus. A review of Resident #27's 5-day MDS with an ARD of 08/29/2024 indicated a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months. A review of Resident #27's Order Summary Report dated 09/16/2024 indicated Resident #27 was to receive a regular enhanced; regular texture and consistency diet with double portions of biscuit and gravy at breakfast; high calorie juice with meals; and a bowl of gravy with meals. On 09/25/2024 at 08:05 AM, Resident #27's diet card read: Enhanced diet with reg texture and thin fluids. Double portion biscuit and bowl of gravy at all meals. Resident #27 ate the bowl of oatmeal and the eggs. Observed bacon on the tray. No biscuits and gravy were on the tray. On 09/26/2024 at 2:30 PM, the Surveyor interviewed the Dietary Manager (DM) and she acknowledged that Resident #27 did not receive biscuits and gravy for breakfast. The DM stated that they normally have them, but did not have biscuits or gravy that morning, because she followed the menu. Also reported that the only thing they did for the enhanced diet was added more butter to the oatmeal. The Dietary Manager also stated she was unsure how to give the residents what they wanted and serve the menu that she is supposed to. 3. A review of Resident #8 Order Summary Report included medical diagnosis of severe protein-calorie malnutrition, muscle weakness, low potassium, heart failure, gastroesophageal reflux disease (GERD), and chronic obstructive pulmonary disease (COPD). A review of Resident #8's admission MDS with an ARD of 08/17/2024 documented a BIMS of 14 which indicated no cognitive impairment, and the resident had no swallowing disorders and was not on a physician prescribed weight loss regimen. A review of Resident #8's Order Summary Report, indicated Resident #8 was on a regular-enhanced food with regular texture, thin consistency diet. A review of Resident #8's care plan with a revision date of 09/26/2024 indicated Resident #8 had a potential for nutritional deficits related to COPD, heart failure with hypoxia and therapeutic diet, and was on a regular fortified diet with regular texture and thin fluids. Interventions included supplements/snacks as ordered; obtain food preferences, likes/dislikes; offer substitutes for foods not eaten; and provide diet as ordered, fortified foods. On 09/25/2024 at 12:44 PM, the Surveyor observed Resident #8's lunch tray. The tray included cubed chicken, broccoli and parsley noodles on a plate. No red bowl was located on the tray. During an interview with the Dietary Manager on 09/25/2024 at 01:15 PM, she confirmed no red bowl was on Resident #8's tray. She stated the noodles were cooked in a lot of butter. Enhanced/fortified is anything that is a food that has a fatty food added such butter, cheese, etcetera (etc.), and the parsley noodles had extra butter on top of what the recipe called for. The Dietary Manager stated she was uncertain whether the parsley noodles on the plate were enhanced or not. Then, she stated that everyone got fortified noodles today. On 09/26/2024 at 2:00 PM, the Dietary Manager disclosed that she has no menus for fortified diets and has only been adding butter, cheese, and things like that to certain items on the trays and serves them as fortified/enhanced diets. She also stated she has no idea what the calories are for what she adds. On 09/26/24 at 2:30 PM, after speaking to the Dietary Manager again, she stated that the parsley noodles had butter added to them more than the recipe called for and they make up what they feel would be a fortified/enhanced diet. 4. A review of Resident #47's Order Summary Report indicated medical diagnoses of dementia with anxiety, cirrhosis of the liver, lung cancer, pulmonary fibrosis, chronic kidney disease, stage 3, abnormal weight loss and gastro-esophageal reflux disease (GERD). A review of the annual MDS with an ARD of 09/17/24, indicated a BIMS score of 7 and required supervision or touching assistance with eating; did not have a swallowing disorder, and had lost 5% of weight or more in last month or 10% or more in last 6 months. A review Order Summary Report, indicated Resident #47 was on a regular-enhanced diet, regular texture, thin consistency. A review of the care plan with a revision date of 06/14/2024 indicated Resident #47 was to be served a regular enhanced diet with regular texture and thin liquids as ordered by the physician. On 09/25/2024 at 01:13 PM, observed Resident #47's lunch tray, there was no red bowl on the tray. Parsley noodles were on the plate with other lunch foods. On 09/25/2024 at 01:13 PM, during an interview the Dietary Manager stated the noodles were the enhanced/fortified food today. She stated that the noodles were not in a red bowl, but they should have been, the enhanced noodles had extra butter in them. She did not know if she got the enhanced/fortified. She asked the kitchen staff and stated that the noodles on the plate were fortified. When asked how the staff could know if the noodles were enhanced/fortified, she said that they just remembered. On 09/26/2024 at 2:00 PM, during an interview the Dietary Manager reported that they do not have enhanced/fortified menus and that they add butter, cheese, etc., to a food that they pick on the meal and use that as enhanced. No measuring or certain amount, just added by the cook. Based on observation, interview, record review, and policy review, the facility failed to provide a diet based on nutritional needs of 6 (Resident #4, #5, #8, #14, #27, and #47) of 37 residents reviewed for nutritional dietary needs and weight loss. Specifically, Residents #4, #5, #8, #14, #27, and #47 did not receive an enhanced/fortified diet as ordered. Findings include: A review of a facility policy titled, Food and Nutrition Services, dated 10/2017, indicated the facility provided each resident with a well-balanced diet to meet nutritional and special dietary needs based on a resident's nutritional need assessment. Meal trays were to be inspected to ensure the correct meal was provided to the resident. 1. A review of the Clinical Resident Profile, indicated the facility admitted Resident #14 on 03/06/2011 with diagnoses that included dementia. A review of Resident #14's care plan, revised on 05/14/2024, revealed the resident had a nutritional risk, required a physician ordered fortified, mechanically altered, puree textured diet. Interventions included offering supplements as ordered by physician, receiving fortified foods; ice cream at lunch, dinner, and at 10/2 (10 AM and 2 PM); receiving a house shake that contains ice cream, peanut butter, and milk with lunch and dinner; 2 ounces of peanut butter each meal; and sending the correct texture and consistency diet. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment. Resident #14 was independent with eating, had a 5% or more weight loss in the last month or 10% or more in the last 6 months, had a mechanically altered diet, and was not on hospice care. A review of the Dietary Quarterly assessment, dated 08/22/2024, revealed Resident #14 had a weight loss and was receiving fortified meal enhancements, a health shake, and peanut butter. A review of Medication Administration Record [MAR], with a start date of 08/23/2024, revealed Resident #14 was receiving an appetite stimulant daily, at bedtime. A review of Clinical Physician Orders, with a start date of 09/06/2024, revealed Resident #14 had a regular enhanced pureed diet. Additional directions revealed, ice cream at 10:00 AM and 2:00 PM and with lunch and dinner. A review of Progress Note with a sub type IDT - Weekly Weight Note, dated 09/13/2024, revealed a late entry Weight Warning of 133.2 pounds and indicated an 11.9% weight deficit in 180 days, and a 1.2-pound weight loss in one week. A review of the weekly weight loss meeting on 09/19/2024, revealed Resident #14 was receiving a regular enhanced diet with puree texture; peanut butter; a house shakes with peanut butter, ice cream and milk; and ice cream at 10:00 AM and 2:00 PM. A review of a facility document titled, [Facility Name] Newsletter, dated 09/23/2024, indicated lunch was a cheeseburger/hamburger, French fries, lettuce, tomato, onion, pickle, Hawaiian cake, and beverages. During an observation on 09/23/2024 at 12:47 PM, Resident #14's meal tray included chocolate milk, whole milk, two puree food items on a divided plate, covered with brown gravy, a green puree item. A clear condiment cup contained a creamy brown substance. A cup contained a puree food item, and a red mug contained an off-white beverage, a clear cup contained a clear beverage, a handled cup contained a dark beverage, and a cup contained a green ice product. A review of the document on Resident #14's meal tray revealed Resident #14's diet order was a pureed regular diet with enhanced foods and thin liquids. Notes: included chocolate milk and 2 ounces of peanut butter; Standing Orders that included a house shake with peanut butter and ice cream served in a red cup with shakes, whole milk, and one-half cup of vanilla ice cream. Fortified foods in red bowl. During an interview on 09/23/2024 at 12:52 PM, Licensed Practical Nurse (LPN) #8 identified the puree foods with gravy as hamburger and mashed potatoes, the green puree as green beans, the puree in the cup as cake, water in the clear cup, coffee in the handled cup, peanut butter in the clear condiment cup, and shake with peanut butter in the red mug. LPN #8 stated the shake contained milk and peanut butter. LPN #8 was asked if the resident should receive vanilla ice cream and LPN #8 stated, They ran out of ice cream, so they gave (resident pronoun) green sherbet. LPN #8 could not identify the enhanced food item. A review of the sherbet label revealed it was 4 ounces of Lime Fat Free Sherbet. During an interview on 09/23/2024 at 01:02 PM, the Dietary Manger (DM) stated Resident #14 was served a pureed burger with mayonnaise, ketchup, cheese, bread, mashed potatoes in place of fries, and green beans. The DM stated the shake did contain vanilla ice cream, that vanilla and chocolate ice cream were available, and could not state why Resident #14 did not receive vanilla ice cream on the meal tray. The DM stated the red mug containing the house shake is the fortified/enhanced food and takes the place of the red bowl. The DM stated all residents received a fortified/enhanced meal at lunch because the fat content in the hamburger made the meal enhanced. During an interview on 09/23/2024 at 01:21 PM, the Director of Nursing (DON) stated vanilla ice cream was obtained from the store and Resident #14 was provided with vanilla ice cream and should have received food per physician orders.

