Based on observation, interview, and record review, the facility failed to revise the care plan interventions to include behavioral-emotional health for 1 (Resident #43) sampled resident. The findings include: Record review of Resident #43's Medical Diagnosis sheet reported the resident had diagnoses to include dementia and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD of 09/03/2024 reported the resident had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident was severely cognitively impaired. Review of Resident #43's Clinical Physician Orders reported admission to the secure unit on 06/26/2024. Review of Resident #43's care plan initiated 10/22/2024, reported that Resident #43 had been physically aggressive toward other residents. Intervention treatment for urinary tract infection (UTI) and separation from a resident. Review of facility provided Incident by Incident Type dated 10/29/2024, reported physical aggression initiated incident on 08/15/2024. Physical aggression initiated incidents on 07/07/2024, and physical aggression initiated incident on 04/30/2024. During a concurrent observation and interview on 10/29/2024 at 10:00 AM, Resident #43 was observed traveling up and down the hallway in the secure unit and speaking with multiple residents. The Director of Nursing (DON) stated that the resident was transferred to a different room following episodes of aggression with other residents. The DON stated that the staff try to intervene and redirect Resident #43 when aggression occurs. The DON stated Resident #43's care plan should include interventions for aggressive episodes.

Based on observation, interviews, and record review, the facility failed to follow proper hand hygiene while preparing food for the 76 residents who received food from the facility kitchen. The findings include: During an observation and interview on 10/30/2024 at 8:30 AM, Dietary Aide #1 was observed scratching her face then touching the resident breakfast trays. Dietary Aide #1 stated she should have performed hand hygiene after touching her face and before touching the resident food trays. During a concurrent observation and interview on 10/30/2024 at 11:30 AM, Dietary Aide #1 was observed placing cups from a cart onto a tray. Without washing her hands or putting on gloves, Dietary Aide #1 opened the food processor, removed the food processor blade and began scooping deserts from the food processor into serving cups to be served to the residents on puree diets for lunch. Dietary Aide #1 stated that hand hygiene should be performed when going from a dirty task to a clean task. During a concurrent observation and interview on 10/30/2024 at 11:40 AM, Dietary Aide #1 was observed scratching her face then touching serving scoops to be used in serving residents at lunch. Dietary Aide #1 stated that hand hygiene should be performed after touching one's body and before touching food preparation items. A review of a facility policy titled, Food Preparation and Service, revised October 2017, reported food and nutrition services staff, will wash their hands before serving food to residents. Employees also will wash hands after collecting soiled plates and food waste prior handling food trays. Employees will follow proper cleanliness and handwashing techniques.

Based on record review and interview, the facility failed to ensure a Minimum Data Set [MDS] assessment was coded correctly for 1 (#124) sampled residents who was prescribed antipsychotic medications. The findings are: 1. Resident #124 had the diagnosis [dx] Major Depressive Disorder, Recurrent, Unspecified and Vascular Dementia, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The admission Minimum Data Set [MDS] with an Assessment Review Date [ARD] of 10/19/23 documented SECTION N - MEDICATIONS .N0415. High-Risk Drug Classes: Use and Indication A. Antipsychotic: No . a. A physician order [PO] dated 10/24/23 documented Abilify Oral Tablet 2 MG (Aripiprazole), Give 2 tablet by mouth at bedtime related to Major Depressive Disorder, Recurrent, Unspecified. b. A PO dated 10/09/23 documented Abilify Oral Tablet 2 MG (Aripiprazole), Give 1 tablet by mouth at bedtime related to Major Depressive Disorder, Recurrent, Unspecified. Discontinue 10/24/32. 2. On 10/26/23 at 11:54 am The MDS Coordinator was asked to look at resident's admission MDS, Section N. The Surveyor asked the MDS coordinator to verify if the resident was taking an antipsychotic medication upon admission to the facility. She stated, Well the MDS says no, but she is taking one. Let me look at her discharge orders from the hospital. Upon review of the hospital orders, it was noted that resident was to continue Aripiprazole 1 tablet by mouth at bedtime. 3. On 10/26/23 at 11:56 am The MDS coordinator stated Yes, it should have been on the MDS. I overlooked it. 4. On 10/26/23 at 12:04 pm The MDS coordinator stated, I fixed that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident with a facility acquired deep tissue abscess to coccyx and left buttock had the correct medication per MD order applied to wound to promote healing for 1 (resident #275). This failed practice had the potential to affect 1 of 8 sample mix residents (#4,#13,#28,#33,#41,#47,#65,and #275 ) who had documented wound treatments on a list provided by the Director of Nurses (DON) on 10/26/23 at 10:00AM The findings are: 1. Resident #275 had diagnosis of Alzheimers and dementia, depression, hypertension. A Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/09/23 documented the resident scored 2(0-7indicates severely impaired) on a Brief Interview for Mental Status (BIMS). Physician Order dated 10/17/2023 clean coccyx with wound cleanser. Pat dry with 4x4 gauze. Apply [Named ointment], then apply calcium alginate and cover with 4x4 foam dressing everyday and PRN (as needed). a. Care plan dated 10/12/23 documents .keep skin clean/dry /monitor wound healing weekly until healed. Measure length, width and depth and type of tissue exudate and any other notable changes. b. The Braden Scale for Predicting Pressure Sores form dated 10/05/23 documented a pressure ulcer risk score of 15-18, with a score of 22 indicating a high risk for developing pressure sores. c. A Skin assessment dated [DATE] documented no pressure ulcers. d. A Skin assessment dated [DATE] documents abscess to coccyx and left buttocks, no measurements documented. e. On 10/25/23 at 09:47 AM The Licensed Practical Nurse #1 was asked, how she knew what specific steps to take when assessing, applying medication, or dressing a wound. LPN #1 replied, I get orders from the nurse practitioner who is here at the facility. The Surveyor asked the LPN#1, Should medication that is ordered be applied to the wound as ordered. The LPN #1 replied, Yes it should, and I know I forgot to put it on the wound. f. 10/26/23 10:20 AM [NAME] informed surveyor they did not have a Policy pertaining to following Physician Orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the 74 residents living at the facility were provided a safe, clean, and comfortable homelike environment. The findings are: 1. On 10/23/23, during initial rounds the following was observed: a. On 10/23/23 @ 11:42 AM in room [ROOM NUMBER]A resident took surveyor into the bathroom to show her the toilet which was completely covered with black substance throughout the entire toilet bowl. The resident stated, they never come in and clean it. b. On 10/24/23 at 09:59 AM room [ROOM NUMBER]A, surveyor observed that the toilet had black substance throughout the entire toilet bowl. c. On 10/25/23 @ 08:14AM, room [ROOM NUMBER]A the surveyor observed that the toilet had large amount of black substance throughout the entire toilet bowl. d. On 