Based on observation, interview and facility policy review, the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items and clean equipment; the ice machine was maintained in clean and sanitary conditions; walls were free of accumulations of dust to ensure meals were prepared in clean, sanitary conditions for two of two meals observed. The findings are: 1. On 04/21/25 at 11:10 AM, during the initial kitchen tour with Dietary [NAME] (DC) #1, the ice machine, in a room on the hallway leading to the kitchen, had a pink discoloration/substance to the inside of the plastic panel dispenser. 2. On 04/22/25 at 02:57 PM, the following observations were made in the kitchen: a. There was a puddle of grayish water over the concrete. During an interview with the Dietary Manager (DM), she stated that the water may have been coming from the concrete and was gray in color. a. The wall behind the oven had an accumulation of dust on it, near food being prepared for the residents. b. The floor tile on the right side of the juice machine, in the food preparation room, was missing. The area where the tile was missing had puddles of discolored liquid settled on it. The DM stated the area needed to be fixed and cleaned. 3. On 04/22/25 at 3:30 PM, the inside right corner of the ice machine, close to the area where ice forms before dropping down into the collector, had wet black residue on it. This surveyor asked the Dietary Manager to wipe the wet black residue. She did so, and the wet black residue easily transferred to the tissue. The DM was asked to describe what was observed around the right corner of the ice machine, how often they cleaned the ice machine, and who used the ice from the ice machine. The Dietary Manager stated it was black residue. The staff cleaned it once a week, and the Maintenance Supervisor cleaned the upper part where the ice forms. The Certified Nursing Assistants (CNAs) use it for the water pitchers in the residents' rooms, for beverages served to the residents, and the kitchen staff use it to fill beverages served to the residents at mealtimes. The DM was asked what the concerns about the ice machine not been cleaned were, and she stated cross contamination. 4. On 4/22/25 at 3:39 PM, during an interview with the Maintenance Supervisor, he was asked how often he cleaned the area in the ice machine where ice formed. He stated he cleaned it once a month. 5. On 04/22/25 at 3:53 PM, this surveyor observed Dietary [NAME] (DC) #1 push the blender motor towards the edge of the counter. Without washing his hands, he picked up a clean blade with his contaminated bare hand and attached it to the base of the blender to be used in pureeing foods to be served to the residents who required pureed diets. DC #1 was asked what he should have done after touching dirty objects and before handling clean equipment. He stated he should have washed his hands. 6. On 04/22/25 at 4:25 PM, this surveyor observed Dietary Aide (DA) #2 wearing gloves on her hands, when she picked up a box of plastic food wrap from the counter and placed it in another location. Without changing gloves and washing her hands, she picked up cornbread with her contaminated gloved hand and placed the cornbread in an individual bag to be served to the residents for supper. 7. On 04/22/25 at 5:18 PM, during an interview with DA #2, she was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have removed her gloves, washed her hands, and then put new gloves on. 8. On 04/22/25 at 4:32 PM, this surveyor observed DA #3 wearing gloves when he picked up a pan of cornbread located on top of the oven and sat it on the counter. He then picked up a box of plastic food wrap and placed it on the counter, contaminating his gloved hands. He then picked up cornbread with his contaminated gloved hands and placed it individually in a bag to be served to the residents for supper meal. DA #3 was asked what he should have done after touching dirty objects and before handling clean equipment. He stated he should have washed his hands and changed his gloves. 9. On 04/23/25 at 10:40 AM, DC #4, removed cartons of whole milk and placed them on the counter. Without washing her hands, she picked up the blender blade and attached it to the base of the blender, to be used in pureeing food items to be served to the residents who received pureed diets for the lunch meal. 10. On 04/23/25 at 11:05 AM, this surveyor observed DC #4 turn on the three (3)-compartment sink faucet with her bare hand as she obtained water in a pitcher. After obtaining water, she used her bare hand to turn off the faucet. Without washing her hands, she picked up the blender blade and attached it to the base of the blender to be used in grounding food items to be served to the residents who received mechanically soft diets for the lunch meal. DC #4 was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. 11. A review of a facility policy titled, Handwashing indicated hands should be washed before entering the kitchen at the start of a shift, during food preparation, as often as possible to prevent cross contamination when changing tasks, and after engaging in other activities that contaminate the hands. 12. A review of a facility policy titled, Food Storage indicated food should be stored by methods prepared, to prevent contamination or cross contamination.