3. A review of Resident #27's Order Summary Report, indicated medical diagnoses of moderate protein-calorie malnutrition, morbid (severe) obesity due to excess calories unspecified dementia with other behavioral disturbance, and cancer of the cervix and uterus. A review of Resident #27's 5-day MDS with an ARD of 08/29/2024 indicated a weight loss of 5% or more in the last month or a loss of 10% or more in the past 6 months. A review of Resident #27's Order Summary Report dated 09/16/2024 indicated Resident #27 was to receive a regular enhanced; regular texture and consistency diet with double portions of biscuit and gravy at breakfast; high calorie juice with meals; and a bowl of gravy with meals. During a concurrent observation and interview on 09/24/2024 at 07:15 AM, Dietary [NAME] #7 placed three pieces of toast, one scoop of oatmeal, two pieces of sausage, and one scoop of egg on a plate to be served to a resident for breakfast service. Dietary [NAME] #7 stated that the resident was to receive double portions per order. During an interview on 09/24/2024 at 10:00 AM, the Dietary Manager stated that residents on double portion receive double of all foods served to the resident during that meal service, except for desserts. The Dietary Manager stated that she decided not to give extra desserts as she felt the calories in the food were sufficient. During an interview on 09/25/2024 at 3:24 PM, the Registered Dietician stated that residents who were to receive double portions, were to receive double portions of all foods being served to the residents during that meal service. The Registered Dietician stated that residents who receive double portions should receive double portions of dessert as well, in an attempt to increase the resident's calorie intake. The Registered Dietician stated it was important to follow the physicians' orders and give the resident the diet as specified in order to help the resident gain weight. 2. A review of the electronic health record indicated the facility admitted Resident #4 with diagnoses that included dementia, muscle weakness, and cerebral infarction. Review of the quarterly MDS with an ARD of 07/12/2024, revealed Resident #4 had a BIMS score of 0 which indicated the resident had severe cognitive impairment. A review of Resident #4's, Order Summary Report, revealed Resident #4 was to receive enhanced/fortified foods with pureed texture, regular consistency, 2 shakes with meals, high calorie juice with meals, and ice cream with all meals. A review of the Dietary Quarterly report dated 07/14/2024 stated Resident #4 was to receive fortified foods, house shakes, and a high calorie juice. Resident #4 weight loss at the time was 4.87% over six months. A review of Resident #4's meal card, dated 09/25/2024, stated, house shake (add peanut butter, ice cream in red cup with shakes). Indicating the recipe for the blended shake should have contained more than one shake. During a concurrent observation and interview on 09/25/2024 at 1:03 PM, Resident #4 was served a tray of pureed chicken with gravy, pureed bread with gravy, pureed broccoli, 4 ounces of a high calorie juice, pureed peach crisp, 4 ounces chocolate ice cream, and a red mug filled with a blended shake. The Dietary Manager (DM) stated the shake was mixed with one container of ice cream, one carton of the house shake, and one scoop of peanut butter. The scoop was described as a regular household flatware teaspoon and not a true measured scoop. The DM stated they did have access to the residents' electronic health record and orders. The DM denied knowledge that the meal card order was not clear and acknowledged the blended shake should have contained two cartons of the house shake. The DM stated the resident was not getting the correct supplements per ordered intake. Based on observation, interview, record review, and policy review, the facility failed to ensure physician ordered foods were provided for 3 (Residents #4, #14, and #27) of 37 residents reviewed for dietary orders. Specifically, Resident #4 did not receive two house shakes, Resident #14 did not receive ice cream at lunch, and Resident #27 did not receive double portions of biscuits and gravy at breakfast, as ordered by a physician. Findings include: A review of a facility policy titled, Food and Nutrition Services, dated 10/2017, indicated the facility provided each resident with a well-balanced diet to meet nutritional and special dietary needs based on a resident's nutritional need assessment. Meal trays were to be inspected to ensure the correct meal was provided to the residents. 1. A review of the Clinical Resident Profile, indicated the facility admitted Resident #14 on 03/06/2011 with diagnoses that included dementia. A review of Resident #14's care plan, revised on 05/14/2024, revealed the resident had a nutritional risk, required a physician ordered fortified, mechanically altered, puree textured diet. Interventions included offering supplements as ordered by the physician, receiving fortified foods; ice cream at lunch, dinner, and 10:00 AM and 2:00 PM. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment, and was independent with eating, had a 5% or more weight loss in the last month or 10% or more in the last 6 months, required a mechanically altered diet, and was not on hospice care. A review of the Dietary Quarterly assessment, dated 08/22/2024, revealed Resident #14 had a weight loss and was receiving fortified meal enhancements, a health shake, and peanut butter. A review of the Medication Administration Record [MAR], with a start date of 08/23/2024, revealed Resident #14 was receiving an appetite stimulant daily, at bedtime. A review of the Clinical Physician Orders, with a start date of 09/06/2024, revealed Resident #14 had a regular enhanced pureed diet. Additional directions revealed ice cream at 10:00 AM & 2:00 PM and with lunch and dinner. A review of the Progress Note titled, IDT - Weekly Weight Note, dated 09/13/2024, revealed a late entry Weight Warning of 133.2 pounds and indicated an 11.9% weight deficit in 180 days, and a 1.2-pound weight loss in one week. During an observation on 09/23/2024 at 12:47 PM, Resident#14's meal tray food items included a cup that contained a green ice product. During an interview on 09/23/2024 at 12:52 PM, Licensed Practical Nurse (LPN) #8 identified the green ice product on Resident #14's meal tray as green sherbet. LPN #8 stated, They ran out of ice cream, so they gave (resident pronoun) green sherbet. A review of the sherbet label revealed it was 4 ounces of Lime Fat Free Sherbet. A review of Resident #14's meal tray document revealed Resident #14's diet order was a pureed regular diet with enhanced foods and thin liquids. Standing Orders included one-half (½) cup of vanilla ice cream. During an interview on 09/23/2024 at 01:02 PM, the Dietary Manger (DM) stated vanilla and chocolate ice cream were available and could not state why Resident #14 did not receive vanilla ice cream on the meal tray. During an interview on 09/23/2024 at 01:21 PM, the Director of Nursing (DON) stated vanilla ice cream was obtained from the store and Resident #14 was provided vanilla ice cream and should have received food per physician orders.

Based on observation, and interview, the facility failed to ensure staff properly washed hands with soap and water to prevent cross-contamination, and equipment was in good repair. The findings include: During an observation and interview on 09/23/2034 at 1:00 PM, Dietary Aid #9 pushed a rack of dirty dishes into the dish washing machine, closed the lid, and began the dish washing cycle. Without washing her hands, Dietary Aid #9 began pulling dishes from a clean dish rack to be used in the resident lunch service. Dietary Aid #9 was noted to have artificial nails in place. Dietary Aid #9 stated she should have washed hands between pushing dirty dishes into dish washing machine and before handling clean dishes to be used in resident meal service. The Dietary Manager stated artificial nails should not be worn by food preparation staff to decrease risk of contamination. During a concurrent observation and interview on 09/23/2024 at 1:53 PM, Dietary [NAME] #10 placed gloves on both hands, grabbed a pan from the bottom dish rack, and without removing the gloves or washing her hands she placed her hands into a bag of shredded cheese to be used in the residents' dinner service. Dietary [NAME] #10 stated her gloves should have been removed, her hands should have been washed, and new gloves should have been applied after grabbing a pan from the dish rack and before putting her hands into the bag of shredded cheese. During a concurrent observation and interview on 09/23/2024 at 2:14 PM, Dietary [NAME] #10 touched her clothing with gloves being used in dinner preparation. Without removing the gloves or washing her hands, Dietary [NAME] #10 placed her hands into bowl to prepare the residents' dinner. Dietary [NAME] #10 stated gloves should have been changed after touching clothing and before continuing to prepare the resident's dinner. During a concurrent observation and interview on 09/23/2024 at 2:30 PM, Dietary [NAME] #10 used her gloved hands to pick up a washcloth containing soap and water and wiped down the kitchen preparation counter. Without changing gloves or washing her hands, Dietary [NAME] #10 began placing pans on the kitchen preparation counter to be used for the dinner service. Dietary [NAME] #10 stated her gloves should have been changed and her hands should have been washed after wiping down the kitchen preparation counter and before continuing with resident's dinner service. During a concurrent observation and interview on 09/23/2024 at 4:17 PM, Dietary [NAME] #10 touched an electrical cord with her gloved hands. Without changing gloves or washing her hands, Dietary [NAME] #10 picked up a bowl of food to be used in resident's dinner service and placed food in a blender. Dietary [NAME] #10 stated her gloves should have been changed and her hands should have been washed after touching the electrical cord and before continuing with dinner service. During a concurrent observation and interview on 09/23/2024 at 4:17 PM, Dietary [NAME] #10 used a blender with several cracks in the side of the blender. Dietary [NAME] #10 stated the cracks in the plastic could contain possible contaminants and should not be used. During a concurrent observation and interview on 09/24/2024 at 4:30 AM, Dietary [NAME] #7 put gloves on to prepare a resident's breakfast then pulled up his pant leg. Without changing gloves or washing his hands, Dietary [NAME] #7 touched butter to be used in resident's breakfast. Dietary [NAME] #7 stated his hands should have been washed and his gloves changed after touching his pant leg and before continuing to prepare the resident's breakfast. Review of a facility policy titled, Hand Washing stated staff are to perform hand washing after touching parts of the human body, after handling soiled equipment or utensils, during food preparation, before donning gloves for working with food and after gloves are removed, and after engaging in other activities that contaminate the hands. Review of a facility policy titled, Quick Resource Tool: QRT Staff Attire stated fingernails will be kept clean, nail polish and/or acrylic nails are not permitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the laboratory waiver was renewed for 1 of 1 facility requiring a waiver to perform testing. Specifically, the facility Centers for Medical & Medicaid Services Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver (COW) was expired. The findings are: Review of a Centers for Medicare and Medicaid Services (CMS) CLIA brochure titled, How to obtain a CLIA Certificate, revealed a COW is issued to perform waived tests, defined as a lab test with insignificant risk of erroneous results. Waived tests include SARS-COV-2 (COVID), Influenza A/B, gastric occult blood, and glucose monitoring devices. During an observation on [DATE] at 12:00 PM, Licensed Practical Nurse (LPN) #1 performed a blood glucose test on Resident #73 using a glucose monitoring device. During an observation of the medication room on [DATE] at 12:38 PM, a document titled, Centers for Medical & Medicaid Services Clinical Laboratory Improvement Amendments [CLIA] Certificate of Waiver, revealed the CLIA ID (Identification) Number was 04D0468396 with an expiration date of [DATE]. The Director of Nursing (DON) stated this is the updated one and pointed to a paper attached to the wall to the left of the CLIA certificate titled, CLIA Laboratory User Fees. A review of the CLIA Laboratory User Fees, with a billing date of [DATE], included a CLIA Fee Coupon at the bottom, indicating the CLIA ID Number was 04D0468396, a certificate period of [DATE] to [DATE]. A note, located above the CLIA Fee Coupon, instructed When renewing a certificate, if full payment is not received prior to the begin date of the above certificate period, your current certificate will expire, and you may not legally perform testing after this date. On [DATE] at 08:50 AM, the Administrator provided a copy of the CLIA Laboratory User Fee and email showing payment of $268.00 was made. The Administrator stated the renewed certificate will come by mail.