10/25/23 at 11:37AM, the surveyor took the Certified Nursing Assistant (CNA#2) into room [ROOM NUMBER]A, Surveyor then asked (CNA) #2, Can you tell me what you see in this toilet bowl? CNA #2 stated, Dark Mold. How often does this toilet get cleaned? CNA #2 stated, housekeepers should do it every day Does this represent a homelike environment? CNA #2), stated no it doesn't I am so sorry I should have been checking this. What could result from this? CNA #2 stated, she could get sick from it. e. On 10/25/23 @ 11:48 AM, the surveyor took the Director of Nurses (DON) into room [ROOM NUMBER] Surveyor asked the DON if she could describe what she sees in the toilet? DON stated, It needs cleaned The surveyor then asked, how often does the Housekeepers clean the toilet? DON stated, daily Surveyor then asked what could result from this? DON stated I don't know. f. On 10/25/2023 @ 12:07 AM, the surveyor interviewed the Housekeeper (HK) #2, Surveyor asked how often do you clean room [ROOM NUMBER]A bathroom? HK #2 stated, not very often, she will ask me sometimes to clean it. g. On 10/24/23 at 03:07 PM Resident #4 & Resident #5 were lying in bed asleep. The Surveyor observed the bathroom. There was a clear plastic tennis ball can sitting on the floor, with no lid, containing dried brown pinto beans. The toilet had a yellowish brown ring around the inside of the toilet bowl encircling where the surface of the water level comes into contact with the inside of the bowl. The restroom smelled of human waste, and the floor around the base of the toilet had a wet brown and black colored substance accumulated on the floor surface. There were human hairs and scattered flecks of brown and black substance accumulated on the base of the toilet under the bowl from the floor to the bottom of the bowl. A blue plastic covered geri chair was parked in the restroom. h. On 10/24/23 at 03:08 PM the surveyor observed the floor on Resident #5's side of the room under the bedside table and noted an empty white plastic jelly container that had some residue of jelly on the inner edges and the bottom. There was also a cheerio on the floor. There was a white towel on the floor under the bedside commode on the floor next to Resident #5's bed. i. On 10/25/23 at 09:00 AM Resident # 5 lying in bed awake. The floor next to Resident #5's bed remained the same with the same empty white plastic jelly container that had what appeared to be dried, dusty jelly residue. The container looked as if it had been stepped upon due to the edges being collapsed. The same white towel remained on the floor between to the resident's bed and the bedside commode. The bedside table, which had a breakfast tray sitting on the surface, was between the resident's bed, and the bedside commode. There was a red non skid sock under one of the legs of the bedside commode, and a used kleenex tissue lying on the floor under the resident's bed. There was also an empty food wrapper under one of the wheels of the bedside table. The bathroom toilet, and remained the same as yesterday, and had not been cleaned. The tennis ball can of dried beans with on lid, remained on the floor of the bathroom. j. On 10/25/23 at 10:00 AM the Surveyor asked HK #1 how often resident rooms are cleaned and how many halls she had to clean by herself. The HK#1 answered, I try to do them before breakfast, and I check again after lunch. Today I have Hall 2 and 3. The Surveyor asked HK #1 what her routine process was for cleaning resident rooms when she walked in the door. The HK #1 answered, First I empty trash, then I put supplies in the bathroom like toilet, paper, paper towels, and soap. Then I spray everything down in bathroom and clean the toilet and the sink. Then I sweep and mop the bathroom and the room. The Surveyor asked the HK #1 how often she changed gloves. The HK #1 answered, I try change every room. The Surveyor accompanied HK #1 into Resident #4 & Resident #5's bathroom and asked what she thought the bathroom smelled like. HK#1 answered, I don't know, it smells kind of like mold. The Surveyor asked the HK #1 if she knew how long the beans had been in the bathroom and how long the towel, jelly container, and debris had been on the floor in Resident #5's side of the room. HK #1 answered, I don't know, I wasn't here yesterday. The Surveyor asked HK #1 if she thought the room and bathroom looked clean and homelike. HK #1 answered, No, it doesn't. I've tried to mop the stains from around the toilet, but they won't come up. 2. On 10/25/23 at 10:10 AM the Surveyor accompanied CNA #5 to Resident #4 and Resident #5's room. Both residents were asleep in bed. The Surveyor asked the CNA #5 if she knew about the open tennis ball can of beans in the bathroom, who put them there, and what they were used for. The CNA #5 answered This is my first time in this room today. I don't know anything about the beans. The Surveyor asked the CNA #5 if she know how long the towel, empty jelly container, and debris had been on the floor on Resident #5's side of the room. The CNA #5 answered, I'm not sure. The Surveyor asked the CNA #5 if she considered the shared bathroom and floor on Resident #5's side of the room very clean and homelike. The CNA #5 answered, No, I would probably take that away. She could fall on it, or it could attract bugs and stuff 3. On 10/25/23 at 10:15 AM The Surveyor accompanied the Director of Nursing (DON) to Resident #4 and Resident #5's room where they remained asleep in their beds. The Surveyor asked the DON what the bathroom smelled like to her, if she knew about how long the open tennis ball can of dried beans had been on the floor, and why they were there. The DON answered, It smells like old urine in here. I've never seen that can of beans. The Surveyor asked the DON if she could think of any issues with leaving dried beans in the bathroom. The DON answered, I don't think bugs are attracted to dried beans, I'll have to look that up The DON picked up the can of beans, walked out of the bathroom and woke Resident #5 up to ask her what the beans were for and if she could throw them away. Resident #5 woke up and answered, They were used for my therapy. I'm not using them anymore. The Surveyor asked the DON if she thought the floor on Resident #5's side of the room looked homelike with the towel on the floor, the old jelly container, the sock, and the debris. The DON answered, I don't know, unless she told them not to clean it. She throws stuff down and stands up and pees on the floor, and yells at people when they come in here. That's care planned. The Surveyor asked the DON who was responsible for keeping the rooms clean. The DON answered, Housekeeping as she picked up the jelly container and threw it away with the can of beans. The DON walked out of the room and spoke to the HK #1 in the hallway. The DON asked CNA #3 and CNA #4 in the hallway 300 if Resident #5 had yelled at them this morning. The CNA #4 answered, Yes, she yelled at me this morning when I delivered her breakfast. The Administrator heard and walked up and the Surveyor asked who was responsible for keeping room clean. The Administrator answered, Not just Housekeeping, anyone that goes in there. 