Based on observation, interview, facility document review, and policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were utilized for two (Resident #1 and Resident #202) of two residents reviewed for Enhanced Barrier Precautions. The findings include: 1. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2025 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #1 had diagnoses which included: spina bifida, quadriplegia, neurogenic bladder, and a colostomy. a. Provider notes, dated 04/21/2025, and the Weekly Wound Evaluation, dated 04/21/2025, indicated the resident had a stage 4 ulcer to the right buttock area. b. On 04/21/25 at 2:25 PM, the Treatment Nurse (TN) was observed performing a dressing change to the right buttock for Resident #1. EBP signage was on the door of Resident #1's room, indicating the need for staff to wear both a gown and gloves when care was provided for Resident #1. The TN performed hand hygiene, put on gloves but no gown, and positioned the resident. The TN took off the old dressing with visible drainage, cleaned the wound, and completed the dressing change. During the procedure, the TN's clothing touched the bed linens and mattress, while the TN's bare forearm propped Resident #1's right hip, making skin-on-skin contact with the resident, in close proximity of the wound. c. Resident #1's Care Plan , revised 04/21/2025, had EBP listed as an intervention with wounds, with an initiation date of 04/04/2024. The Care Plan stated, gloves and gown required prior to the high-contact care. High-contact care activities listed included, but not limited to, wound care: any skin opening requiring a dressing. d. During an interview with the TN on 04/24/25 at 10:43 AM, the TN indicated that a gown should have been put on for the dressing change to prevent cross-contamination. e. During an interview 04/24/25 at 12:25 PM, the Medical Director (MD) indicated wearing a gown would be appropriate during wound care. 2. The MDS with an ARD of 04/11/2025 indicated Resident #202 had a BIMS score of 4 (which indicated the resident was severely cognitively impaired). The MDS also indicated Resident #202 had diagnoses, which included: a urinary tract infection (last 30 days), dementia, sepsis, and osteomyelitis of the vertebra, sacral and sacrococcygeal region. a. On 04/23/25 at 7:25 AM, Licensed Practical Nurse (LPN) #5 was observed administering an intravenous (IV) antibiotic medication, to Resident #202. EBP signage was on the door of Resident #202's room, which indicated the need for staff to wear both a gown and gloves when care was provided for the resident. The nurse donned gloves, dated and timed the IV tubing, primed the line, entered the room, and began to manipulate the resident's arm, gown, and Peripherally Inserted Central Catheter (PICC), without putting on a gown. b. On 04/23/2025, immediately following the antibiotic administration observation described above, LPN #5 was interviewed and indicated a gown should have been put on for the encounter. LPN #5 indicated EBP should be followed anytime staff does personal care for the resident, because a PICC line goes straight into the bloodstream and to the heart, and a gown would help protect the resident. c. Resident #202's Care Plan , revised on 04/16/2025, indicated that EBP was required for high-contact care. The list of high-contact care included: the use of a central line. 3. During an interview with the Director of Nursing (DON) on 04/24/2025 at 10:30 AM, the DON indicated a gown should have been put on during the dressing change for Resident #1. 4. During an interview with the Administrator on 04/25/2025 at 3:03 PM, the Administrator indicated a gown should have been worn during the dressing change for Resident #1. 5. A review of the policy titled Medication Administration, revised 11/25/2022, stated Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of the medications, as applicable. 6. A review of the posted EBP signage on both the doors of Resident #1 and Resident #202 revealed that providers and staff must wear gloves and gown for central line and wound care dressings.

Based on observations, interviews and policy review, the facility failed to ensure Resident or Resident representative was invited to a comprehensive care plan meeting for 1 (Resident #45) of 98 residents who receive a care plan. The findings are: 1. On 03/26/2024 at 07:45 AM, the Administrator provided Resident Rights which indicate a Resident, Be informed of, and participate in his or her care planning and treatment. 2. On 03/26/2024 at 09:37 AM, by phone Surveyor spoke with Resident #45's Representative [RR]. RR #45 indicated that it had been two years since she had received notification or a call regarding a care plan meeting. 3. On 03/27/2024 at 10:10 AM, interviewed Social Services Director [SSD] regarding when the last time Resident #45's family was invited to a care plan meeting. SSD indicated it was about two years ago. SSD was specifically asked what was the last date Resident #45's family was invited to a care plan meeting? SSD stated, It had been about two years ago. 4. On 03/28/2024 at 11:50 AM, the Administrator reported that the facility does not have a policy for care plans.

Based on observation and interview, the facility failed to ensure residents had a clean and homelike environment. The findings are: 1. On 03/28/2024 at 09:44 AM, the Surveyor observed a wall on D-Hall with large sections of chipped and missing paint with black rub marks along the wall. The bathroom on D-Hall had missing floor tiles and thick, black matter under the shower seat on the floor, along the baseboards, in the corners, and around the commode. The Secure Unit on D-Hall had a cobweb in the corner behind the entrance door. The wall above the rail behind the entrance door had brown matter. A bag with dry, pink matter and an empty medicine cup was tucked behind the handrail. The fire extinguisher cover had small rust spots along the bottom of the door. In room D29 the heating and air conditioning wall unit had dark matter with loose particles inside the vent and one of the vent's slats was broken. The horizontal blinds covering the window had a broken string, would not go up and down, or close. The bathroom between rooms D27 and D29 had black, crusty matter around the commode and in the corners. The commode was twisted 5-6 inches to the right. 