During a concurrent observation and interview on 09/25/2024 at 11:51 AM, the following items were located in a refrigerator on the F Hall: a can of soda, a lunch box, flavored gelatin cups, a bottle of water, a reusable thermos with an unidentified drink, a small bag of pizza bites, and a jar of pickles. When asked who used the refrigerator on the F Hall, Certified Nursing Assistant (CNA) #5 stated the staff and residents use the refrigerator. When asked how items were labeled for identification, CNA #5 stated the items were not labeled. During an interview on 09/25/2024 at 12:00 PM, the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #6 stated staff and residents both use the refrigerator on the F Hall. During an interview on 09/25/2024 at 12:30 PM, LPN #3 stated the residents and staff foods/beverages should not be stored in the same refrigerator due to the risk of contamination. During a concurrent observation and interview on 09/26/2024 at 8:12 AM, the following items were located in a refrigerator on the F Hall unit: two breast pumps with a substance in the bottom, a lunch bowl, a pack of hamburger buns, four bottles of water, a lunch box, flavored gelatin cups, fruit cups, two reusable thermoses with an unidentified drink, and two cans of soda. CNA #4 stated she was breastfeeding, and her pumps were kept in the refrigerator. During an interview on 09/26/2024 at 8:30 AM, LPN #3 stated the breast pumps with substance in the bottom should not be kept in the same refrigerator as resident foods/beverages due to the risk of contamination. During an interview on 09/26/2024 at 9:30 AM, the Activity Director stated she was responsible for cleaning the F Hall refrigerator. The Activity Director stated the residents and staff foods/beverages should not be kept in the same refrigerator due to the risk of contamination. The Activity Director stated breast pumps with a substance in the bottom should not be kept in a resident refrigerator due to the risk of contamination. During an interview on 09/26/2024 at 10:00 AM, the Assistant Director of Nursing (ADON) stated that staff and residents could use the same refrigerator. The ADON stated breast pumps containing a substance in the bottom should not be kept in the same refrigerator as resident foods/beverages due to risk of contamination. During an interview on 09/26/2024 at 10:30 AM, the Director of Nursing (DON) and Consultant #2 were asked for a policy and/or procedure outlining the storage of resident and staff foods/beverages. Consultant #2 stated that no current policy and/or procedure existed, that items stored together should be labeled. On 09/26/2024 at 11:00 AM, Consultant #2 provided an outline for storage of staff and resident foods/beverages. When asked if the policy outlining storage of staff and resident foods and beverages was in place before being brought to the Surveyor, Consultant #2 stated no, she identified the concerns, and a new refrigerator would be brought to the F Hall for staff to use and both staff and resident refrigerators would have a lock added for safety. Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain Legionella surveillance for 1 of 1 water management plan and maintain sanitary conditions for 1 of 1 resident unit refrigerator reviewed for infection control. Findings include: A review of the facility's undated policy but with a copyright date of 2022 titled Legionella Surveillance, indicated Legionella was a bacteria found in water that caused a serious type of pneumonia called Legionnaires' Disease. Legionella surveillance is one component of the facility's water management plan for reduction risk of bacteria in the facility's water system. Legionella grew best in water which is stagnated or did not have enough disinfectants and at 77-108 degrees Fahrenheit. Temperature control measures included hot water shall be stored at 140 degrees Fahrenheit and circulated at a minimum of 124 degrees Fahrenheit. A review of a facility policy titled, Legionella Water Management Program, revised in July of 2017, indicated a management program was to identify areas where Legionella bacteria can grow by first using a diagram of the facility's water system which mapped out where water was received, cold water distribution, heating, hot water distribution, and waste. Second, map identified areas which encourage growth and spread of Legionella and other waterborne bacteria like storage tanks, water heaters, filters, aerators, showerheads/hoses, humidifiers, hot tubs, fountains, and medical devices. Third, map identified situations such as presence of biofilm, sediment, water temperature fluctuations, water pressure changes, water stagnation, and inadequate disinfection. Lastly, a diagram of where control measures are applied and a system to monitor control limits and effectiveness. During an interview on 09/26/2024 at 11:00 AM, the Maintenance Supervisor (MS) stated he only monitors the hot water temperature of every hall and the hot water heaters were currently set at 110 degrees Fahrenheit which were completed weekly. The MS stated he had no knowledge of a diagram mapping the plumbing/water flow of the building and added several water lines that had been dug up and replaced prior to his employment. He indicated a main shut off valve was at the hub in the center of the building by the nurses' station and the gray water drained somewhere out by C-Hall. The MS stated he had no knowledge of identified areas of concern to be monitored like stagnated water. The MS stated the facility provided two days of training with the prior MS, then an unidentified regional employee later put the maintenance books in order. The MS stated the city had done water testing earlier this year but was unable to find the documentation they provided. During the Exit Conference Consultant #2 stated, if the MS would have come to the consultant the regional employee could have been contacted for a copy. A review of an untitled, undated floor plan sent to the survey team on 09/30/2024 post exit conference identified five hot water heater location, one boiler location and one in-flowing water line to the facility. No water flow through the facility was identified so no areas of stagnation could have been assessed.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for 2 (Residents #117 and #167) of 2 sampled residents whose Care Plans were reviewed. The findings are: 1. Resident #117 had diagnoses of End Stage Renal Disease and Heart Failure, Unspecified. a. A Physicians Order dated 07/17/23 indicated the resident was to receive Furosemide 160 milligrams (mg) by mouth two times a day and to monitor Resident #117 every shift for decreased oral intake, acute confusion, delusions, agitation, aggression, lethargy, decreased sweating, tachycardia, hypotension, generalized weakness and/or sunken eyes due to the resident being on a diuretic. b. Resident #117 had a previous order for Furosemide 80 mg. to be given on Monday, Wednesday, and Friday with a start date of 6/28/23 and an end date of 7/11/23. c. Resident #117 had a previous order for Furosemide 80 mg to be given on Tuesday, Thursday, Saturday, and Sunday with a start date of 6/29/23 and an end dated of 7/11/23. d. Resident #117 had a previous order for Furosemide 80 mg two times a day with a start date of 7/12/23 and an end date of 7/17/23. e. The Care Plan did not address diuretic therapy. f. On 07/20/23 at 2:29 PM, the Surveyor asked the MDS Coordinator to check Resident #117's electronic record for the Care Plan to see if she could find where diuretics were ordered. She stated, It's not there. I missed it on the MDS therefore I missed it on the Care Plan. It should be there so they can observe and monitor for side effects and labs. 2. Resident #167 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure with Hypoxia. The MDS with an Assessment Reference Date (ARD) of 06/28/23 documented the resident required a Bilevel Positive Airway Pressure (BiPap)/Continuous Positive Airway Pressure (CPAP). a. A Physicians Order dated 06/21/23 indicated Resident #167 used a BiPAP at bedtime related to Chronic Obstructive Pulmonary Disease. b. The Care Plans for emphysema/COPD and altered respiratory status with a revision date of 07/13/23 did not address Resident #167's use of a BiPAP. c. On 07/18/23 at 12:26 PM, the Surveyor asked MDS Coordinator to check Resident #167's Care Plan and see if she could find the Bipap on it. She stated, It isn't. I'm not sure he has one. I haven't been able to verify to see if he had a BiPAP in place. The Surveyor asked where she got her information from to build the Care Plan. She stated, From the Doctors Orders and past records. 3. The facility policy titled, Care Plans, Comprehensive Person-Centered, provided by the DON on 07/19/23 at 3:26 PM documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .

Based on observation, record review and interview, the facility failed to ensure necessary care and treatment were provided for management of a Peripherally Inserted Central Catheter (PICC) for 1 (Resident #57) of 1 sampled resident. The findings are: 1. On 7/17/23 at 12:33 PM, Resident #57 was lying in bed, observed a self-adhering dressing covering a clear self-adhering dressing on his right upper arm covering a PICC line insertion site with two lumens dangling. Resident #57 stated, I'm on some really strong antibiotics for the infection of my amputation. 2. On 07/20/23 at 1:15 PM, Resident #57 was lying in bed, a self-adhering dressing was halfway covering a clear self-adhering dressing over a PICC line insertion site. Resident #57 stated the nurse put that over my dressing to keep the IV from being pulled on. 3. A Physicians Order dated 07/13/23 indicated Resident #57 was to receive 1 gram of Merrem (an Antibiotic) Intravenous (IV) Solution one time a day for infection to stump for 14 days intravenously. The Physician Orders did not contain orders for monitoring for infection, dressing changes, or flushes. 4. A Care Plan with an initiated date of 07/14/23, last revised on 7/17/23, indicated Resident #57 was receiving antibiotics via IV access related to stump infection and was to have medications administered as ordered, the dressing changed as ordered, the IV port flushed as ordered and the site observed for infection and infiltration. 5. On 7/20/23 at 1:35 PM review of the July 2023 Medication Administration Record (MAR) documented Resident #57 was receiving the antibiotic since 07/13/23, but contained no information regarding flushes, monitoring for infection, or dressing changes had been done. 6. On 7/20/23 at 3:00 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 about orders for a dressing change to Resident #57's PICC line. She stated, I'm not sure. I haven't changed it. LPN #2 stated, We aren't to change the dressing, just reinforce it. The Dialysis gives the antibiotics and dressing changes, and we just reinforce it. We aren't giving him antibiotics here. LPN # 1 stated, Yes, they are giving the antibiotics through the PICC on the night shift. 7. On 07/20/23 at 3:30 PM, the Surveyor asked the Director of Nursing (DON) how often a dressing on a PICC line should be changed. She stated, Every seven days, The Surveyor asked if a Physicians Order was needed for dressing changes. She stated, Yes. The Surveyor asked if Resident #57 had a PICC line in place on admission. She stated, Yes. The Surveyor asked when he was admitted . The DON stated, 7/13/23. The Surveyor asked how she knew when it was changed and what should she do when a resident is admitted /readmitted with a dressing without a date on a dressing. She stated, I don't know when it was last changed, and I would call the Doctor for orders. 8. On 07/20/23 at 4:10 PM, LPN #2 stated, I talked to dialysis, and they are not giving his IV antibiotics or providing his dressing change. 9. A facility policy titled, Peripheral and Midline IV Dressing Changes, provided by the Treatment Nurse on 07/20/23 at 4:45 PM documented, .The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter site dressing changes.4. Change the dressing . a. at least every 7 days . c. immediately if the dressing or site appears compromised . 10. A facility policy titled, admission Assessment and Follow Up: Role of the Nurse, provided by the Treatment Nurse on 7/20/23 at 4:45 PM documented, Purpose The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident . Steps in the Procedure .12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings . Reporting 1. Notify the supervisor and the attending Physician of immediate needs that the resident may have .

Based on observation, interview, and record review, the facility failed to ensure tobacco products and ignition devices were secured for 1 (Resident #34) of 4 (Residents #17, #34, #48 and #117) sampled resident identified as a smoker in the facility per a list provided by the Administrator on 07/17/23 at 11:10 AM. The findings are: 1. On 07/17/23 at 1:44 PM, Resident #34 was sitting in the hallway outside his room in a wheelchair. A black lighter, and an open pack of cigarettes were resting in the chair next to the resident's right hip. a. On 07/18/23 at 3:49 PM, Resident #34 was seated in their wheelchair in their room. A black lighter, and a single cigarette were resting in the chair next to the resident's right hip. b. On 07/19/23 at 1:24 PM, Resident #34 was entering the dining hall in advance of the scheduled 1:30 PM smoke time. a black lighter, and an open pack of cigarettes were resting in the chair next to the resident's right hip. c. A facility policy regarding tobacco use with no title was provided by the Administrator on 07/19/23 at 1:37 PM documented, Policy: It is the policy of [Facility] to have all residents who wish to smoke at the facility to be properly supervised to ensure a safe environment for all residents, Procedure: 1. Any resident that wishes to smoke . will be required to keep their cigarettes, cigars, lighters, matches, electronic cigarettes and any other smoking items locked up . d. On 07/19/23 at 2:15 PM, the Surveyor asked the Director of Nursing (DON) if residents were permitted to have tobacco products and lighters inside the facility. The DON stated, No. Who does? The Surveyor informed the DON Resident #34 was seen with these items. The DON stated, I'll report this to the Administrator now. e. On 07/19/23 at 2:28 PM, the DON and Administrator approached the Surveyor to report they had retrieved the lighter and an empty cigarette pack from Resident #34's room. The Administrator stated, He's only been here for six weeks, and we've already talked about this with him. We'll just have to check him every morning from now on.