4. On 10/25/23 at 10:52 AM The Administrator provided documentation entitled, Quality Control, Environmental Services which documented under .Policy Statement A quality control program shall be maintained by the housekeeping and laundry departments . m. On 10/25/23 at 11:06 AM The Administrator provided a document entitled, Resident Rights which documented under Policy Interpretation and Implementation, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/23/2023 @ 12:32 PM, surveyor noticed resident #22 in dining area eating. He had stubble on face and his nails were ¼ inch longer than finger tips with jagged nails on several of his fingers on both hands. a. On 10/24/2023 @ 11:01 AM, surveyor again observed Resident #22 in dining room watching TV with ¼ in stubble to face and ¼ inch jagged nails to several of his fingers on both hands. b. On 10/25/2023 @ 11:31PM, surveyor went into Resident #22 room to observe him sitting in his recliner with ½ inch white stubble to face and ¼ inch jagged nails on both hands. c. On 10/25/2023 @ 11:37AM, surveyor interviewed CNA#1, How often do you shave a resident? (CNA#1) stated, Every time they take a shower. How often do they get a shower? (CNA#1) stated, at least twice a week, this Resident #22 got a shower yesterday. Surveyor then asked, did he get shaved yesterday? CNA#1 stated, no he did not. surveyor then asked ( CNA#1) to look at resident #22 nails and describe them. CNA #1 stated, They need cut but I think he is diabetic so the nurse would do that surveyor then ask him can a cna tell the nurse that they need trimmed? (CNA#1) stated, yes we can. e. On 10/25/2023 @ 12:11 PM surveyor asked DON, how often do you make sure a resident is shaved? DON stated, when they take a shower we shave them. Surveyor showed DON Resident #22 facial growth and DON asked Resident #22 when did you take a shower last? Resident #22 stated yesterday DON then asked CNA#1 why did he not get shaved and CNA#1 stated, I don't really know. Surveyor then asked DON to look at Resident#22 nails and describe them to me. DON stated, they need trimmed, I'll tell the nurse to trim them. Based on Observation, Interview and Record Review the facility failed to ensure that 2 residents (#17 and #22), of sampled residents had been shaved and nails cleaned and trimmed to promote good hygiene, cleanliness and sense of wellbeing. The findings are: 1. Resident #17 had a diagnoses of unspecified dementia, unspecified severity , with agitation. A Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 10/10/23 documented a Staff Assessment of Mental Status (SAMS) for Memory Problem, Severely Impaired Cognitive skills for daily decision making. A MDS with and ARD of 7/10/23 documented extensive assistance for toileting and personal hygiene with 1 person physical assist and limited assistance with 1 person support with eating. a. A Care Plan with an initiation date of 12/2/15 documented, .[name] has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) osteoarthritis . and .[name] preferred bedtime routine is to brush her teeth, wash her face, and change into her pajamas. Date initiated 2/22/18 .and .[name] requires extensive assist x 1 staff with hygiene, dressing, bed mobility, toileting, and locomotion on/off of the unit. Date initiate 11/16/2018 . and .[name] requires total assist x 1 staff with showers. Date Initiated: 4/27/23 . b. On 10/23/23 at 12:13 PM the Surveyor observed Resident # 17 eating with her fingers in the dining area. Finger nails on right had were dirty with a medium brown substance underneath, especially the index finger. Several of her finger nails jagged and approximately 1/4 inches in length from finger tips. c. On 10/24/23 at 10:05 AM the Surveyor observed Resident # 17 lying in bed awake. The Surveyor was unable to visualize left hand under covers, but right hand was outside and nails were approximately 1/4 inch past nail tips with medium brown substance visible underneath the finger nails. The thumbnail was slightly longer than the other 4 finger nails, and had sharp pointed corners on the edges. d. On 10/25/23 at 08:44 AM Resident #17 was sitting up in her room in a [Named] chair. [Name] from Human Resources (HR) and Certified Nurse Assistant (CNA) #3 were in room cleaning armrests of chair as finger nails remained the same. The Surveyor asked CNA#3 and [Name] from HR to describe Resident #17's finger nails. There was no response. [Name] from HR stated, What do you think? to CNA#3 who answered, Well, they are long and not the cleanest. Well, we tried to clean them this morning. The Surveyor asked CNA #3 describe what was under the fingernails specifically such as color. [Name] HR left the room. The CNA #3 answered, her nails are yellow on top. I don't know. I'd have to say brown underneath The Surveyor asked who was responsible for nail care and what day Resident # 17 got her shower. The CNA answered, I don't usually work on this hall, I'm usually in the unit. It takes 2 people to distract her. [Name of CNA#4] and I tried to clean her nails this morning. We got one hand done pretty good The Surveyor asked the CNA #3 what could happen if finger nail care isn't done on a regular basis. The CNA answered, She could scratch herself or someone else. e. On 10/25/23 at 08:57 AM The Surveyor observed CNA #3 was putting socks on. LPN#1 was also in the room holding a pair of nail clippers. The Surveyor asked the CNA to remove Resident # 17 socks to observe toenails. The left great toenail was approx 1/4 inch past the tip of the toe with sharp corners, the second and 5th toenail were also more than 1/4 inch in length past the tip of the toe. The Surveyor asked the CNA #3 when toe nailcare was done and who was responsible for it. The CNA did not answer. The Surveyor asked the LPN#1, who answered, I think the Podiatrist came and saw her 2 weeks ago and looked at her toenails. The Surveyor asked if the Podiatrist had trimmed the toenails and if the Resident was Diabetic. The LPN answered, I can't say if he did or didn't. The Surveyor asked the LPN to look at the toenails and describe the length. The LPN#1 answered, I'm not trying to tell you how to do your job but it looks like these 2 have been trimmed. I'm not supposed to trim them too close. The Podiatrist comes every 2 weeks or monthly The Surveyor asked if the other 3 nails looked like they needed to be trimmed. The LPN answered, Yes they look like they could be, but these two look like they've been trimmed The Surveyor asked who was responsible for fingernail care and toe nail care for Resident # 17. The LPN answered, The nurses and the CNA's are responsible for both, but the Podiatrist does nail care also The Surveyor asked the LPN#1 when Resident # 17 had finger nail care last. The LPN answered, I cleaned her nails out on Monday. The Surveyor asked the LPN#1 what could result from nail care not being done for Resident # 17 on a regular basis. The LPN answered, She could scratch herself or get an infection. f. On 10/25/23 11:07 AM The DON stated to Surveyor that Resident #17 resists nail care and it's care planned. Our Podiatrist does everything. g. 10/25/23 11:32 AM The Surveyor asked the DON to pull up Podiatry Documentation for Resident # 17's toe nail care. The DON answered, There are no Podiatry notes for Resident # 17, but The Podiatrist comes every 3 months. They are down there right now taking care of her toenails h. On 10/25/23 at 11:10 AM Administrator provided documentation entitled, Activities of Daily Living (ADLs), Supporting which documented under Policy Statement, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene . and under section 4.If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate . i. On 10/25/23 at 11:52 AM Administrator provided documentation entitled, Fingernails/Toenails, Care of which documented under Purpose, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Under General Guidelines number 1. Nail care includes daily cleaning and regular trimming . and 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Under Documentation The following information should be recorded in the resident's medical record: .1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered nail care .and 4.Any difficulties in cutting the resident's nails .