1a. On 03/28/2024 at 09:57 AM, the Surveyor asked the Housekeeper (HSKP), Can you describe the walls behind the entrance doors? The HSKP said there is a cobweb in the corner and that could be coffee or spit on the wall. The Surveyor asked, Can you describe what is behind the handrail? The HSKP said trash. The Surveyor asked, Can you describe the bathroom between Rooms D27 and D29? The HSKP said it looked like it could be feces or rust around the toilet and in the corner. The Surveyor asked, How often do you clean the handrails, rooms, and bathrooms? The HSKP said I clean the handrails, rooms, and bathrooms once a day and whenever it is needed. 1b. On 03/28/2024 at 10:09 AM, the Administrator confirmed the following on D-Hall; chipped paint on the wall of the hallway, trash behind the handrail, rust spots on the fire extinguisher door, a cobweb in the corner behind the door, and the dirty wall above the handrail; the shower room with missing tiles, and the dirt under the shower seat, and the corners. The broken blinds in Room D29 the dirty air conditioning unit, the bathrooms between Rooms D27 and D29 and the loose commode. 1c. On 03/28/2024 at 10:27 PM, the Surveyor asked the Director of Nursing (DON) who was responsible for reporting maintenance concerns. The DON said everyone is. If housekeeping, nursing, or dietary notices anything that needs to be fixed they should report it immediately. 1d. On 03/28/2024 at 11:05 AM, the Surveyor asked Maintenance, How are you made aware of problems in the facility that need to be fixed? Maintenance said we have a text system and a maintenance request book at the front desk. I wasn't made aware of the toilet on D-Hall until this morning. The Surveyor asked, Can you describe what is wrong with the commode? Maintenance said it look like loose bolts. 1e. Review of the Maintenance Request Book showed no requests related to the above issues. 2.On 03/25/2024 at 10:57 AM, in room B8 scrapped paint was observed on the walls. a. On 03/25/2024 at 10:58 AM, in room B10 scrapped paint was observed on the walls. b. On 03/25/2024 at 11:16 AM, in room B12 scrapped paint was observed on the walls. c. On 03/25/2024 at 11:39 AM, in room B1 scrapped paint was observed on the walls. d. On 03/28/2024 at 09:15 AM, the Maintenance Supervisor was asked, Can you tell me why the walls are scrapped in rooms B8, B10, B12, and B1? He stated, We're working on them. 3. On 03/26/2024 at 07:45 AM a form titled Policies and Procedures: Resident Rights Effective Date 4/2021 Review Date 1/2024 was received from the administrator. It documented, .federal and state laws guarantee certain basic rights to all residents of this facility . include the right to . a safe, clean, homelike environment . 4. On 03/25/2024 at 10:57 AM, in room B8 scrapped paint was observed on the walls. a. On 03/25/2024 at 10:58 AM, in room B10 scrapped paint was observed on the walls. b. On 03/25/2024 at 11:16 AM, in room B12 scrapped paint was observed on the walls. c. On 03/25/2024 at 11:39 AM, in room B1 scrapped paint was observed on the walls. d. On 03/28/2024 at 09:15 AM, the Maintenance Supervisor was asked, Can you tell me why the walls are scrapped in rooms B8, B10, B12, and B1? He stated, We're working on them. 3. On 03/26/2024 at 07:45 AM, a form titled Policies and Procedures: Resident Rights Effective Date 04/2021 Review Date 01/2024 was received from the administrator. It documented, .federal and state laws guarantee certain basic rights to all residents of this facility .include the right to .a safe, clean, homelike environment .

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 03/27/2024 at 12:09 PM, Dietary Employee (DE) #1 poured the pureed cauliflower into a pan and placed it in a pan of hot water on the stove. The consistency of the pureed cauliflower was not formed, water was separated from the vegetable. At 01:16 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed cauliflower served to the residents on pureed diets. She stated, They should have added a little thickener. 2. On 03/28/2024 at 08:14 AM, the residents on pureed diets were served the following food items. a. Pureed sausage served to the residents on pureed diets was gritty with sausage skin in it and not smooth. b. The pureed bread served to the residents on pureed diets was thick, had lumps in it and was not smooth. 3. On 03/28/2024 at 10:40 AM, the surveyor asked Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets, she stated, Pureed sausage had sausage skin still in it. We will remove the skin next time we use it. Pureed bread had little lumps in it.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator was covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods were dated the day received or opened to assure first in, first out usage to prevent potential for food bone illness, and dietary staff washed their hands before handling clean. equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 96 residents who received. meals from the kitchen. The findings are: 1. On 03/27/2024 at 08:19 AM, two opened plastic lock bags that contained cheese slices were on a shelf in the walk-in refrigerator. The bags were not sealed. 2. On 03/27/2024 at 08:33 AM, an opened bag of coffee was on the counter. The bag was not sealed, exposing it to cross contamination. 3. On 03/27/2024 at 08:39 AM, the following observations were made on a shelf in the refrigerator at the nurse's station on the D-hall. a. Two cartons of 2% milk with expiration date of 03/10/2024. b. Three unopened cups of nectar thickener water with an expiration date of 03/17/2024. c. An opened bag of Mexican style cheese with no received or opened date. d. A bowl of chocolate and a bowl of apple sauce covered with saran wrap. There was no date as of when they were stored. 