Based on observation, interview, and record review, the facility failed to store medications in a secure manner. This failed practice had the potential to affect 4 residents who are independent in ambulation as stated on the Resident Census and Conditions of Residents, form CMS-672. The findings were: 1. On 07/20/23 at 11:04 AM, the Surveyor opened an unlocked door on the D Hall, labeled Medication Room. The Surveyor entered the room and discovered two large plastic tubs containing a variety of medications resting immediately inside the door. While the Surveyor was inside the doorway of the room the Director of Nursing (DON) passed by in the hallway and inquired if the Surveyor needed help locating anyone. The Surveyor stated that he was observing the contents of the unlocked room. The DON left the Surveyor inside the room and continued down the hall. 2. On 07/20/23 at 11:14 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to the unlocked Medication Room. The Surveyor was again able to easily open the door to the room. The Surveyor asked LPN #1 to observe the medications inside the room and asked if the door should be unlocked. LPN #1 stated, No, it should be locked, and adjusted the doorknob so that it would lock. 3. On 07/20/2023 at 11:27 AM the DON confirmed medications were left on the medication room countertop, with the door unlocked. 4. On 07/20/23 at 3:20 PM, the Surveyor asked the DON if it was possible for a resident to open the door to the unlocked medication room. The DON stated, Yes, it should have been locked. The Surveyor asked what the outcome could have been if a resident had consumed some of the unsecured medication. The DON stated, They could get sick. 5. On 07/20/23 at 3:28 PM, the Surveyor asked the Administrator what the outcome could have been if a resident had entered the unlocked medication storage room and consumed medication that was not ordered for them. The Administrator stated, It could have made them very sick. 6. The facility policy titled, Storage of Medications, provided by LPN #1 on 07/20/23 at 4:45 PM documented, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperatures, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 4. Discontinued outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on interview and record review, the facility failed to employ a qualified Social Worker on a full-time basis as required by a facility licensed to provide care for more than 120 residents. The findings are: 1. Review of the Facility Assessment tool, dated 1/1/23 noted the facility is licensed to provide care for 154 residents. 2. On 07/19/2023 at 2:56 PM, the Surveyor asked the Social Services Director (SSD) to provide details regarding her level of education. She stated, I have a high school diploma and CNA [Certified Nursing Assistant] training. The Surveyor asked the SSD to verify that she did not possess a bachelor's degree. She confirmed that she did not. The Surveyor asked if the facility employed a qualified social worker with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field and at least one year of supervised social work experience. She confirmed they did not. The Surveyor asked if she was aware that having a qualified social worker employed on a full-time basis was a requirement for facilities licensed to provide care to 120 or more residents. She stated that she did not know. 3. On 07/19/23 at 3:04 PM, the Surveyor asked the Administrator how many residents the facility was licensed to provide care for. She stated, 154 residents. The Surveyor asked if the facility employed a qualified full-time Social Worker. She stated, No, we don't. I was under the impression that it was only necessary if we had over 120 residents in the facility. I went back and read the regulations this morning, and we are supposed to have one if we're licensed for more than 120.

Based on observation, interview, and record review, the facility failed to ensure staff documented dryer lint trap cleaning accurately to prevent the potential for fire in 1 of 1 facility. The findings are: 1. On 07/18/23 at 11:24 AM, the Surveyor asked Laundry Aide #1 and the Dietary Manager (DM) how often the lint traps were emptied. Laundry Aide #1 stated, Every hour. The Laundry Vent Trap Log documented signatures for every hour from 5:30 AM to 2:30 PM for 07/18/23. The Surveyor asked Laundry Aide #1 for the current time. Laundry Aide #1 stated, Almost 11:30. I did it until I leave today. The Surveyor asked what could happen if she signed the log ahead of time if someone else would know it needed to be performed. The Laundry Aide #1 stated, I'm sorry for doing that. a. On 07/18/23 at 11:37 AM, the District Manager stated, If we are going to do it, we must do it correctly. b. On 07/18/23 at 11:52 AM, the Surveyor asked the DM what outcomes could occur when the vent trap log was completed ahead of the process being performed and if the documentation should be accurate. The DM stated, If she was called away, then it could catch on fire. Yes ma'am, always it should be. c. On 07/18/23 at 11:56 AM, the Surveyor asked Laundry Aide #1 if the log should be completed as the process was performed or ahead of the process and if she was trained on compliance and ethics of accurate documentation. Laundry Aide #1 stated, I'm so sorry. I know I shouldn't have done that. I'm sure I have been. I have been here a long time. d. The facility in-service titled, Compliance and Ethics Inservice Training, dated 03/14/23 provided by the Administrator on 07/18/23 at 12:50 PM documented a discussion and handouts were provided and contained Laundry Aide #1 signature. e. On 07/20/23 at 2:56 PM, the Administrator stated the facility did not have a policy on laundry dryer lint trap cleaning, only dryer vent cleaning. The Administrator stated the Maintenance person and Dietary Manager both could not locate the manufacturer instructions for the dryers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident funds were refunded promptly to the resident or resident's representative within 30 days after the resident's discharged and/or death for 9 (Residents #66, #67, #68, #69, #70, #71, #72, #73 and #115) of 9 sampled residents who had been discharged /expired and had a remaining balance in the resident trust fund account. This failed practice had the potential to affect 51 residents who had a personal trust account managed by the facility, according to the Trial Balance Report dated [DATE], provided by the Administrator on [DATE] at 1:24 PM. The findings are: 1. The facility Trial Balance Report documented 9 names of discharged or expired residents with balances remaining in their resident trust account. a. Resident #66 had a balance of $4.02 and a Death in Facility Minimum Data Set (MDS) dated [DATE]. b. Resident #67 had a balance of $814.34 and a discharged Return Anticipated MDS dated [DATE]. c. Resident #68 had a balance of $27.61 and a discharged Return Anticipated MDS dated [DATE]. d. Resident #69 had a balance of $240.00 and a Death in Facility MDS dated [DATE]. e. Resident #70 had a balance of $0.01 and a Death in Facility MDS dated [DATE]. f. Resident #71 had a balance of $407.00 and a Death in Facility MDS dated [DATE]. g. Resident #72 had a balance of $383.61 and a Discharge Return Anticipated MDS dated [DATE] and a Discharge summary dated [DATE] documented, .Addendum: Resident expired . h. Resident #73 had a balance of $0.01 and a Death in Facility MDS dated [DATE]. i. Resident #115 had a balance of $49.32 and a Discharge Return Anticipated MDS dated [DATE]. 2. On [DATE] at 2:29 PM, the Surveyor asked the Business Office Manager [BOM] how long the facility had to return funds from resident trust accounts after the resident was discharged or expired. The BOM stated, I can find the answer because I am not sure. The BOM called the BOM Consultant who stated, You have 30 days. The Surveyor asked the BOM to verify the balances and if she knew of any circumstances the resident should not have received the funds. The BOM stated, All the discharge date s are right and the fact that they still have money is also right. The money should have gone to them or their family. I don't know of any circumstances. The Surveyor asked the BOM the reason the funds were not returned. The BOM stated, I was not aware that there was a 30-day window. If they have a beneficiary it goes to who is listed, if they did not fill a form out, then it goes back to the source either private pay or Social Security. 3. On [DATE] at 3:54 PM, the Surveyor asked the Administrator when funds are to be returned to discharged or expired residents. The Administrator stated, I did not know about the 30-day time frame until [BOM] told me. It has not come up in the 8 years I have been here. 4. The facility policy titled, Conveyance of Resident Funds, provided by the BOM on [DATE] at 10:08 AM documented, .Any funds on deposit with the facility are refunded to the resident, resident representative, or the resident's estate, upon discharge, eviction or death . 1. The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate jurisdiction per state law) within thirty (30) days from the date of the resident's discharge or eviction from the facility, or death .

Based on observation, interview, and record review, the facility failed to ensure No Smoking/Oxygen in Use signs were posted outside of the resident room for 3 (Resident #54, #62 and #167) sampled residents and the oxygen flow rate was administered per Physician Orders for 1 (Resident #54) sampled resident of 12 (Residents #17, #21, #33, #52, #54, #57, #58, #62, #116, #117, #120 and #167) who required oxygen therapy, and failed to ensure Bilevel Positive Airway Pressure (BiPap) masks and tubing were properly stored for 1 (Resident #167) of 1 sampled resident who required a BiPAP. The findings are: 1. On 07/17/23 at 10:52 AM, upon entering the facility, there was not a No smoking/oxygen in Use sign posted on the front door. 2. On 07/17/23 at 11:38 AM, Resident #54 was lying in bed with Oxygen (O2) on per Nasal Cannula at 3 liters per minute (LPM). A No Smoking/Oxygen in Use sign was not posted on the resident's door. a. On 07/18/23 at 8:42 AM, Resident #54 was lying in bed with oxygen at 3 LPM via nasal cannula (NC). No Smoking/Oxygen in Use sign was not posted on the resident's door. b. A Physicians Order dated 04/10/23 indicated Resident #54 was to receive O2 at 2 LPM via NC every night shift. c. A Care Plan with an initiated date of 05/15/23 indicated the resident was to receive O2 via NC at 2 LPM as needed. d. On 07/18/23 at 12:17 PM, the Surveyor asked Registered Nurse (RN) #2 if she could point out the No Smoking/Oxygen in Use sign and the importance of the sign when a resident received oxygen. RN #2 looked toward the doorway and stated, There isn't one. It's to remind us to go check on the resident and someone could go in the room that doesn't need to be near the oxygen. The Surveyor asked to visually observe the flow rate on Resident #54's concentrator. RN #2 stated, I don't think it's supposed to be on 3 and that's what it's on. I'll have to check the Physician Orders. RN #2 looked in the electronic record and stated, Nope it's supposed to be on 2. The Surveyor asked if it was ok for Resident #54 to be receiving the incorrect flow rate. She stated, Well no. The Surveyor asked what could happen by Resident #54 receiving the wrong flow rate. She stated, He could start retaining carbon dioxide and become confused, fall or have a mental change. 3. On 07/17/23 at 11:53 AM and 2:59 PM, Resident #62 was lying in bed with oxygen on by nasal cannula at 1 LPM. A No Smoking/Oxygen in Use sign was not posted on the resident's door. a. On 07/18/23 at 10:14 AM, Resident #62 was lying in bed with oxygen being administered by nasal cannula at 1 LPM. A No Smoking/Oxygen in Use sign was not posted on the resident's door. b. A Physicians Order dated 07/02/23 indicated Resident #62 was to receive O2 at 1 LPM via NC as needed for shortness of breath. c. A Care Plan with an initiated date of 07/18/23 indicated Resident #62 was to receive O2 at 1 LPM as needed. d. On 07/18/23 at 12:19 PM, the Surveyor asked RN #2 to go to Resident #62's room. The Surveyor asked if Resident #62 was being administered oxygen. She stated, Yes. The Surveyor asked RN #2 to verify where the No Smoking/Oxygen in Use sign was located. She stated there's not one. The Surveyor asked why there should be a warning sign on the door during oxygen administration. She stated, To remind us to go check it and someone could go in there that doesn't need to be near the oxygen. 4. On 07/17/23 at 10:35 AM, Resident #167 was lying in bed with oxygen running at 2 LPM via nasal cannula. A No Smoking/Oxygen in Use sign was not posted on the resident's door. A BiPAP mask and tubing were lying on the bedside table not in a bag. a. On 07/18/23 at 9:59 AM, Resident #167 was lying in bed with oxygen running at 2 LPM per nasal cannula. A No Smoking/Oxygen in Use sign was not posted on the resident's door. A BiPAP mask and tubing were lying on the bedside table not in a bag. The Surveyor asked Resident #167 if he used the BiPAP. He stated, Every night. The Surveyor asked if he puts the mask on and off himself. He stated, Oh no, the nurses do that for me. b. A Physicians Order dated 06/20/23 indicated Resident #167 received O2 at 2 to 4 LPM via NC as needed and may remove as desired. c. A Physicians Order dated 06/21/23 indicated the resident used a BiPAP at bedtime. d. A Care Plan with a revision date of 06/28/23 indicated Resident #167 was to receive O2 via NC at 2 to 4 LPM as needed. The Care Plan did not address the use and care of the BiPAP. e. On 07/18/23 at 12:10 PM, the Surveyor asked RN #1 if Resident #167 was actively receiving oxygen. She stated, Yes. The Surveyor asked if she could locate the No Smoking/Oxygen in Use sign on the door to Resident #167's room. She stated, There's not one and we need one of those. The Surveyor asked if it was necessary to have a No Smoking/Oxygen in Use sign on the door when a resident was receiving oxygen. She stated, Yes, so others are aware, and oxygen is flammable. The Surveyor asked RN #1 to observe the location of the BiPAP mask and tubing. She stated, It is laying directly on the table beside the bed. They should be bagged when not in use. The Surveyor asked RN #1 to explain why the mask and tubing should be bagged. She stated, So it doesn't fall in the floor and get contaminated with bacteria. 5. On 07/19/23 at 2:08 PM, the Surveyor asked the Director of Nursing (DON) to explain why a No Smoking/Oxygen in Use sign should be placed on the door of a resident who is being administered oxygen. She stated, For people who smoke because oxygen is flammable. The Surveyor asked if the No Smoking/Oxygen in Use sign should be placed on the door of a resident receiving oxygen. She stated, Yes. The Surveyor asked the DON to explain the process for storage of a BiPAP mask and tubing. She stated, It should be stored in a bag. The Surveyor asked why storage in a bag was necessary. She stated, To keep bacteria off of it. The Surveyor asked what the process for ensuring oxygen is being administered as ordered by Physician. She stated, Go by the Physicians Order, set the oxygen at that rate. The Surveyor asked the DON to explain what could happen by not following physicians prescribed orders. She stated, He will get an increase of carbon dioxide and that causes confusion. 6. A facility policy titled, Oxygen Administration, provided by the DON on 07/19/23 at 3:26 PM documented, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure . 4. No Smoking/Oxygen in Use signs . 7. A facility policy titled, CPAP/BIPAP Support, provided the DON on 07/19/23 at 3:26 PM documented, .Equipment and Supplies 1. NO SMOKING sign for the resident's room . The policy did not address storage of the mask and tubing when not in use. 8. A facility policy titled, Oxygen Management, provided by the DON on 07/20/23 at 9:47 AM documented, .Equipment: #4 .Oxygen sign (If not on the entrance door to the facility) .#7 Store oxygen accessories such as tubing's in a designated container-like device .