Based on observation, interview, and record review the facility failed to ensure the medication error rate did not exceed 5%. This failed policy had the potential to effect 74 Residents according to the Resident Matrix provided by the Administrator on 10/23/2023 at 11:30 AM. The findings are: 1. As of 10/25/23 at 08:44 AM, The surveyor observed Medication Technician [MT] #1 administer Citracal Calcium 650 milligrams [mg] with Vitamin D 25 micrograms [mcg] x2 tablets to Resident #49. The physician's Order Summary dated 10/25/2023 showed an order for Citracal Maximum Tablet 315-250 MG-UNIT (Calcium Citrate-Vitamin D) Give 2 tablets by mouth one time a day Start Date 8/16/23. 2. As of 10/25/23 at 11:43 AM, The surveyor observed Licensed Practical Nurse [LPN] #2 administer 4 bottles of Osmolite 1.5, each bottle contained 237 milliliters [mL] for a total of 948 mL, to Resident #63. The physician's Order Summary dated 10/25/2023 showed an order for Enteral Feed Order every shift Osmolite 1.5 at 55 cubic centimeters [cc]/hour [hr] to equal 1320 cc/24 hrs start date: 8/30/23. 3. As of 10/25/23 at 02:25 PM, The surveyor asked MT #1, Can you tell me what the order was for Resident # 49's Citracal Calcium? MT #1 stated, Calcium Citrate 315-250mg 2 tablets by mouth one time a day. The surveyor asked, Can you tell me what the dosage showed on the bottle of Citracal? MT #1 stated, 650mg/25mcg per tablet. The surveyor asked, Was the Resident given the correct dose of Citracel Calcium? MT #1 stated, No ma'am. 4. As of 10/25/23 at 02:36 PM, The surveyor asked LPN #2, Can you tell me what the order is for Resident # 63's enteral feed? LPN #2 stated, 1320cc in a 24-hour period of [named tube feed]1.5 at 55cc an hour. The surveyor asked, How much enteral feed did the resident get in 24 hours? LPN #2 stated, The resident received 1320cc of [named tube feed]1.5 every shift. The surveyor asked, Did the resident get the ordered amount of enteral feed? LPN#2 stated, I gave 948 mL at noon and then the night shift nurse will add more when it gets low. The surveyor asked, Can you show me anywhere on the Medication Administration Record [MAR] for the next shift to document the extra [named tube feed]1.5? LPN #2 stated, No, they can only check off the order. 5. As of 10/25/23 at 03:01 PM, The surveyor asked the Director of Nursing [DON], How do you know if the Resident's are given the right amount of medication? The DON stated, You would follow the Dr's orders. The surveyor asked, Can you tell me what the order is for Resident # 49's Citracal Calcium? The DON stated, Calcium Citrate 315mg/25mcg 2 tablets once a day. The surveyor asked, Can you tell me what dosage the bottle of Citracal shows? The DON stated, 650mg/25mcg, it's the incorrect dose for the resident. The surveyor asked, Can you tell me what the order is for Resident # 63's enteral feed? The DON stated, 1320cc in a 24-hour period of [Named tube feed]1.5 at 55cc an hour. The surveyor asked, How many mL's would the resident receive with 4 bottles of [Named tube feed] 1.5? The DON stated, 948mL's, the night shift nurse will add more, it is a continuous order, if the bag is almost empty it would be common sense to add more. The surveyor asked, How would you know the extra enteral feed was given on the MAR? The DON stated, The resident received new orders last week and I guess it didn't pull over to the MAR where each shift could document how much was added. 6. A Policy titled Administering Medications [2001 MED-PASS, Inc. (Revised December 2012)] provided by the DON on 10/25/23 at 2:46 PM showed, .Medications must be administered in accordance with the orders, including any required time frame .