4. On 03/27/2024 at 11:05 AM, Dietary Employee (DE) #1 peeled cooked sweet potatoes skins off. She pushed the food cart towards the counter. Without washing her hands, she attached a clean blade at the base of the blender to be used in pureeing food items to be served to the residents for lunch meal. 5. On 03/27/2024 at 11:13 AM, DE #1 pushed a cart that contained baked chicken towards the food preparation counter and without washing her hands, she attached a clean blade to the base of the blender, placed 10 servings of baked chicken breast into a blender, ground and poured into a pan. 6. On 03/27/2024 at 11:18 AM, DE #1 picked up a pan of baked chicken from the stove and placed it on the counter. Without washing her hands, she attached a clean blade at the base of the blender with her bare hand to be used in pureeing food items to be served to the residents who required pureed diets. At 01:10 PM, the Surveyor asked the DE #1 what should have been done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 7. A Facility policy titled, hand washing/When to wash hand, provided by the Dietary Supervisor on 03/28/2024 at 09:33 AM documented, .When entering the kitchen at the start of a shift and after engaging in other activities that contaminate the hands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to consider the residents' food preferences and serve items listed on the meal ticket for 1 (Resident #66) of 1 sampled resident. This failed practice had the potential to affect 92 residents who received a meal tray from the kitchen as documented on a list provided by the Administrator on 02/24/23 at 9:00 AM. The findings are: Resident #66 had diagnoses of Multiple Sclerosis (MS), Personal History of Transient Ischemic Attack, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Paraplegia, Unspecified. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision after set up for eating. a. The Physicians Order dated 01/26/20 documented, .General diet, Regular texture, Thin Liquids consistency. b. The Care Plan with revision date of 03/03/20 documented, .The resident is presently within his/her ideal body weight (IBW) range . Present weight is 162lbs [pounds] . 9/1/20 Magic cup with dinner . Determine food preferences through one-to-one interview &/or family interview . Offer between meal snacks & meal substitutions, as appropriate. Offer the resident a bedtime snack . c. The Dietary Progress Note dated 07/05/22 at 16:51 (4:51 PM) documented, RD [Registered Dietician] / Wt [weight] Change Review: .Wt indicating significant wt loss of -12.21% x [times] 180 days. Wt change of -0.98% x 30 days . Resident is a very picky eater, but the kitchen is working w/ [with] him to meet his needs. Met with him today and he spoke about specific requests for a particular fruit at each meal. He was educated that fruit wouldn't necessary encourage weight gain, however, he was adamant that that's all he desired at this time. Tray card updated and communicated to DM [Dietary Manager] onsite. Staff reports that health decline and wt loss may also be r/t [related to] MS dx [diagnosis] and food prefs [preferences] he made are in order to slow the progression of the dz [disease]. The MS diet guidelines encourage consuming more plant based foods and grains. RD to f/u [follow-up] at next visit to see how things are going and be available prn [as needed] . d. The Grievance dated 02/08/23 documented Resident #66 filed the following complaint, .For breakfast, tired of getting same fruit and oatmeal . Resolution: Resident receives other fruits and alternates . e. On 02/21/23 at 12:03 PM, Resident #66 was in his room, seated in his wheelchair (w/c). The Surveyor asked if he had lost any weight since living at facility. He stated, Yes, I've lost some. I don't know how much but I've gained some back. I don't like beef or pork, so they used to send me junk food to replace them, but I wouldn't eat it. I started asking for fruit. I like grapes, oranges and bananas. The Surveyor asked if he received fruit for breakfast this morning. He stated, Yes, I got oranges for breakfast, and I get orange slices every meal. It's usually the only fruit I get. f. On 02/21/23 at 1:01 PM, Resident #66 was in his room, seated in his w/c when his lunch tray was set up in front of him on the bedside table by Certified Nursing Assistant (CNA) #1. His lunch consisted of 2 bowls of orange slices, 2 bowls of green beans and 2 slices of whitish colored fileted meat. The Surveyor asked Resident #66 if the meat on his plate was chicken or fish. He stated, It's fish. I can eat fish, but I don't want it on Monday, Wednesday, and Friday. I get the same thing all the time. The Surveyor asked if she could see his meal ticket that was on his tray. He stated, Yes. The meal ticket stated, Chicken tenders and oranges. At 1:04 PM, the Surveyor asked CNA #1 if the meat on his plate was chicken or fish. She stated, I don't know but it looks like fish. CNA #1 looked at the meal ticket, then asked Resident #66 if he wanted chicken tenders instead of fish. He stated, Sure, I could eat some chicken. CNA #1 told Resident #66 that she would go to the kitchen to get him some. CNA #1 returned to resident's room after approximately 5 minutes and told Resident #66 that someone from the kitchen would be bringing his chicken. g. On 02/22/23 at 8:00 AM, Resident #66 was eating breakfast in his room. Orange slices were in a bowl on breakfast tray. h. On 02/22/23 at 1:00 PM, Resident #66 was finishing up lunch in his room. A banana peeling was on his lunch tray. The Surveyor asked if he got a different fruit for lunch. He stated, Yes, I had a banana. i. The Nutritional assessment dated [DATE] documented, .Significant Change . 11. A. Food Preferences . 