Based on observation, interview, and record review, the facility failed to ensure food stored in the facility's refrigerator, freezer, and dry storage were dated when received and/or opened, spices were discarded after a year, foods stored in opened boxes were in sealed bags, and perishable foods were accurately dated with the date prepared in 1 of 1 kitchen. The failed practice had the potential to affect 71 residents who received meals from the kitchen as documented on the Dietary Diet report provided by the Director of Nursing (DON) on 07/19/23 at 3:44 PM. The findings are: 1. On 07/17/23 at 11:24 AM, during the initial tour of the kitchen, the dry storage room, and the walk-in freezer the following observations were made: a. Kitchen: i) On the shelf under the coffee makers was a box of 4 lemonade packets with no received or use by dates. The Dietary Manager (DM) stated, No, I do not see any dates on those. and proceeded to ask Dietary Employee (DE) #1 to date them. b. Dry Storage Room: i) a plastic container of ground basil dated received on 3/17/21, and a plastic bottle of almond extract dated received on 3/22/18. The DM stated, Those are only good for 1 year. ii) A can of olives dated received 6/23/22. The DM stated they were good for a year or barely. Some items aren't even good a year in cans. iii) An opened bag of cake mix was in a thin plastic bag that was not sealed sitting in a broken plastic container. The District Manager stated, I did not seal that after I checked to see if it was opened this morning. iv) An opened bag of flour was in a plastic container with a cracked open top. The DM stated, The bag should be rolled down to seal it. c. In the walk-in freezer located outside. i) A zippered bag of peas dated 7/11 and a zippered bag of cauliflower dated 7/14. The Surveyor asked if the dates were received or opened dates. The DM stated, They are opened dates. I am not sure when they were received. ii) On the bottom shelf of the freezer was a box of 2 roasts sealed in plastic dated 1/12/23. The Surveyor asked if the facility had served a roast since 1/12/23. The DM stated, I don't think so, but those should have been used already. The District Dietary Manager stated, We just in-serviced on using oldest items first. iii) An opened box of tilapia fillets dated 7/5 were contained in an unsealed bag. The DM stated, That should be sealed better. d. On 07/17/23 at 12:08 PM, in the kitchen on the second shelf from the bottom of a stainless shelving rack between the entrance door and the steam table there was a blue plastic bowl of 11 pastries and 3 cookies not dated that had no best by dates. The DM stated, I guess we have no way to prove when those were received. DE #1 asked if they needed to be dated. The DM stated, I think they need to be. 2. On 07/19/23 at 7:05 AM, DE #2 took a stainless steel square container of peeled eggs and poured them into a zippered bag of hard boiled eggs dated 7/18. The Surveyor asked DE #2 the date of the new eggs and the date of the eggs in the bag and if she could tell the difference between them now. DE #2 stated, these were made today (holding up the empty stainless steel square container) and those are dated 7/18 (pointing to the zippered bag). I don't know which ones were made today now. The Surveyor asked what the outcome could be of combining items from different days in the same bag. DE #2 stated, I don't know which ones are from which days. The DM stated, They need to be dated correctly. 3. A facility policy titled, Food Storage, provided by the Administrator on 07/20/23 at 9:28 AM documented, .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .10. All packaged and canned food items will be kept clean, dry, and properly sealed .11. Storage areas will be neat, arranged for easy identification, and date marked as appropriate .

Based on observation, record review and interview, the facility failed to ensure oxygen tubing and nebulizer tubing and mouthpiece were properly stored when not in use to prevent potential cross contamination and/or respiratory infection for 1 (Resident # 50) of 9 (Residents #16, #19, #20, #22, #23, #30, #36, #50, and #58) sampled residents with physician orders for oxygen therapy. This failed practice had the potential to affect 20 residents with physician orders for oxygen therapy according to a list provided by the Administrator on 2/21/22 at 10:05 AM. The findings are: 1. Resident #50 had diagnoses of Respiratory Failure with Hypoxia, Anemia, and Moderate Persistent Asthma. The admission Minimum Data Set with an Assessment Reference Date of 3/14/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and received oxygen therapy. a. The Care Plan with a revision date of 03/15/22 documented, .I have a Respiratory Infection COPD [Chronic Obstructive Pulmonary Disease] exacerbation . Administer oxygen as needed/ordered . I have altered respiratory status/difficulty breathing r/t [related to] COPD, respiratory failure, aortic stenosis . Administer medication/treatment as ordered. Observe for effectiveness and side effects . b. The April 2022 Physician's Orders documented, .Change oxygen tubing q week every night shift every Tue [Tuesday] . Order Date 03/30/22 Oxygen 2 LPM [liters per minute] via NC [nasal cannula] as needed for shortness of breath . Order Date 03/30/22 .Albuterol Sulfate Nebulization Solution (2.5 MG/3ML [Milligrams per Milliliter]) 0.083% [percent] 1 vial inhale orally via nebulizer one time a day . Order Date 03/11/22 . c. The April 2022 MAR [Medication Administration Record] documented, Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 1 vial inhale orally via nebulizer one time a day .0800 [8:00 AM] . Change oxygen tubing q [every] week every night shift every Tue -Start Date- 04/05/2022 1900 [7:00 PM] .Clean external filter on oxygen concentrator weekly and as needed every night shift every Tue -Start Date- 04/05/2022 . The Albuterol Sulfate Nebulization Solution was documented as given every day except for 04/11/22 and 04/12/22. There was no documentation the oxygen tubing was changed, or the external filter was cleaned as ordered on Tuesday April 12, 2022. d. On 04/18/22 at 10:56 AM, Resident #50's nebulizer kit was lying on the bed not in a bag with no date on the tubing. The oxygen concentrator was running at 2 liters per minute. The nasal cannula tubing was also lying on the bed and was dated 04/05/22 and was not in a bag. Resident #50 was not in the room. e. On 4/21/22 at 2:30 PM, the Director of Nursing (DON) was asked what the process for changing oxygen tubing and nebulizer kits were. The DON stated, They are changed weekly and should be stored in a bag when not in use, that is our policy. f. The facility's policy titled, Oxygen Management, provided by the DON on 4/19/22 at 3:47 PM documented, .6.oxygen materials to be changed weekly and PRN [as needed]. Store oxygen accessories such as tubing in a designated container-like device that is accessible to the patient and staff. Change at designated frequencies . g. The facility policy titled, Nebulizer Medication Administration Guidelines, provided by the DON on 04/25/22 at 8:26 AM documented, . 8) When mediation is completed nebulized, turn off machine. Rinse nebulizer cup per organization procedure. Dry completed and store tubing assembly within dated bag . e. Storage of nebulizer machine and accessories 2) nebulizer accessories will be stored in a container-like device and replaced at designated intervals .

Based on record review and interview, the facility failed to ensure there was a qualified social worker employed to meet individual needs of the residents. The findings are: 1. On 04/19/22 at 10:55 AM, the Administrator was asked for a copy of the Social Service Director's (SSD) degree and license. The Administrator stated their SSD did not have a license or degree. SSD was a good CNA that they promoted. This surveyor stated their facility was licensed for 154 beds according to the Nursing Home Directory maintained by the Office of Long Term Care and therefore needed a license SSD with a degree. The Administrator then stated they did not because their census was only 73. 2. On 04/20/22 at 12:45 PM, the Administrator was informed the regulation is based on licensure and not census and was read the 483.70 regulation, Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is: An individual with a minimum of a bachelor's degree . and . One year of supervised social work experience in a health care setting working directly with individuals. The Administrator stated, Wow, I didn't know that. We are not going to be able to find one for what we pay. 3. On 04/21/22 at 2:00 PM, the Administrator was asked how many beds the facility was currently licensed for. The Administrator stated, 154 beds.