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee implemented appropriate plans of action to prevent repeated deficiencies with Treatment/Services to prevent/heal pressure ulcers and Maintaining effective pest control. These failed practices had the potential to affect 8 residents who receive treatment for pressure ulcers as identified on a list provided by the Director of Nurses [DON] on 10/26/23 at 10:00 am and 74 residents who reside in the facility as identified on the Resident Matrix provided by the administrator on 10/23/23 at 11:30 am. The findings are: 1. A Recertification survey was conducted on 10/26/2023 at the facility. During this survey, the team identified concerns with providing correct treatment for wound care. a. The Plan of Correction for wound care with a completion date of 08/26/22 documented Corrective Action: On 8/4/22 Director of Nursing received order from MD to change treatment order on resident #42 to wound cleanser. On 8/5/22 Director of Nursing counseled RN performing treatment on proper handwashing and glove use, cross contamination, and proper use of supplies during a treatment and following MD orders. Upon notification on 8/4/22 Director of Nursing removed all supplies for resident #42 from treatment cart and disposed of supplies and treatment cart disinfected. Identification: On 8/4/22 Director of Nursing assessed each resident's orders requiring a treatment to cleanse wound with antibacterial soap. All negative findings were corrected immediately. On 8/3/22 Director of Nursing completed an in service with all licensed nursing staff regarding Wound care policy, following MD orders, handwashing, proper use of gloves and cross contamination pertaining to wound care. Systemic measures: On 8/5/22 a competency assessment was performed with all licensed nurses in regards to wound care, infection control, following MD orders in regards to treatments by DON/Designee. Monitoring: DON/Designee will observe 1 treatment 3 times per week for 1 week and 1 treatment weekly until compliance to ensure proper use of gloves, proper handwashing, following MD orders, and cross contamination all pertaining to wound care. All findings will be reported to Monthly QA Committee. 2. A Recertification survey was conducted on 10/26/2023 at the facility. During this survey, the team identified concerns with roaches in resident's room. b. A review of the facility' s Plan of Correction, with a correction date of 08/26/22 documented Corrective Action: On August 2, 2022, Administrator contacted pest control service to perform immediate treatment for pests in kitchen and dry storage areas to ensure pests are eliminated. Identification: On August 9. 2022, Administrator conducted an all staff in service regarding reporting sighting of pest to Administrator and make note in maintenance daily binder at nurses station. Systemic measures: On August 2, 2022, Administrator set up scheduled treatments for each Tuesday for treatment in kitchen, dry storage, and dish room until successful. Monitoring: DM will monitor kitchen areas 5 days per week for pests for 2 weeks and 2 times weekly to ensure pests are eliminated from the facility. Any negative findings will be reported to Administrator immediately and corrected. Findings will be reported to monthly QA. 3. On 10/26/23 at 01:58 pm the Surveyor asked the Administrator, How does the QAA Committee know when a deviation from performance or a negative trend is occurring? She answered, By observation and monitoring. The Surveyor asked, How does the QAA Committee decide which issues to work on? She stated, Any area of concern, we investigate, develop a plan or if we can't solve it, we do a PIP at that time. The surveyor asks How does the facility know that corrective action has been implemented, is effective, and improvement is occurring? The Administrator stated, We do ongoing audits, observations, depending on QAA, we may have weekly meeting instead of monthly, assign a team to work on the problem. She was asks What plans of action are developed and implemented by the QAA Committee to correct identified quality deficiencies or potential problems? She stated, Plan Of Corrections, monitoring, doing audits and observations. The surveyor asks After implementing actions to improve performance, how does the facility measure its success and track performance to ensure improvements are realized and sustained? The administrator stated, By monitoring, having routine audits, measure and gage improvement to make sure we aren't going backwards, and until we will continue until we reach compliance. 4. A policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, provided by the Administrator on 10/23/23 at 11:00 am documented .Policy Interpretation and Implementation .4. Establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcome; .

Based on observation, interview, and record review the facility failed to ensure that hands were sanitized or washed between donning and doffing of gloves and to properly replace a piston syringe. This failed practice had the possibility of affecting 1 [Resident #13] Resident of 2 [Resident's #4 & 13] sample mixed residents with pressure ulcers and 1 [Resident #63] Resident of 2 [Resident's #13 & 63] sample mixed residents that receive tube feedings according to lists provided by the Director of Nursing [DON] on 10/26/23 at 9:29 am titled, List of residents with pressure ulcers and List of residents with tube feedings. The findings are: 1. Resident # 13's diagnosis showed, pressure ulcer of left buttock, stage 4. a. Physician's Order Summary dated 10/25/23 showed, Clean stage 4 PU to left ischial tuberosity with wound cleanser. Pat dry with 4x4 gauze. Apply [named medication] around peri wound. Sterile woven gauze sponge 2x2 soaked with betadine, pack loosely into wound. Cover with 3x3 hydrocelluar foam dressing every day shift and PRN Reassess in 14 days. every day shift for Stage 4 PU Start Date: 9/16/23. b. As of 10/25/23 at 09:56 AM, The surveyor observed Licensed Practical Nurse [LPN] #1 set up wound care treatment for Resident #13. LPN #1 washed hands, donned gloves, then sanitized the bedside table and top of treatment cart. Then they removed gloves, sanitized, and donned a new pair of gloves. LPN #1 then opened the cart and placed 3 pieces of barrier paper on top of the cart. They then opened the cart and retrieved the bottle of [named medication] and poured a small amount into a plastic medicine cup. They then set the cup on the barrier. With the same gloves on LPN #1 then opened multiple drawers on the cart and gathered 4X4 gauze, wound care spray, 2X2 package of sterile woven gauze, and a 3X3 package of hyrocelluar foam dressing and placed the packages on the barrier. LPN #1 then removed gloves and threw them away, sanitized hands, and donned new gloves. LPN #1 then opened the 2X2 sterile gauze and placed the gauze on the barrier. They then opened the 3X3 hydrocelluar foam dressing package, dated and initialed with a black marker, then placed the open package on the barrier. LPN #1 then removed gloves and sanitized. They then sanitized the bottle of sanitizer and placed it on the barrier. LPN #1 then picked up all 3 pieces of barrier with the items on top and placed it on the sanitized table in the room. They then removed gloves, washed hands, and donned new gloves to perform treatment. c. As of 10/26/23 at 11:14 AM, The surveyor asked LPN #1, What process do you follow for changing gloves while preparing the treatment cart and performing wound care? LPN #1 stated, While doing treatments I wash my hands and put gloves on, remove the old dressing, remove gloves, sanitize hands, don new gloves, perform treatment, remove gloves, sanitize hands, don new gloves, gather all trash into red bag and throw it away, then I wash my hands. The surveyor asked, Should you have gloves on while getting supplies out of the treatment cart? LPN #1 stated, Not unless I'm opening something in the hall. The surveyor asked, Should hands be washed or sanitized in between changing gloves? LPN #1 stated, Yes. d. As of 10/26/23 at 11:26 AM, The surveyor asked the DON, Should hands be washed or sanitized between changing gloves? The DON stated, Yes. 2. On 10/25/2023 09:47AM during observation of wound care surveyor observed Licensed Practical Nurse #1 not sanitizing hands before and after donning and doffing of gloves. The findings are . a. On 10/25/23 @ 09:47AM LPN#1 went into resident #275 room to clean off bedside table donned her gloves without sanitizing hands first. LPN#1 then cleaned table with cleanser and returned to her cart, doffed gloves and did not sanitize hands before setting up supplies to do wound treatment. b. On 10/25/2023 @ 09:47AM, LPN#1 went into room with wound care supplies inside of folded wax paper. LPN#1 sat supplies on clean table and then donned gloves. She pulled old dressing off resident coccyx, and then doffed her gloves and threw them and dressing into the trash. LPN#1 donned new gloves on without sanitizing hands and applied wound cleanser to abscess. LPN#1 doffed gloves placed in trash and donned new gloves again without sanitizing hands. Applied lodosorb and doffed gloves and placed them in trash. c. On 10/25/2023 @ 09:47AM, LPN#1 doffed gloves and began to remove back of dressing off the 4x4 when she placed her gloved finger of right thumb in the center of the clean dressing. LPN#1 then applied contaminated dressing to Resident #275 coccyx. LPN#1 doffed gloves and returned to her cart. d. On 10/25/2023 at 09:47AM, surveyor asked LPN#1, When donning and doffing of gloves what process or steps should you take. LPN#1 stated , I should sanitize my hands before and after putting gloves on and taking them off. Surveyor asked LPN#1 When removing backing from a dressing Should you ever touch the clean part of the dressing? LPN#1 stated no I shouldn't. e. On 10/26/2023 at 09:29AM received policy from DON titled Handwashing/Hand Hygiene . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies(sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents. C. Before preparing or handling medications G. Before handling clean or soiled dressings, gauze pads, etc .I. After contact with a resident's intact skin .K. After handling used dressings, contaminated equipment etc .M. After removing gloves. N. before and after entering isolation precaution settings .