6. List any Food/Beverage DISLIKES NO FRIED FOODS, NO PORK, NO RICE. Serve only one sweet potato when on menu, NO GRAVY, NO DAIRY, BEEF, BREAD, CUCUMBERS, EGGS 7. Additional Comments Related to Food Preferences DM is working with resident to accommodate food preferences . j. On 02/23/23, Resident #66's Care Plan was revised with the following information, .The resident is presently within his/her ideal body weight (IBW) range .9/1/20 Magic cup with dinner . Resident prefers a variety of fruits with meals where fruits are served. Doesn't like to receive same fruit repeatedly . k. On 02/24/23 at 10:16 AM, the Surveyor asked the Dietary Manager, How often are residents assessed for likes and dislikes? She stated, Quarterly. The Surveyor asked, Are you familiar with [Resident #66]? She stated, Yes. The Surveyor asked, On 02/21/23 [Resident #66's] lunch meal ticket stated, Chicken and oranges, but was served fish. Was fish his alternative? She stated, No. The Surveyor asked, How did you know to put fish on his plate and not chicken? She stated, He tells us that he gets tired of the same old thing all the time, so I've bought turkey and fish to try to please him. The Surveyor asked, Are there set alternatives or is it a choice? The Dietary Manager stated, There is always a choice, even if the resident doesn't want either they can suggest something they want. l. The facility policy and procedure titled Meal Identification and Preference Cards/Tickets, provided by the Dietary Consultant on 02/24/23 at 11:00 AM documented, .Policy: A meal identification and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preferences . 4. Meal ID cards/tickets will be used during meal service to assure the correct diet is being served and food preferences are honored .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure a Baseline Care Plan was developed within 48 hours of admission to include the minimum healthcare information necessary to provide for the resident's care needs to promote continuity of care and minimize the potential for adverse events after admission for 1 (Resident #142) of the 4 (Residents #21, #69, #71 and #302) sampled residents who were admitted to the facility in the past 30 days as documented on the MDS (Minimum Data Set) Resident Matrix provided by the MDS Coordinator on 02/22/23 at 10:43 AM. The findings are: Resident #142 was admitted to the facility on [DATE] and had a diagnoses of Other Lack of Coordination, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus with Diabetic Neuropathy. The Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/16/23 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 two plus persons with transfers and dressing, extensive physical assistance of one person with bed mobility, locomotion on and off the unit, toilet use and personal hygiene, and limited physical assistance of one person with eating, had an indwelling catheter and had frequent bowel incontinence. The Baseline Care Plan with an initiated date 02/14/23 was not completed and contained no documentation related to the resident's Activities of Daily Living until a revision of the Care Plan on 02/21/23. On 2/24/23 at 9:35 AM, the Surveyor asked the MDS Coordinator, When should the Baseline Care Plan be initiated for a resident? The MDS Coordinator stated, On admission and completed within 48 hours. The Surveyor asked, Why is the Baseline Care Plan important? The MDS Coordinator stated, It establishes the specialized needs for those particular residents care. The Surveyor asked, What could the potential outcome be if the Baseline Care Plan is not completed in a timely manner? The MDS Coordinator stated, It could delay the proper care a resident needs. The Surveyor asked, Would you consider a resident who was admitted on [DATE] and the Baseline Care Plan initiated on 02/13/23 timely? The MDS Coordinator stated, No, that's 72 hours. On 02/24/23 at 10:12 AM, the Surveyor asked the Director of Nursing (DON), When should the Baseline Care Plan be initiated for a resident? The DON stated, It should be done upon admission by the admitting nurse. The Surveyor asked, Why is the Baseline Care Plan important? The DON stated, So all staff members involved in caring for that particular resident knows what care needs to be provided. The Surveyor asked, What could the potential outcome be if the Baseline Care Plan is not completed in a timely manner? The DON stated, The appropriate care may not be provided for that particular resident. The Surveyor asked, Would you consider a resident who was admitted on [DATE] and the Baseline Care Plan initiated on 02/13/23 timely? The DON stated, It is not. On 2/24/23 at 10:45 AM the Surveyor asked Licensed Practical Nurse (LPN) #2, When should the Baseline Care Plan be initiated for a resident? LPN #2 stated, It should be done upon admission by the nurse doing the admission and completed in 24 hours. The Surveyor asked, Why is the Baseline Care Plan important? LPN #2 stated, So all staff members involved can care for the resident's individualized needs. The Surveyor asked, What could the potential outcome be if the Baseline Care Plan is not completed in a timely manner? LPN #2 stated, The individualized care needs for a resident may not be provided. The Surveyor asked, Would you consider a resident who was admitted on [DATE] and the Baseline Care Plan initiated on 02/13/23 timely? LPN #2 stated, No sir. The facility policy and procedure titled, Baseline Care Plans, provided by the DON on 02/24/23 at 9:11 AM stated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . 1. To ensure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission . 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan .

Based on observation, record review, and interview, the facility failed to ensure nursing staff assessed and obtained treatment orders for a laceration with sutures to promote healing and prevent potential infection for one (Resident #59) of 1 sampled resident who had sutures and required suture care and removal. The findings are: Resident #59 had diagnoses of Dementia and Repeated Falls. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required one person extensive physical assistance with personal hygiene and bathing. a. The February 2023 Physician Orders did not contain orders for treatment to suture line or suture removal. b. The Care Plan with a revision date of 02/08/23 did not address an injury to Resident #59's forehead. c. On 02/21/23 at 11:54 AM, Resident #59 was sitting up in bed, the right side of her forehead had a dry scab with several sutures visible. d. On 02/22/23 at 10:31 AM, Resident #59 was in her room. She had a dry scab with sutures on the right side of her forehead. e. On 02/23/23 at 10:15 AM, the Surveyor asked the Wound Nurse/Licensed Practical Nurse (LPN) #1, How long should sutures stay in? LPN #1 stated, Usually they are removed between 7 to 21 days. The Surveyor asked, Who is responsible for suture removal? LPN #1 stated, It depends on the order, usually I remove them with an order. If there is no order for treatment or removal, I contact the physician or Advanced Practice Nurse [APN] to get an order for treatment and removal, if appropriate. The Surveyor asked, When should [Resident #59] have the sutures on her forehead removed? The LPN #1 stated, I didn't know she had sutures. f. On 02/23/23 at 10:25 AM, the Surveyor asked LPN #2/Unit Manager, Who is responsible for obtaining orders for wounds, suture removal and such when someone returns from the hospital, doctors or ER [Emergency Room]? LPN # 2 stated, The Wound Nurse. If someone returns on evening or night shift, then the floor nurse receiving them is responsible for informing the other shifts and getting orders. g. On 02/23/23 at 10:29 AM, the Surveyor asked the Director of Nursing (DON), Who is responsible for continuity of care and orders when someone is sent out to the emergency room and returns? The DON stated, The floor nurse, if it's the middle of night they write the orders, then the administrative staff follows up on it the next day. h. On 02/24/23 at 11:55 AM, the Surveyor asked the Nurse Consultant for the policy and procedure on suture care. The Nurse Consultant stated, We don't have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Rushing, [NAME] Based on observation, interview, and record review, the facility failed to provide incontinence care to promote a healthy and an odor free environment for 1 (Resident #2) of 3 (Residents #2, #23 and #48) sampled residents who had urinary catheters. This failed practice had the potential to affect 3 residents who had a foley catheter as documented on a list provided by the Nurse Consultant on 02/24/23. The findings are: Resident #2 had diagnoses of Neurogenic Bladder, Quadriplegia and Spina Bifida. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and had an indwelling catheter. a. The Care Plan with a revision date of 12/16/19 documented, .I am at risk for delayed wound healing due to bladder leakage from impaired urinary meatus . I have a Suprapubic Catheter (#24 with 30cc [cubic centimeter] bulb), Dx [diagnosis]: Neurogenic bladder . I have a 24FR [French] suprapubic catheter with 30cc bulb. Position catheter bag and tubing below the level of the bladder . Check tubing for kinks each shift . Monitor/record/report to MD [Medical Doctor] as indicated, s/sx [signs and symptoms] UTI [Urinary Tract infection]: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color . Urinary frequency, foul smelling urine . b. The February 2023 Physician's Orders documented, .Oxybutynin Chloride Tablet 5 MG [milligrams] Give 1 tablet by mouth four times a day for bladder related to OVERACTIVE BLADDER . Order Date 06/01/21 . Suprapubic Catheter Size: 24 fr with 30ml [milliliter] bulb Diagnosis: NEUROMUSCULAR DYSFUNCTION OF BLADDER . c. The February 2023 CNA Task Sheet provided by the Director of Nursing (DON) on 02/24/23 at 10:00 AM documented incontinence care was given every shift with 2 blank areas (02/22/23 and 02/23/23) on the 7:00 AM to 3:00 PM shift, 2 blank areas (02/03/23 and 02/07/23) on the 3:00 pm-11:00 pm, 4 blank areas (02/09/23, 02/14/23, 02/19/23 and 02/22/23) on the 11:00 pm -7:00 am shift. d. On 02/22/23 at 8:35 AM, Resident #2 was lying in bed, a strong urine odor was present in her room. Resident #2 had a catheter bag connected to tubing that went up resident's right pant leg and connected to her suprapubic foley catheter lying on the mattress on the foot of the bed. e. On 02/23/23 at 8:16 AM, Resident #2 was lying in bed, a very strong urine odor was noted at the resident's bedside. f. On 02/24/23 at 9:11 AM, Resident #2 was lying in bed, there continued to be a strong urine odor in her room. g. On 02/23/23 at 9:55 AM, the Surveyor observed the Wound Nurse/Licensed Practical Nurse (LPN) #1 perform suprapubic catheter care to Resident #2 with no leakage or odor from the insertion site noted. At 10:00 AM, the Surveyor asked LPN #1, [Resident #2] has a suprapubic catheter, can you explain why she has a urine odor? LPN #1 stated, Depending on how she is positioned, sometimes the suprapubic catheter will leak, also she voids small amounts of urine at times. She is supposed to be seeing her urologist about this. h. On 02/24/23 at 9:13 AM, the Surveyor asked LPN #3, How do the Certified Nursing Assistants [CNAs] determine who needs incontinent care/perineal care [pericare]? She stated, They are checked regularly. They check them every hour. The Surveyor asked, Do residents, who have a catheter, require peri-care? LPN #3 stated, Yes, they need peri-care. i. On 02/24/2023 at 9:25 AM, the Surveyor asked CNA #3, How do you know who requires incontinence/pericare? CNA #3 stated, Most of the residents back here (Secure Neighborhood) are independent, but we check them regularly to make sure because sometimes they have incontinent episodes. The Surveyor asked, Is it on their Care Plan who requires incontinent care/pericare? CNA #3 stated, Not that I know of. I haven't seen a Care Plan. The Surveyor asked, How long have you worked here?' CNA #3 stated, About five months. j. On 02/24/2023 at 10:45 AM, the Surveyor asked the DON, How does the staff know who requires incontinent care/pericare? The DON stated, It comes through on the [NAME]. What is triggered from the Care Plan will show up. The Surveyor asked, Should someone with a Foley Catheter receive pericare? The DON stated, Yes, they should. k. The facility policy and procedure titled, Incontinence Policy, provided by the Nurse Consultant on 02/24/23 at 10:00 AM documented, .Assessment and Recognition 1.The interdisciplinary team (IDCP) will identify individuals who are continent but have risk factors of incontinence . 2. The IDCP will identify individuals with complications of existing incontinence . Treatment/Management 7. The IDCP will encourage incontinence care for residents who require assistance .