Based on observation, interview and record review, the facility failed to follow & implement an appropriate plan of action to correct an identified quality deficiency cited on the 2021 2021 annual survey to monitor, track, and evaluate the effectiveness of their Infection Control Plan for their Quality Assurance corrective action/performance improvement activities/plan. This failed practice had the potential to affect all 73 residents in the facility per the resident census provided by the Administrator on 4/18/22. The findings are: 1. On 04/21/22 at 2:30 PM, review of the 2021 Annual Survey Results dated 3/5/21 documented a F880 tag was cited for Infection Control of Quarantine/Isolation rooms. 2. On 04/19/22 at 10:40 AM, Housekeeper (HSK) #2 was asked how Isolation (ISO) and Quarantine linens and personable clothing were transported. HSK #2 stated, They are yellow bagged, and CNAs [Certified Nursing Assistants] bring them to the laundry room. They put the yellow bag and all in the washer to empty and then the yellow bag goes into the red bin. HSK #2 was asked if there were any yellow bags in the red bin. She stated she did not know. She was asked about the location of current ISO/Quarantine rooms. HSK #2 stated there were some on A Hall currently. She was asked if ISO/Quarantine rooms were treated like COVID rooms. She stated, Not really, their things are not taken outside. This surveyor asked for clarification about transporting ISO and Quarantine linens in yellow bags and HSK #2 stated, They should be brought here in yellow bags. 3. On 04/19/22 at 11:00 AM, surveyor entered Resident #271's room who was on Airborne Quarantine (per sign on door) to check for a yellow bag in the laundry hamper. There was not a yellow bag for his linens. 4. On 04/20/22 at 12:45 PM, the Administrator was asked if Quarantine linens, trash, etc. [etcetera] were handled the same as ISO. The Administrator stated Oh, yes definitely. 5. On 04/20/22 at 1:41 PM, CNA #1 was on B Hall and was asked how laundry was handled for TBP (Transmission Based Precautions) for Resident #272. CNA #1 stated, Her laundry is in a bag in the closet and her family comes and gets it and does it. 6. On 04/20/22 at 1:43 PM, CNA #2 was on A Hall and was asked how trash and laundry was handled for TBP, Resident #270 and Resident #271. CNA #2 stated, Yellow bags are used for their laundry and are double bagged and taken to the laundry room and put in the specific barrel for the yellow bags. The trash is in regular bags but double bagged and put into the regular trash cart. CNA #2 was asked where the yellow bags were kept. CNA #2 could not find any in the PPE drawers of either room. 7. On 04/20/22 at 1:48 Licensed Practical Nurse (LPN) #1 was asked how trash and laundry was handled for TBP, Resident #270 and Resident #271. LPN #1 stated, To tell you the truth, staff are using regular bags for trash and regular bags to transport laundry and staff hang onto their gowns and hang them on the back of the doors and use the same gowns and only switch gloves. LPN #1 was asked if it was one or two bags and LPN #1 stated she was not sure. She was asked if yellow bags were used to transport laundry. LPN #1 stated, I have never seen a yellow or red bag used. 8. On 04/20/22 at 1:52 CNA #2 found surveyors at nurses' station and stated I was mistaken. We do not use yellow bags for quarantine, just for isolation. 9. On 04/20/22 at 1:54 PM, the Infection Control Preventionist (ICP) was asked about Quarantine linens and trash. The ICP stated, Quarantine laundry and trash are handled just like everyone else's out here. The ICP was asked if Quarantine and ISO were the same. The ICP stated, They are not. Quarantine is only 14 days. 10. On 04/20/22 at 2:08 PM, the Director of Nursing (DON) was asked if there was a difference between ISO and Quarantine. The DON stated, Not really. The only difference is a movement restriction for the residents on isolation. The DON was asked how laundry was handled for ISO and Quarantine. The DON stated, Isolation uses vinegar yellow bags and Quarantine uses regular bags. The DON was asked why a resident is on Quarantine. The DON stated, It is to monitor for COVID symptoms and is only for 14 days. The DON was asked if non-vaccinated quarantine resident's linens should be treated as if they had COVID. The DON stated No, there is no reason to. 11. On 04/21/22 at 10:00 AM, the Administrator was asked if residents' laundry on TBP Quarantine should be handled as if they had COVID. The Administrator stated, Yes, they should. They are washed on high heat and kept separate. This surveyor stated that the surveyors were trying to clarify what the facility's actual process was for non-vaccinated Quarantine residents. The Administrator stated she would go get [HSK #1]. 12.On 04/21/22 at 10:06 AM, HSK #1 was asked how housekeeping knows linens have come from Quarantine and Isolation. HSK #1 stated, Laundry from both Quarantine and Isolation rooms come to laundry in yellow bags by the CNAs. COVID hall bags come in red bags. HSK #1 was asked if there were currently any TBP rooms that should have their laundry come via yellow bags. HSK #1 stated, Yes there are a few. HSK #1 was asked if she had noticed any laundry coming in yellow bags. HSK #1 stated she had not. The Administrator was asked if there were yellow bags in the building. HSK #1 stated there were because they had changed a while back from white and clear to yellow and clear. This surveyor stated that [CNA #2] and [LPN #1] on A hall stated yellow bags were not being used and [CNA #2] could not find yellow bags when asked to show them to the surveyors. 13. On 04/21/22 at 1:20 PM, the DON, Administrator and the HSK Supervisor came into conference room and stated that the facility's consultant told them they did not need to handle laundry from quarantine rooms any different than other resident rooms because they are only on quarantine for 14 days because they are not vaccinated. This surveyor asked if quarantine should be handled as if they could be or are contagious and the DON stated there was no need. 14. On 04/21/22 at 3:05 PM, the Administrator was asked, How often does QA [Quality Assurance] meet? The Administrator stated, Monthly. The Administrator was asked how she tracks and monitors deficiencies from each survey. The Administrator stated a plan is developed and implemented, that last year's Infection Control tag was because a bag of laundry from a Quarantine room had air in it and when it got to the laundry room it went POOF and that is what the surveyor wrote us up for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the Care Plan was revised to address the care and monitoring of a central line in a resident on dialysis for 1 (Residents #19) of 1 sampled resident who received dialysis and failed to ensure the code status of a resident who was admitted to Hospice was updated to Do Not Resuscitate for 1 (Resident #58) of 1 sampled resident whose code status changed. This failed practice had the potential to affect all 73 residents who resided in the facility. The findings are: 1. Resident #19 had diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease and Dependence on Renal Dialysis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received dialysis while a resident. a. The Physician's Order dated [DATE] documented, . Dialysis at [Company] Dialysis on M-W-F [Monday-Wednesday-Friday] . Order Date [DATE] . The Physician Orders did not address the central line. b. The Care Plan with a revision date of [DATE] documented, . I am at risk for complications as I receive Dialysis on Monday, Wednesday, and Friday . My shunt site will be accessed by the dialysis center only or as ordered . The Care Plan does not address the resident's central line. c. The History of Accesses document provided by the DON on [DATE] at 9:52 AM documented, [Resident #19] . Patient Access . Effective Date [DATE] . Status: Primary .Location LIJ [left Internal Jugular] . d. On [DATE] at 11:37 AM, Resident #19 was asked when she went to dialysis. She stated, I go to dialysis Mondays, Wednesdays and Fridays. I just got back. She was asked where she gets her dialysis. She pulled down her shirt, a double lumen central line located on the left upper chest. The dressing dry was and intact and not dated. She stated, I used to get it in my arm, but they had to put this in and now I get it here . e. On [DATE] at 1:51 PM, Licensed Practical Nurse (LPN) #2 was asked, Where is [Resident #19] receiving her dialysis? She stated, Her upper chest, it was in her shunt in her arm .we check her bandage when she gets back and make sure she is not bleeding. She was asked, Who is changing the central line dressings? She stated, They take care of it at Dialysis. f. On [DATE] at 2:49 PM, the Director of Nursing (DON) was asked, Where is [Resident #19] receiving her dialysis? She stated, It was in her arm, but they put in a port. She was asked, Should there be an order for central line care? She stated, Yes. The DON was asked, Should the central line interventions be addressed in the care plan? She looked at her computer screen and stated, Yes. The DON was asked, When was the central line inserted? The DON stated, I am not sure. 2. Resident #58 had a diagnosis of Undeferential Schizophrenia, Unspecified Dementia with Behavioral Disturbance and Cerebral Infarction. The Quarterly MDS with an ARD of [DATE] documented the resident scored 0 (0-7 indicates severely cognitively impaired on a BIMS and was on hospice and did not dialysis. required limited assist with one person for bathing, supervision with two persons assist for bed mobility, and transfer. a. The Care Plan with a revision date of [DATE] documented, I am a Full Code . I need you to initiate CPR [Cardiopulmonary Resuscitation] if you find me pulseless and breathless and continue CPR until Emergency personnel arrive to take over. b. The [DATE] Physician Orders documented, Admit to [name] Hospice . Order Date [DATE] . Do Not Resuscitate . Order Date [DATE] . c. On [DATE] at 2:34 PM, the MDS Coordinator was asked, What is [Resident #58's] code status? She looked in the physician's order in the electronic record and stated, On [DATE] they changed her to DNR [Do Not Resuscitate]. The MDS Coordinator was asked, What is [Resident #58's] code status on her Care Plan? She looked at Resident #58's care plan in the electronic record and stated, .You need to initiate CPR . That needs to come off of there . They should have updated it [care plan code status] when she went into Hospice . The MDS Coordinator was asked, Who is responsible for updating the code status on the resident's care plans? She stated, [Name] in Social Services .she is off due to . 3. The facility policy titled, Comprehensive Care Plans, provided by the Administrator on [DATE] at 10:05 AM documented, .It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident .1. The following health care professionals contribute to the interdisciplinary Care Plan by collaboration and direct documentation: Social Services Coordinator .