Based on observation and interview the facility failed to provide effective pest control for the facility on a regular basis. This had the potential to affect all 74 residents listed on the Resident Matrix provided by the administrator on 10/23/23 at 11:30 am. The findings are: a. On 10/24/23 at 09:08 AM R#4 and R#5 were in room awake. R#5 was lying in bed, and stated there are roaches in both the room and the bathroom, at night especially. It's just gross, I mean what if you would sit on that. You can hear them [staff (nurses and CNA's (Certified Nurse Assistants)] come in and stomp them. When they come in and it's dark and they turn the light on, and they just scatter. They look like teenagers or baby roaches. The Surveyor asked R#5 if food was kept in the room. R#5 answered, No. just when they leave the trays in here. They usually gather right there (as she pointed to the floor next to her bed under the bedside table) and when the light comes on they just scatter The Surveyor asked R#5 if she had actually seen them, and how many. R#5 answered, Yes, there are 3-4 at the most that scatter The Surveyor asked R#5 if she had seen them anywhere else besides her bathroom and her room. R#5 answered, I've seen them in the dining room too. I know they use [named company] for pest control. Maybe they should use a different company like [named company]. I know they spray, but I think they've become immune. The Surveyor asked R#5 if she had told anyone. #5 answered, I've told the nurses and the CNA's, but not [name of DON (Director of Nursing)] b. On 10/24/23 at 10:11 AM The Surveyor opened the door to the resident's bathroom which was dark, and flipped the light on. The Surveyor observed a baby cockroach crawling on toilet set which scurried under the tank. c. On 10/25/23 at 12:45 PM Administrator provided a handwritten copy entitled, [facility name] Nursing Home Monthly Pest Control Service with dates of service and specific areas of facility serviced. There was no documentation for resident rooms being serviced. d. On 10/25/23 at 10:52 PM The Administrator provided a copy of a service agreement from [named company] Exterminators. e. On 10/25/23 at 10:52 AM The Administrator provided documentation entitled, Quality Control, Environmental Services which documented under .Policy Statement A quality control program shall be maintained by the housekeeping and laundry departments . f. On 10/25/23 at 11:06 AM The Administrator provided a document entitled, Resident Rights which documented, .Employees shall treat all residents with kindness, respect, and dignity Section v.have the facility respond to his or her grievances . g. On 10/24/23 at 1:59 PM The Administrator provided documentation of Grievance Logs from August - October in which one unsampled resident and one sampled resident (R#19) filed grievances dated 9/19/23 and 9/20/23 relating to .Bugs in room . with resolutions of traps near bed .traps applied .

Based on observation, interview and record review, the facility failed to ensure physician orders were followed for use of antibacterial soap during a pressure ulcer dressing change to prevent the potential for developing an infection and failed to ensure gloves were changed and universal precautions/clean technique were followed during and after wound care for 1 (Resident #42) of 1 sampled resident who had physician orders for antibiotic soap and dressing changes. The findings are: 1. Resident #42 had diagnosis of Stage 3 Pressure Ulcer. The Quarterly Minimum Data Set with an Assessment Reference Date of 6/22/2022 documented the resident scored 3 (0-7indicates severely cognitively impaired) on a Brief Interview for Mental Status and was at risk for of developing pressure ulcers/injuries and had one Stage 3 pressure ulcer. a. The Plan of Care with a revision date of 06/21/22 documented, .has a Stage 3 pressure ulcer on his right hip , Administer treatments as ordered and monitor for effectiveness . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . b. The Physician's Orders dated 07/28/22 documented, .Clean stage 3 P/U [pressure ulcer] to right hip with ABT [antibiotic] soap and water, pat dry with 4x4 gauze, loosely pack wound with plain packing strip (leave 1 to 2 inches out for removal for next dressing change) apply calcium alginate (cut to fit), apply allevyn gentle border 4x4 Q [every] day and PRN [as needed]. Reassess in 14 days. as needed . c. On 8/2/2022 at 2:20 PM, Registered Nurse (RN) #1 performed pressure ulcer treatment on Resident #42. Clean 4x4's were placed in two separate 1 ounce medicine cups, packing tape in the container, Calcium Alginate 4x4 in the package, island dressing, scissors, Sani-wipes, box of gloves from the cart and a drape. RN #1 gathered these same supplies, carried them into resident's room and sat them down on the bedside table that held resident's tv without cleaning the table. RN#1 stated, I need to get a table, then stepped out and took an overbed table from the room next door. After bringing the overbed table into the room, she turned to the supplies on bedside table #1, moved the items to bedside table #2 next to it, with the items for the treatment sitting partially on the brim of a soiled cowboy hat. She put on gloves, retrieved, and opened a Sani-wipe packet, wiping the overbed table. She placed a sterile drape over part of the table and picked up the supplies from bedside table #2 and placed them on the undraped part of the table. She cleaned the scissors with a Sani-wipe then placed them on the drape and washed her hands. Taking one of the medicine cups with 4x4's she went into the bathroom and put a squirt of the 'Luxury Hand Soap' that was hanging on the wall into the cup stating that ICP (Infection Control Preventionist) had instructed her to use the wall hand soap. RN #1 then added a small amount of tap water into the cup. She removed the old dressing and changed her gloves after using ABHS [alcohol based hand sanitizer]. RN #1 then used the 'Luxury Hand Soap' and 4x4's to wipe around the perimeter of the stage 3 pressure ulcer. Without changing her gloves, she used dry 4x4's and wiped around the perimeter of the wound. Without sanitizing her hands or changing her gloves, RN #1 picked up the packing strip container, moved over to residents' bed, removed the cap, placed it on the bed next to the resident. RN #1 pulled out a length of packing tape which was still connected to the container and used a Q-tip to pack the tape into the wound, pulling the tape out of the container two more times and packing it into the wound. She then cut the tape with the scissors from the overbed table. Without changing her gloves, she picked up the lid from the resident's bed, replaced it onto the packing strip container and placed the container back onto the overbed table with the remainder of the supplies. Gloves were changed and ABHS used. RN #1 opened the Calcium Alginate dressing and cut a 1x1 inch square with the scissors that had been lying on the resident's bed. This 1x1 inch square piece of dressing was placed on the wound and the wound was covered