Based on observation, interview, and record review, the facility failed to take actions directed at the Performance Improvement Plan (PIP) by not implementing those actions, measure the success of those actions, and track performance of those actions to ensure improvements goals were met and sustained. The failed practice had the ability to affect all 93 residents who resided in the facility according to the Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 02/22/23 at 10:43 AM. The findings are: 1. On 02/21/23 at 10:50 AM, in the kitchen, the walk-in freezer had frozen water on the floor. The water originated from the motor/condenser located on the top of the unit. The water had traveled down the wall and accumulated on the top of a case of previously opened hamburger buns. 2. On 02/22/23 at 8:40 AM, the floor of the walk-in freezer continued to have frozen water on the floor. The water on the floor was located directly beneath the motor/condenser attached to the top of the freezer. An area directly under one leak extended from the floor of the freezer up approximately 6 inches. The water had run down the wall, freezing on the wall and on top of an opened box of hamburger buns. The ice on top of the box had accumulated and formed an area of ice approximately 1/4 inch to 1 and 1/2 inches thick. The running water had also frozen on the front of the box. The Surveyor asked the Dietary Manager if she had reported the issue of the water to the Maintenance Department. She stated, .No, it's been doing that since I got here so I really didn't think anything about it . The Dietary Consultant stated that the issue with the water dripping will be reported on this date. 3. On 02/22/23 at 1:45 PM, the Dietary Manager and Dietary Consultant approached this Surveyor. The Dietary Consultant reported that the Dietary Manager misspoke on 02/21/23 when she stated that she had not spoken to the Maintenance Department about the water in the freezer. The Dietary Consultant described that the Dietary Manager was simply unaware that action had been taken previously. The Dietary Consultant described that the administration had written a PIP. Review of the plan revealed that the plan was written in August 2021. The August 2021 PIP provided by the Dietary Consultant on 02/22/23 documented, Observation during routine inspection there was ice buildup noted in different areas of the freezer. A handwritten note in the observation section documented, Can't come due to COVID. Notation was not signed or dated. Action the unit has been looked at for repair at different times. Supply chain issues as well as labor issues have prevented timely repair. Will continue to discuss repair time with vendor. Maintenance immediately removed built up ice. Dietary staff will keep the ice chipped away as needed until vendor can make repairs. Dietary personnel will contact maintenance if there are any issues noted to temperatures. A handwritten note in this section documented, Oct. [October] 2022 Maint. [Maintenance] repaired. Person Responsible Dietary, Maintenance. Evaluation Method Observations. Multiple handwritten notations made in this section documented, Holding temp-no negative outcomes; dietary keeps ice chipped-temps [temperatures] good. Notations were not dated. On 12/22 a handwritten notation documented, Some buildup, temps good. Goal or Measure of Success and Date No ice buildup in unit. Evaluation Date/Results On-going. An Invoice dated 08/25/2021 provided by the Dietary Consultant documented service had been provided on the freezer on 8/02/21. 4. On 02/23/23 at 8:30 AM, the Surveyor asked the Administrator to review the PIP that was provided on 02/22/23 and to address the Goal or Measure of Success and Date. The Surveyor asked, for the date of the PIP completion, as one was not listed. The Administrator stated, With COVID and everything, I couldn't put in a date. Because of COVID and staffing and not knowing when I could get someone in here, I couldn't put down a date. Do you want me to make one up? The Surveyor asked the Administrator for a policy concerning the QA [Quality Assurance]/QAPI [Quality Assurance and Performance Improvement] program including the completion date of the PIP. Administrator stated, Let me look. At 9:40 AM, the Nurse Consultant reported that there was no policy for the PIP process. 5. On 02/23/23 at 3:55 PM, the Surveyor asked the Maintenance Director if he was aware of the problem with dripping water in the freezer. The Maintenance Director stated, .I didn't really know that it was happening all the time . I know we have had people out here before . The Surveyor asked when was the last time that he worked on the freezer. The Maintenance Director stated, .A month or two ago I was called because I think the temperature was dropping a little bit . I defrosted the coil . The Surveyor asked if there was a maintenance log which would provide a record of reported issues and when they were addressed. The Maintenance Director stated, They just started that log system again about a month ago. So, before that I wouldn't be able to tell you . The Maintenance Director stated that he was out during November and December of 2022 and that he thought that an outside repair service had been called in to fix a problem during this time. However, he was uncertain of the exact nature of the problem. The Surveyor asked the Maintenance Director to provide an invoice of this service call. 6. The Administrator provided an Invoice dated 02/24/23 that documented service had been provided to the freezer on 02/23/23. 7. The facility policy and procedure titled, QAPI Improvement Activities, provided by the Activity Director on 02/24/23 at 9:11 AM documented, .Purpose The facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained .

Based on observation, record review, and interview the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for 2 (Residents #16 and #23) of 17 [Residents #11, #13, #16, #21, #23, #29, #33, #34, #35, #38, #55, #56, #59, #62, #78, #82 and #142) sampled residents reviewed. The findings are: 1. Resident #16 had diagnoses of Depression, Cerebral Infarction, Hemiplegia and Hemiparesis - Right Side Effected, and Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. On 02/21/23 at 12:08 PM, Resident #16's bathroom had multiple brownish spots, and a half inch sized ball of hair on the floor. The metal trim around the inner bathroom door was rusted with jagged edges and parts were missing at the bottom where the frame meets the tile floor. Three wall tiles were missing on the wall directly above the floor trim with black and brown stains visible on the wall where the tile was missing. There were multiple tan and brown spots on the floor around the toilet. 