Based on observation, interview and record review the facility failed to ensure fingernails were trimmed, clean, and free of jagged edges for 2 (Residents #27 and #41) of 21 (Residents #24, #50, #31, #57, #55, #39, #16, #272, #273, #43, #44, #47, #48, #11, #41, #30, #27, #45, #58, #25 and #22) sampled residents who were dependent on staff for nail care. This failed practice had the potential to effect 44 residents who were dependent on staff for nail care according to a list provided by the Administrator on 4/21/2022 at 1:18 PM. The findings are: 1. Resident #27 had diagnoses of Dementia, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease and Bipolar Disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with personal hygiene and bathing. a. The Care Plan with a revision date of 04/12/22 documented, . I have an ADL [activities of daily living] self-care performance deficit . I require limited to extensive assist x [times]1 staff for personal hygiene . I am at risk for altered skin integrity . Keep my nails trimmed and or filed to minimize jagged edges . b. On 04/19/22 at 2:08 PM, Resident #27 was sitting in the day area. His fingernails were approximately 3/8 inches from the end of his fingers, jagged and pointed with brown debris underneath all of them. c. On 04/20/22 at 10:25 AM, Resident #27 was up in main dining room drinking coffee. The fingernails on both hands were jagged and pointy and had brown debris under them. His pinky fingernail was approximately a quarter inch from nail bed, jagged and pointy with brown debris under the nail. d. On 4/21/22 at 11:25 AM, the Director of Nursing (DON) was asked to assess Resident #27's fingernails. Resident #27 was sitting in the main dining room with a plate of food in front of him and several empty coffee cups. The DON asked to see his nails. She took his hand and he opened up his fingers. She ran her fingers across his nails and stated, .Yes, those are jagged, they need to be cut. [Resident #27] can I cut your nails? Resident #27 said .Yes . and shook his head up and down. The DON was asked, How often are fingernails to be cut? She stated, .Well that depends, some don't like their nails cut . She was asked, Has [Resident #27] refused to have his nails cut and/or cleaned? She stated, .He does have some behaviors with care . She was asked, Has he refused to have his nails cut, trimmed or cleaned? She stated, .I think he has . She was asked, Is it documented in his chart that he has refused to have nail care provided? She stated, .Probably not, and if it's not it didn't happen . 2. Resident #41 had diagnoses of Encephalopathy, Mild Cognitive Impairment and Reduced Mobility and Muscle Weakness. The Quarterly MDS with an ARD of 3/08/2022 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with personal hygiene and bathing. a. The Care Plan with a revision date of 04/12/22 documented, . I have an ADL [activities of daily living] self-care performance deficit . Personal Hygiene: I require extensive assist x [times] 1-2 staff with personal hygiene ., I am at risk for Impaired Skin Integrity . Assist me to keep my nails trimmed and or filed to minimize jagged edges . b. On 04/18/22 at 12:01 PM, Resident #41 was sitting up in the day area. The fingernails of both hands were approximately ¼ inch from the end of his fingers, some were broken and jagged with brown debris under all of them. c. On 04/20/22 at 12:23 PM, Resident #41 was seated at a table in the main dining room for lunch. His nails on both hands were approximately ¼ inch from the end of his fingers, some were broken, jagged or pointy and all of them had brown debris under them. Resident #41 fed himself after his tray was set up using his fingers. d. On 4/21/2022 at 11:27 AM, the DON was asked to assess Resident #41 fingernails. Resident #41 had just got up to his chair for lunch. The DON asked to see his nails. Resident #41 held out his right hand. The DON held his hand and he straightened out his fingers. The DON was asked to describe his nails. She stated, .They are long, jagged and dirty . Resident #41 was asked, May we check the other hand? Resident #41 opened his hand and the DON stated, .Yes, they definitely need to be cut and cleaned . She was asked, When are nails supposed to be checked and cut if needed? She stated, .At least weekly with their showers . She was asked, How often do residents get showers? She stated, .Usually two times a week . 3. The facility policy titled, Footcare/Nailcare, provided by the Administrator on 04/21/22 at 1:26 PM documented .Procedure Purpose: ., to prevent infection of the nails/fingertips ., to prevent irritation of the nails/fingertips ., to prevent injury ., to promote cleanliness ., fingernails are to be clipped and filed smoothly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.Resident #52 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure with Hypoxia, Cerebral Infarction and Fracture of Left Shoulder Girdle. The 5 Day MDS with an ARD of 3/20/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required extensive physical assistance of one person for bed mobility, dressing, and toilet use, and limited physical assistance of one person for transfers and personal hygiene. a. The Care Plan with initiated dates from 02/18/22 to 04/19/22 did not address the resident smoking until 04/18/22. b. The Smoking Safety Screen dated 04/11/22 at 11:50 AM documented, .6. Can resident light own cigarette? Yes .8. Does resident need facility to store lighter and cigarettes? No . IDTC decision 2. Team Decision: 1. Safe to smoke without supervision. Rationale/conditions: able to smoke in designated smoking areas without supervision . c. On 04/18/22 at 2:21 PM, Resident #52 was going out of the door to smoke with another resident. Resident #52 had her own cigarettes and lighter. d. On 04/19/22 at 10:02 AM, Resident #52 was going out to smoke. Resident #52 removed cigarettes and a lighter from a black zippered pouch from inside her wheelchair. e. On 04/19/22 at 1:30 PM, Resident #52 was asked where she keeps her cigarettes and lighter. Resident #52 removed a black zippered pouch from inside of her wheelchair and displayed to this surveyor. Resident #52 stated she keeps an extra pack of cigarettes in her dresser drawer. When asked where she keeps her pouch at night, she said in her nightstand drawer and has not had any problems with anyone coming into her room. Resident #52 stated, I didn't know I had to have a locked box until last week. I have one at home and will get it here. f. On 04/20/22 at 10:32 AM, Resident #52 was outside at this same time as Resident #30, and she stated .I've been here three weeks and I haven't got a lock box yet . Resident #52 was asked if she kept her cigarettes and lighter with her or in her room. She stated, .Yes, I keep them, but I don't have a lock box. I didn't know I needed one until she (pointing to Resident #30) told me I had to get one . They both had lighters and lit their own cigarettes. g. On 04/21/22 at 2:30 PM, the DON was asked where residents who smoke are supposed to store their cigarettes and lighter when not in use. The DON stated. If they are assessed to smoke, we give them lock boxes. The DON was asked if [Resident #52] had a lock box to store her smoking supplies in. The DON stated, When we became aware of it, [Resident #52] was provided a lock box. She was asked when the facility became aware of it. The DON stated, Yesterday, I believe. 5. The facility policy title, Smoking Safety provided by the Administrator on 4/20/2022 at 1:29 PM documented .All residents will be asked about tobacco use during the admission process and assessed as smoking or non-smoking during each quarterly or comprehensive MDS assessment process ., Residents who smoke will be further assessed, to determine whether supervision is required for smoking, or if resident is safe to smoke at all . Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan ., All safe smoking measures will be documented on each resident's care plan . Based on observation, record review and interview, the facility failed to ensure smoking materials were kept secured in a locked box when not in use to prevent access to cognitively impaired residents for 2 (Residents #30 and #52) of 4 (Residents #30, #36, #51 and #52) sampled residents who were allowed to keep their smoking materials in their room. This failed practice had the potential to effect 10 residents who were ambulatory on A Hall and D Hall with a BIMS of 12 or less according to a list provided by the Administrator on 4/21/2022 at 11:19 AM. The findings are: 1. A document with the Facility's name at the top provided by the Administrator on 04/18/22 at 11:40 AM documented, .Policy: It is the policy of [Facility] to have all residents who wish to smoke at the facility to be properly supervised to ensure a safe environment for all residents. Procedure: 1. Any resident that wishes to smoke while a resident at [Facility] will be required to keep their cigarettes, cigars, lighters, matches, electronic cigarettes and any other smoking items locked up . 2. The Smoking Procedure admission Packet provided by the Administrator on 4/18/2022 at 12:38 PM documented, .The resident's smoking materials will be kept by the facility in a secure location. Smoking assessments will be completed upon admission, quarterly, annually, and with any significant change that determines the level of assistance required with the resident smoking population. Resident's will be supervised while smoking at the facility during designated smoking times. Any form of non-compliance with the facility storage of smoking articles, smoking inside the facility, smoking without supervision, etc. [etcetera] will require immediate notification to the administrator/designee and a care plan meeting or a behavioral contract can be instituted in an attempt to create compliance with the smoking procedure . Residents and/or representatives will receive smoking information upon admission into the facility . 3. Resident #30 had diagnosis of Muscle Weakness and Chronic Obstruction Pulmonary Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/28/2022 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was independent with bed mobility, transfers walking in the room, locomotion on and off the unit and required limited physical assistance of one person with walking in the corridor. a. The Smoking Safety Screen dated 03/18/22 at 11:42 AM documented, .6. Can resident light own cigarette? Yes .8. Does resident need facility to store lighter and cigarettes? No .IDTC [Interdisciplinary Team Committee] decision . 2. Team Decision: Safe to smoke without supervision. Rationale/conditions: Able to smoke in designated smoking areas . b. The Care Plan with a revision date of 04/12/22 documented, I will participate in activities of my choice . I enjoy going outdoors to smoke . Smoking Safety . Educate resident about the facility policy on smoking: locations, times, safety concerns . Ensure oxygen canisters/concentrators are not present when resident is smoking . I am cleared by PT to go outside by myself to smoke. I keep my cigarettes on me and in my room . c. On 04/18/22 at 2:19 PM, Resident #30 was asked if she kept her cigarettes and lighter with her or did the nurses keep them. She stated, .I keep them . then she proceeded to feel the outside of her jacket pockets then stated, .They are in there . pointing to the bureau drawer. She then moved over to the bureau, pulled open the top drawer, and pointed to the pack of cigarettes that was sitting on the right hand side of the drawer. She stated, .I have a lock box . from her wheelchair, she reached inside of the drawer and stated, .It's right here in my drawer, oh, it's supposed to be locked . She chuckled and tried to close the lid, it wouldn't close due to the tray not being centered correctly and an article of clothing stopping the lid from closing. Resident #30 was asked where her lighter was. She pulled the tray out of the lock box and pointed inside the bottom; her lighter lay on the bottom of the box. d. On 04/18/22 at 2:19 PM, Resident #30 was asked if her cigarettes and lighter should be secured in the lock box when not in use. She stated, .Yes, I'm supposed to keep them in there . She was asked, Who instructed you to keep them in your lock box? She stated, .[Director of Nursing] . She was asked, Who provided you with the lock box? She stated, .I'm not sure, someone up front . She was asked, But it came from the facility? She stated, .Yes . e. On 04/19/22 at 11:36 AM, Resident #30 was not in her room. The top drawer of her bureau (approximately chest high) was open, and her lockbox was in the top drawer with the lid partially open. An opened package of cigarettes was lying on top of the clothing in the drawer. f. On 4/21/22 at 11:21 AM, the Director of Nursing (DON) was asked, Is [Resident #30] allowed to keep her own smoking materials [cigarettes and lighter]? She stated, .Yes, her cigarettes and lighter . She was asked, How should it be stored? She stated, .In her room, she has a lock box . She was asked, If kept in a lock box, is this allowed to be in the resident's room? She stated, .Yes, they are allowed to keep it . She was asked, Should the lock box be locked at all times? She stated, .We encourage her to keep it locked, it should be locked . She was asked, Who provides the lock boxes for the resident? She stated, .The facility provides them . She was asked, Are residents instructed on how to store their smoking materials? She stated, .Yes, they are . She was asked, Does the facility have any monitoring in place for these lock boxes? She stated, .No, we don't . She was asked, Then how do you know the resident is using the lock box correctly? She stated, .We encourage them to use the lock boxes . She was asked, But how does the facility ensure they are used correctly, for safety? She stated, .We don't .

Based on observation, record review and interview, the facility failed to ensure proper infection and control practices were implemented to prevent the development and transmission of COVID-19 and other communicable disease and infections by failure to handle contaminated linens appropriately during transportation of linens and personals from TBP rooms to the laundry room for 2 (Residents #270 and #271) of 3 (Residents #270, #271 and #272) sampled residents who were on Airborne Quarantine due to being unvaccinated new admissions. The findings are: 1. On 04/19/22 at 10:40 AM, Housekeeper (HSK) #2 was asked how Isolation (ISO) and Quarantine linens and personable clothing were transported. HSK #2 stated, They are yellow bagged, and CNAs [Certified Nursing Assistants] bring them to the laundry room. They put the yellow bag and all in the washer to empty and then the yellow bag goes into the red bin. HSK #2 was asked if there were any yellow bags in the red bin. She stated she did not know. She was asked about the location of current ISO/Quarantine rooms. HSK #2 stated there were some on A Hall currently. She was asked if ISO/Quarantine rooms were treated like COVID rooms. She stated, Not really, their things are not taken outside. This surveyor asked for clarification about transporting ISO and Quarantine linens in yellow bags and HSK #2 stated, They should be brought here in yellow bags. 2. On 04/19/22 at 11:00 AM, surveyor entered Resident #271's room who was on Airborne Quarantine (per sign on door) to check for a yellow bag in the laundry hamper. There was not a yellow bag for his linens. 3. On 04/20/22 at 12:45 PM, the Administrator was asked if Quarantine linens, trash, etc. [etcetera] were handled the same as ISO. The Administrator stated Oh, yes definitely. 4. On 04/20/22 at 1:41 PM, CNA #1 was on B Hall and was asked how laundry was handled for TBP (Transmission Based Precautions) for Resident #272. CNA #1 stated, Her laundry is in a bag in the closet and her family comes and gets it and does it. 5. On 04/20/22 at 1:43 PM, CNA #2 was on A Hall and was asked how trash and laundry was handled for TBP, Resident #270 and Resident #271. CNA #2 stated, Yellow bags are used for their laundry and are double bagged and taken to the laundry room and put in the specific barrel for the yellow bags. The trash is in regular bags but double bagged and put into the regular trash cart. CNA #2 was asked where the yellow bags were kept. CNA #2 could not find any in the PPE drawers of either room. 6. On 04/20/22 at 1:48 Licensed Practical Nurse (LPN) #1 was asked how trash and laundry was handled for TBP, Resident #270 and Resident #271. LPN #1 stated, To tell you the truth, staff are using regular bags for trash and regular bags to transport laundry and staff hang onto their gowns and hang them on the back of the doors and use the same gowns and only switch gloves. LPN #1 was asked if it was one or two bags and LPN #1 stated she was not sure. She was asked if yellow bags were used to transport laundry. LPN #1 stated, I have never seen a yellow or red bag used. 7. On 04/20/22 at 1:52 p.m., CNA #2 stated I was mistaken. We do not use yellow bags for quarantine, just for isolation. 8. On 04/20/22 at 1:54 PM, the Infection Control Preventionist (ICP) was asked about Quarantine linens and trash. The ICP stated, Quarantine laundry and trash are handled just like everyone else's out here. The ICP was asked if Quarantine and ISO were the same. The ICP stated, They are not. Quarantine is only 14 days. 9. On 04/20/22 at 2:08 PM, the Director of Nursing (DON) was asked if there was a difference between ISO and Quarantine. The DON stated, Not really. The only difference is a movement restriction for the residents on isolation. The DON was asked how laundry was handled for ISO and Quarantine. The DON stated, Isolation uses vinegar yellow bags and Quarantine uses regular bags. The DON was asked why a resident is on Quarantine. The DON stated, It is to monitor for COVID symptoms and is only for 14 days. The DON was asked if non-vaccinated quarantine resident's linens should be treated as if they had COVID. The DON stated No, there is no reason to. 10. On 04/21/22 at 10:00 AM, the Administrator was asked if residents' laundry on TBP Quarantine should be handled as if they had COVID. The Administrator stated, Yes, they should. They are washed on high heat and kept separate. This surveyor stated that the surveyors were trying to clarify what the facility's actual process was for non-vaccinated Quarantine residents. The Administrator stated she would go get [HSK #1]. 11. On 04/21/22 at 10:06 AM, HSK #1 was asked how housekeeping knows linens have come from Quarantine and Isolation. HSK #1 stated, Laundry from both Quarantine and Isolation rooms come to laundry in yellow bags by the CNAs. COVID hall bags come in red bags. HSK #1 was asked if there were currently any TBP rooms that should have their laundry come via yellow bags. HSK #1 stated, Yes there are a few. HSK #1 was asked if she had noticed any laundry coming in yellow bags. HSK #1 stated she had not. The Administrator was asked if there were yellow bags in the building. HSK #1 stated there were because they had changed a while back from white and clear to yellow and clear. This surveyor stated that [CNA #2] and [LPN #1] on A hall stated yellow bags were not being used and [CNA #2] could not find yellow bags when asked to show them to the surveyors. 12. On 04/21/22 at 1:20 PM, the DON, Administrator and the HSK Supervisor came into conference room and stated that the facility's consultant told them they did not need to handle laundry from quarantine rooms any different than other resident rooms because they are only on quarantine for 14 days because they are not vaccinated. This surveyor asked if quarantine should be handled as if they could be or are contagious and the DON stated there was no need. 13. On 04/21/22 at 3:15 PM, CNA #3 walked into Resident #270's room who was on Airborne Quarantine precautions wearing only a blue surgical mask to deliver ice and water. CNA #3 was asked upon exiting the room what she needed to wear when entering a room with that sign on the door, (pointing to the Airborne Quarantine sign). CNA #3 stated, I probably should have had on a gown. 14. The Linen Protocol Isolation Linens policy and procedure received from the Administrator on 4/20/2022 at 12:48 p.m. documented, .All linen should be considered potentially infectious. Linens should be in a designated red red/yellow linen barrel. Linens should be in a melt away laundry bag. Ensure appropriate PPE in use prior to handling linens. Gloves at minimum . The CDC COVID 19 guidelines updated 2/2/2022 documented, . Empiric use of Transmission-Based Precautions (quarantine) is recommended for residents who are newly admitted to the facility . if they are not up to date with all recommended COVID 19 vaccine doses .