with an island dressing. RN #1 removed her gloves and washed her hands. RN #1 then picked up the remaining supplies that included a partial box of gloves, the packing strip (a partial container), the remainder of the 4x4 piece of Calcium Alginate and the pair of scissors taking them out of the resident's room to the treatment cart. RN #1 placed these items on top of the cart, used a Sani-wipe to clean the scissors, placed them into the top drawer. RN #1 then replaced the gloves, the container of packing tape and the remainder of the Calcium Alginate dressing into separate drawers of the treatment cart that held other treatment materials without wiping off the remaining supplies with a Sani-wipe. d. On 8/2/2022 at 2:27 PM, the surveyor asked RN #1, Does the luxury hand soap provide the antibacterial aspect of the physician's order? She stated, .I don't know, [ICP] told me this is what he uses all of the time . The surveyor asked, Does it say on the container if it is antibacterial? She stated, .I don't think so . e. On 8/2/2022 at 2:37 PM, the surveyor asked RN #1 at what point were the supplies considered dirty when taking them from the cart into the resident's room. She stated, .I don't know, when I sat them down on the bedside table? The surveyor asked, What is your facility policy? She stated, .I don't know . The surveyor asked, Should the dressing supplies be placed on an unclean surface? She stated, .No, they shouldn't. I don't usually do treatments . The surveyor asked, Was either bedside table cleaned prior to placing the treatment supplies on them? She stated, .No, I didn't clean either of them . The surveyor asked, Is there a potential for contamination of the supplies when they are placed on an unclean surface? She stated, .Yes, there is a potential for contamination . The surveyor asked, Is there a potential for contamination with the packing strips with packing the wound directly from the container? She stated, .Yes, I guess there is . The surveyor asked, Should the strip, used for the wound, be cut first prior to packing the wound? She stated, .I didn't know how much I would need, that's why I didn't cut it . The surveyor asked, Should gloves be changed from dirty to clean after cleaning the wound? She stated, .Yes, I was just nervous . The surveyor asked, Should gloves be changed prior to replacing the cap on the packing strip? She stated, .Yes, I should've taken my gloves off . The surveyor asked, Are supplies taken into the resident room, considered dirty? She stated, .I don't know . The surveyor asked, Are supplies used on a resident meant to be taken from the room and used on another resident? She stated, .No, they shouldn't be used on anyone else . The surveyor asked, Once supplies are brought out of the resident's room, are they considered dirty or contaminated? She stated, .Yes, I guess so . The surveyor asked, Should they be placed back into the treatment cart? She stated, .No they shouldn't, and I just put them back in there . The surveyor asked, Because the contaminated supplies were put back into the treatment cart with other treatment supplies, are the remainder of the supplies considered contaminated? She stated, .Yes, they would be, if you say it like that . f. On 8/4/2022 at 12:04 PM, the Maintenance Supervisor was shown the Material Safety Data Sheet (MSDS) form for the Luxury hand soap and asked if anywhere on the sheet did it document that it provided an antibacterial ingredient. After reviewing the document, he stated, .I don't see where it says that it is antibacterial . The surveyor asked, Is this brand of soap what is installed in the wall dispensers? He stated, .Yes, all of the wall dispensers have the same soap in them . g. On 8/4/2022 at 12:17 PM, the surveyor asked the Director of Nursing if a Physician's Order reads 'use ABT soap' what does that mean. She stated, .Use antibiotic soap . The surveyor asked, This MSDS was provided by the Maintenance Supervisor, can you review it and show me where it stated it is antibacterial? After reviewing the sheet, she stated, .No, it doesn't . The surveyor asked, Should the luxury hand soap be used as a wound cleanser? She stated, .No, no, I mean no . The surveyor asked, What could be a potential problem with using this type of soap with a Stage 3 Pressure Ulcer? She stated, .Well if it just suds, it won't be beneficial. Without studying the effects, I don't know . The surveyor asked, If it had perfume in it, could it hurt? She stated, .It could, does it have perfume in it? The surveyor asked, Should Physician's orders be followed as written? She stated, .Always, and if you can't, you need to call and get the order changed . The surveyor asked at what point are treatment supplies considered contaminated when they are taken into the resident's room? She stated, .Put them in a bag, take just what you need for your treatment, just what you need, put in a bag that's your clean. Clean the table with a Sani wipe, cover the table, put your clean supplies on the table, line them up as I'm going to need them . The surveyor asked, Should multi use supplies be taken into the residents room? She stated, .No ma'am . The surveyor asked, What is a potential with multi, or single use supplies taken into the resident's room and then returned to the treatment cart? She stated, .Cross contamination . The surveyor asked, If contaminated supplies are replaced into the treatment cart, could there be a higher potential for infection with any resident that receives a treatment from supplies taken from the cart? She stated, .Yes, I'm cleaning the cart out . The surveyor asked, Do you expect your staff to follow the policies and procedures of the facility? She stated, .Yes, ma'am, I do . h. The facility policy titled, Medication and Treatment Orders, provided by the Administrator on 8/4/2022 at 9:59 AM documented, .Orders for medications and treatments will be consistent with principles of safe and effective order writing . All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order . i. The facility policy and procedure titled, Wound Care, provided by the DON on 08/03/22 at 12:34 pm documented, . Purpose 3. Assemble the equipment and supplies as needed . Wipe nozzles, foil packets, bottle tops, etc., with alcohol pledget before opening, as necessary. (Note: This may be performed at the treatment cart.) .Equipment and Supplies 4. Personal protective equipment (e.g., gowns, gloves, masks, etc., as needed) .Steps in the procedure . 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly . 4. Put on exam glove. Loosen tape and remove dressing. 5.Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . 10. Wear gloves when physically touching the wound or holding a moist surface over the wound . 16. Dress wound. Pick up sponge with paper and apply directly to area. Be certain all clean items are on clean field . 23. Wipe reusable supplies with alcohol as indicated (i.e [that is], outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to resident's drawer in treatment cart. 24. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart .

Based on observation, interview and record review, the facility failed to ensure the opening between the clean and dirty side of the laundry room had negative air pressure from the clean side to the dirty side to help prevent the potential from cross contamination. The findings are: 1. On 08/02/22 at 2:30 PM, during the laundry tour with the Administrator, the Administrator stated there was a fire on 7/1/22 and the laundry room was partial burned. They had no washers for 12 to14 days. The Facility had used a local laundromat. The surveyor observed a curtain between the clean and dirty sides and towels around the washers on the ground soaked with water. Water was dripping from the tubing in the corner of the room. Maintenance had followed the Administrator and the Surveyor into the side with the washers and stated, They should have told me. 2. On 08/02/22 at 2:50 PM, when the Laundry Supervisor entered the door to the dirty side, the curtain moved into the clean side approximately 12 inches. The surveyor asked the Administrator if the ventilation was finished or if the curtain was permanent. The Administrator stated they planned to leave the curtain. The Surveyor asked the Administrator if she saw that the curtain went into the clean side when the door opened. The Administrator stated she did. The surveyor stated the negative air pressure is pulling the dirty to the clean. The Administrator asked how she should fix that. The Surveyor stated there were a few solutions but that was up to the facility to determine, but the issue was when the door to the dirty side opens, which is the side they need to enter on with the dirty laundry, the air pressure pulls from dirty to clean. The Administrator stated she would ask Life Safety when they come and the surveyor stated Life Safety most likely will not give an answer, as it is an infection control issue. 3. The facility policy titled, Departmental (Environmental Services) - Laundry and Linen, provided by the Administrator on 08/04/22 at 9:02 AM did not address the negative air pressure cross contamination between the dirty and clean sides of the laundry room.

Based on observation, interview and record review, the facility failed to ensure waste was properly contained in dumpsters and covered with lids to reduce the potential of insect and/or rodent infestation. The findings are: 1. On 08/01/22 at 10:45 AM, the following observations were made during the initial tour of the kitchen with the Dietary Consultant (DC) and the Dietary Manager (DM): a. At 11:12 AM, the surveyor accompanied the DC and the DM to the dumpsters. Four dumpsters were found full and overflowing to the point of lifting the lids of two of the dumpsters straight up and trash falling out onto the ground. The lids of the other two dumpsters had trash piled on top and bags were torn open with trash falling out of them. The Surveyor asked the DM how often trash was picked up. The DM stated, Twice a week but I am not sure what days. 2. On 08/03/22 at 9:02 AM, the Administrator stated they do not have a contract, but they came on Mondays and Thursdays. The Administrator asked if the dumpsters were full or if staff just were lazy and piled the bags on top of the lids because that had been an issue previously. The Surveyor stated the dumpsters were observed full but in addition there was also trash bags piled on top of the lids. 3. The (Name) Sanitation Invoice dated 7/1/2022 provided by the Administrator on 08/03/22 at 9:02 AM stated, .Ship Qty [quantity] 4 .Dumpster 6 Yard Monthly . The invoice did not state how often dumpsters were emptied.

Based on observation, interview and record review, the facility failed to ensure an effective pest control program was in place to keep the facility free of insects/pests to prevent the potential spread of infectious diseases. The findings are: 1. On 08/01/22 at 10:45 AM, during the initial tour of the kitchen with the Dietary Consultant (DC) & (and) the Dietary Manager (DM) the following observations were made in the Dry Storage Room: a. At 11:02 AM, six roaches were under the folded tops of the cranberry, grape & apple juice cartons on the middle shelf of the storage rack. b. At 11:03 AM, one roach was crawling on a bag of rice on the bottom shelf. The DM grabbed a paper towel and killed the roach. c. At 11:06 AM, the surveyor moved a box of rice cereal on the top shelf to read the date and fourteen roaches crawled from all sides of the box, up the side wall and the back wall and fell into a bin/tub of snacks below. The DM stated roaches had been an issue for a while. The DM stated Pest Control comes almost monthly. 2. On 08/02/22 at 11:18 AM, the following observations were made while observing Dietary Staff (DS) #1 pureeing food: a. At 11:27 AM, two roaches crawled on the back ledge of the prep counter where puree was being performed. DS #1 stated, We've been dealing with them for a while. I told them to use fire to kill the roaches. and laughed. b. At 11:50 AM, four roaches were seen crawling along the edge of the floor, under the counter to the right of the steam table. c. At 12:14 PM, one roach crawled over the toe of the surveyor's tennis shoe when the surveyor's leg bumped the leg of stainless table when the surveyor moved out of way of DS #2 going out the door. d. At 3:18 PM, while observing dessert puree being processed by DS #3, the surveyor observed two roaches crawling along the edge of the ceiling where the ceiling meets the wall. The two roaches fell onto the shelf above the prep table that held the spice containers. 3. The (Business) Exterminators Service Agreement dated 04/10/14 provided by the Administrator on 08/01/22 at 12: 32 PM stated .General pest control service. Spiders, flies, roaches, and mice . 7. Pest control service for Inspections and preventive treatment will be provided at least once a month and/or when called . The surveyor asked the Administrator for the monthly receipts or statements. The Administrator stated the man that owns the company is old school and does not give us any kind of receipts or statements. 4. On 08/03/22 at 11:50 AM, the surveyor began watching lunch service due to food temperature complaints from resident council interviews. At 12:26 PM, a roach was crawling in the groove where the wall & the ceiling meet above the hanging pots and fell onto the ledge of the stainless 3 compartment sink. 5. On 08/03/22 at 2:37 PM, the surveyor called the Pest Control Employee (PCE) and asked if he had records of the dates he came and performed pest control at [Facility]. The PCE stated, Not for a while. I haven't kept paper records since 2018. We stopped about then because it became a hassle. The facility should have record of when I do that screening thing. 6. On 08/03/22 at 3:19 PM, the Administrator handed the surveyor the COVID screenings for the PCE for February 2022 to May 2022. The Administrator then stated she did not have screenings for June and July. The Administrator stated the PCE was not screened in June and July because he came in the evening and entered through the back door of the kitchen, when it was closed, to spray while no one was working. The surveyor asked, Who let him in? The Administrator and the RN Consultant stated, The evening nurse supervisor. The surveyor stated, Then he came into contact with a staff member and was not screened? The Administrator stated, I will check with her to see if she let him in. a. At 3:42 PM, the Administrator informed the surveyor that June 29th and July 19th or 20th, Pest Control only came to spray outside for flies and did not come in the building at all. The Administrator stated Maintenance could confirm if surveyor needed. The surveyor stated, To clarify, no indoor pest control has been completed since May. The Administrator stated, I guess not.