Based on observation, record review and interview, the facility failed to ensure the kitchen equipment, refrigerators, and walls were clean; the kitchen ceiling was maintained in safe clean condition; fans in the food prep area were clean; staff wore facial hair coverings while preparing and or serving food; food items stored in the freezer, refrigerator and dry storage room were sealed and dated to maintain freshness and prevent and potential cross contamination; leftover food items were promptly used or discarded; and expired food items were removed / discarded on or before the expiration or use by dates to prevent potential food borne illness; for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 72 residents (total census 73) who received meals from the kitchen as documented on a list provided by the Administrator on 04/21/22 at 10:06 AM. The findings are: 1. On 04/18/22 at 10:45 AM, in the Dining Room there was a table with beverages on it and a coffee station. Three gallon-sized pitchers one with a red liquid (1/2 full), one with a brown liquid (1/8 full), and one with a clear liquid (1/4 full) with no date or description on the pitcher or lids. The coffee station had a white towel under it with brown liquid soaking into it. 2. On 04/18/22 at 10:48 AM, the Dietary Manager (DM) stated he is both DM and [NAME] since September 2021 due to not being able to hire a cook for the past 9 months. The step lever was not functioning on trash can inside the entry door to the kitchen. The DM stated, You have to lift the lid on that one. The high temp dish washing area had ceiling tile and metal trim falling above sink. The wall panels were falling inward in the dish washing area. The DM stated it had been this way awhile. There were 2 ceiling tiles with a brown discoloration above the clean dinnerware storage area. The DM stated the ceiling previously had a leak. The DM had no beard covering over his beard which was 1/4 to 1/2 inch long. 3. On 04/18/22 at 10:53 AM, the following observations were made in the indoor standing refrigerator: a. There were 2 packages of turkey bologna not dated. b. An opened container of strawberry jam approximately 1/2 full was not dated. c. Six small plastic cups of salsa were not labeled or dated. d. Three small plastic cups of sour cream were not labeled or dated. The DM stated they were leftovers, and he wasn't sure when they were served. e. Two square cubes of sliced cheese, the DM guessed 60 slices, were not labeled when they were opened and were in a plastic bag partially sealed with an office binder clip. f. Onion slices were in a ziplock bag and were not dated. The DM stated, Those should be dated. The DM was asked how long they had been in the refrigerator and DM stated, At longest, from last Thursday. The DM then stated, It's hit or miss when we have time to date them. g. An opened bag of salad was partially sealed by an office supply binder clip. h. An opened plastic bag with 3 hardboiled eggs was not dated. The DM was asked when they had been prepared. The DM stated, I'm not sure. The DM was asked, What should be on all items stored? DM stated, Should have an open date and/or use by date. i. A pitcher, 1/3 full of brown liquid did not have a label. The DM was asked what it was. The DM stated, It's tea. The DM was asked if pitchers needed to be labeled and he stated, They should be. j. An opened bag of sausage was partially sealed with an office binder clip. The DM was asked how many were in the bag. He stated, looks about 20 to 30. The DM then stated, Dialysis is Monday, Wednesday, and Friday and they have to eat at 5:00 AM, so those are quick items for them. 4. On 04/18/22 at 11:06 AM, the following observations were made of the outdoor refrigerator: a. The refrigerator's door was open when this survey and the DM walked out the back door of the kitchen. The DM stated, must have not been shut. b. A metal food tray container with 3 Styrofoam cups of yellow-orange food not dated. The DM was asked what it was, and the DM stated, leftovers of vanilla pudding. c. A square plastic container of corn in a whitish-yellow liquid was dated 11/27(21). The DM was asked to describe the corn. The DM stated, Excess starch. This Surveyor smelled the corn and it smelled sour. The DM was asked to smell the corn and he stated he thought it smelled fine. d. Seven hot dogs in an orange liquid were in a plastic bag and were not dated. e. A package of bologna had an expiration date of 4/18/22. f. Two gallons of mixed fruit were in a square plastic container with no date. The DM was asked when it was from. The DM stated Unknown. g. A silver square container with pureed food was not dated. The DM was asked when the food had been prepared, and stated, Leftovers from the mornings. h. A box of meatballs had a received date of 9/16/21 and an expired date of 3/16/22. i. An opened package of bacon was not dated and was partially sealed with an office binder clip. The DM stated, I know these things should be labeled. 5. On 04/18/22 at 11:13 AM, the following observation were made in the outdoor freezer: a. Six packages of hotdog buns with a best by date of 3/13/22. b. Five pie crusts in a plastic bag not dated. c. Two open containers of Blue Bunny ice cream not dated. d. A bag of breaded boneless chicken with translucent shiny particles on breading was partially sealed with an office binder clip. e. The DM stated he has no time to date and check foods . have not had a cook for 9 months. The freezer roof had a leak and a cone shaped ice formation approximately 10 inches tall was on the floor. The DM stated they had to put a tarp on the roof until it was fixed. 6. On 04/18/22 at 11:20 AM, the following observations were made in the Dry Storage room: a. The ceiling vent had a dark gray fuzzy build up that was hanging 2 to 3 inches from the air vent cover above the dry storage foods. The DM was asked to describe the ceiling vent. The DM stated, I'm not sure, dust maybe. b. Four spice bottles with the lids open. c. Four hamburger buns in a zip locked bag not labeled or dated. d. A box of Spanish [NAME] best buy 2/6/22; 4 packages of tortillas best buy date 2/24/22; 6 packages biscuit mix expiration date 2/24/22. 7. On 04/18/22 at 11:26 AM, a black, sticky substance was dripping down the edge of the fry top to the stove top; a yellow orange splatter was dried on the side and the top of the stove. The back of the stove had a light gray fuzzy build up on the air vents, fan, and metal tubing. There were two ceiling panels hanging 1 to 2 inches down from the air vents with a gray and brown fuzzy substance on the edges at the back of the stove hood. The heater/air conditioner vent was covered in gray and black substance hanging off the edges and covered the slats that were separated from the seal and participles were floating out of vent. 8. On 04/18/22 at 11:28 AM, a metal pan with cooked french fries was sitting uncovered on a table next to the fryer. Above the table was a ceiling panel hanging loose with fuzzy grey film hanging off the edges. 9. On 04/18/22 at 11:29 AM, the Ice Machine in Dining Room had the Sanitize light on. 10. On 04/19/22 at 10:43 AM, a towel under the coffee station was completely brown with some dried and some wet brown liquid dripping off of the table. There were 3 gallon-sized pitchers with a red liquid (3/4 full), a brown liquid (1/2 full), and a clear liquid (1/2 full) with no date or description on the pitchers or lids. The Sanitize light was still on, on the ice machine in Dining Room. 11. On 04/19/22 at 10:48 AM, the indoor standing refrigerator had non-dated strawberry jam, one square cube of sliced cheese not labeled in a plastic bag partially sealed with a binder clip and an opened bag of salad partially sealed with a binder clip. 12. On 04/20/22 at 1:18 PM, the Maintenance Supervisor was asked if he was aware of the ceiling issues in the kitchen. The Maintenance Supervisor asked this surveyor to show him as he was not sure. Surveyor showed him the hanging metal and tiles above the dish washing area, that now had silver tape on metal bars. The Maintenance Supervisor stated he temporarily fixed that last night. Surveyor pointed out the wall paneling falling in, and The Maintenance Supervisor stated he has ordered glue to adhere panel to the wall because the drywall no longer holds screws well. He was asked about the brown areas on the ceiling over the clean dishware area and he stated, A pipe burst previously, and he needs to get the ceiling tiles put back in place. He was asked about the heater and air-conditioning vent with gaps and dirt and particles hanging down and coming out of vent. He stated the vent seems to be bent and needs to be put back into place to help keep out debris. He stated he would add that to his list. 13. On 04/20/22 at 1:27 PM, the Dining Room Beverage Station had three gallon-sized pitchers one with a red liquid (1/2 full), one with a brown liquid (1/8 full), and one with a clear liquid (1/8 full) with no date or description on the pitcher or lids. 14. On 04/20/22 at 2:00 PM, the Administrator was asked how staff know to inform Maintenance of repairs needed. The Administrator stated, They all know about the maintenance logbook at the nurses' station and are told when hired about it. The Administrator was asked if they had a policy for repairs and the Administrator stated they did not. The Administrator was asked if she was aware of the ceiling and wall issues in the kitchen. She stated, I was made aware of it yesterday morning when Maintenance was made aware of it. It must have happened over the weekend. The Administrator was informed that the DM had formed this surveyor that it had been like that for a while.