2. On 02/23/23 at 2:00 PM, the Surveyor accompanied the Maintenance Director to Resident #16's bathroom. There continued be multiple brownish spots, a half inch sized ball of hair, and rusted, jagged edges of the metal door frame, multiple areas of brown and black discoloration with 3 missing tiles on the wall and multiple tan and brown areas around the toilet. The Surveyor asked the Maintenance Director if he knew how long the bathroom had been in this condition. The Maintenance Director answered, No, but it couldn't have been long since the tiles are stacked up here behind the toilet. The Surveyor asked if it had been reported to him. The Maintenance Director answered, No. The Surveyor and the Maintenance Director walked to two additional resident rooms that had discolored areas on multiple ceiling tiles. The Surveyor asked the Maintenance Director how long the ceiling tiles had been discolored. The Maintenance Director answered, I had someone repair the roof on one of the wings and replaced the roof on that wing within the last 3 to 4 years. The Surveyor asked the Maintenance Director if there was a record of repairs. The Maintenance Director answered, No, that would be something to talk to the Administrator about. a. On 02/23/23 at 2:27 PM, the Surveyor requested all roof/ceiling repair invoices from the Administrator. b. On 02/23/23 at 3:30 PM, the Nurse Consultant stated, There are no repair invoices . It's an old building and leaks are not uncommon in an old building. 3. Resident #23 had diagnoses of Paraplegia, and Pressure Ulcer of Sacral Region, Stage 4. The 5 Day admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) had one Stage 3 and one Stage 4 pressure ulcers present on admission and used a wheelchair. a. On 02/21/23 at 12:38 PM, Resident #23 was lying in bed, an electric power chair was across from the bed with a pressure relief cushion in the seat. There were multiple white colored dried spots on the cushion. The Surveyor asked Resident #23 how often the wheelchair and cushion were cleaned and if the spots bothered him. He stated, Yes, it bothers me. Can you take care of that for me? b. On 02/22/23 at 8:30 AM, LPN #1 performed wound care on Resident #23 in bed. There were white spill stains on the cushion in the seat of Resident #23's wheelchair. c. On 02/23/23 at 8:50 AM, the Surveyor asked the Director of Nursing (DON) for the policy and procedure and process for cleaning wheelchairs and wheelchair pressure relief cushions. The DON stated, They are cleaned on Monday and Thursday. If they are soiled or not cleanable, we replace them. We do not have a policy and procedure for cleaning the resident cushions and wheelchairs. d. On 02/23/22 at 3:15 PM, the Surveyor asked Licensed Practical Nurse (LPN) #4 how often the wheelchair and pressure relief cushions were cleaned, who was responsible, and what if there were spill spots and stains on them. LPN # 4 stated, The 11-7 [11:00 PM to 7:00 AM] shift. Certified Nursing Assistants [CNA's] rotates the odd and even rooms for cleaning of the wheelchairs and pressure relief cushions. We should clean any spills immediately. The Surveyor asked if it was acceptable for Resident #23's pressure relief cushion in his wheelchair to have the white spots and spill stains visible for two days in a row. LPN # 4 stated, No, it's not. e. On 02/23/22 at 3:15 PM, the Surveyor asked CNA #4 how often the wheelchair and pressure relief cushions were cleaned, who was responsible, and what if there were spill spots and stains on them. CNA #4 stated, We clean them two times a week, Monday, and Thursday. We are supposed to clean spills as they occur. The Surveyor asked if it was acceptable for Resident #23's pressure relief cushion in his wheelchair to have the white spots and spill stains visible for two days in a row. CNA #4 stated, No, it's not. f. On 02/23/22 at 4:00 PM, the DON stated the facility did not have a policy on the cleaning of wheelchairs and pressure relief devices.

Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided to maintain good hygiene for 2 (Resident #66 and #78) of sampled residents who were dependent on staff for bathing and failed to ensure fingernails were cleaned and groomed to promote good personal hygiene and grooming for 1 (Resident #16) of 23 (Residents #1, #2, #11, #16, #23, #25, #29, #33, #34, #38, #39, #45, #48, #50, #55, #56, #59, #62, #65, #78, #80, #82 and #85) sampled residents who were dependent on staff for fingernail care. This failed practice had the potential to affect 29 residents who were dependent on staff for bathing/showers and 93 residents' who were dependent on staff for nail care as documented on list provided by the Director of Nursing (DON) on 02/23/23 at 3:45 pm. The findings are: 1. Resident #66 had diagnoses of Multiple Sclerosis, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Paraplegia. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Data (ARD) dated 02/04/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of one person with personal hygiene and was totally dependent on one person for bathing. a. The Care Plan with a revision date of 12/23/19 documented, . I'm at risk for an ADL [activities of daily living] self-care performance deficit r/t [related to] External devices, Hemiplegia, Impaired balance, Limited Mobility . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . The resident requires extensive assist by (X1) [times one] staff with showering . PERSONAL HYGIENE: The resident requires extensive assist by (X1) staff with personal hygiene and oral care . b. The Resident Grievance Reports for the last 3 months documented on 11/02/22 Resident #66's complaint, Did not get a bath on Monday . Resolution: Received bed bath same day. On 01/16/23 Resident #66's complaint, Didn't receive bath on previous Friday . Resolution: R [Resident] A&O [Alert and oriented] x [times] 4 and able to communicate needs. Bath was given after grievance. c. On 02/22/23 at 7:51 AM, Resident #66 was in his room, seated in his wheelchair. He stated, Something I forgot to tell you yesterday is. I'm not getting bed baths like scheduled. I'm supposed to get one on Mondays, Wednesdays, and Fridays. I got one last Friday and today is Wednesday, so I didn't get one on Monday. They may say that I refuse, but I never refuse. The Surveyor asked if the staff is responsible for shaving him also. He stated, No. I have a homeboy that comes in and shaves me. d. On 02/24/23 at 9:54 AM, the Surveyor asked Certified Nursing Assistant (CNA) #5, Who is responsible for giving residents showers? She stated, The aide for that hall. The Surveyor asked, How does the CNAs know which resident gets showers on which day? CNA #5 stated, It's in [Facility Computer Software]. The Surveyor asked, If a resident refuses a shower, what do the CNAs do? She stated, We will try multiple times to get them to take a shower. Then we will tell the nurse. e. On 02/24/23 at 10:03 AM, the Surveyor asked the DON, Who is responsible for giving residents showers? She stated, The CNAs. The Surveyor asked, If a resident refuses a shower, what do the CNAs do? She stated, They will document refusal in [Facility Computer Software], try multiple attempts and then notify the nurse so they can intervene.2.Resident #78 had diagnoses of Cognitive Communication Disorder, Anxiety, and Cerebral Infarction without Residual Deficits. The Quarterly MDS with an ARD of 01/19/23 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and required extensive one person physical assistance with personal hygiene and one person physical assistant with bathing activity. a. The Care Plan with a revision date of 05/015/22 documented, .BATHING/SHOWERING: The resident is totally dependent on (X1) staff to provide bathing . b. The February 2023 ADL Survey Report for bathing provided by the DON on 02/23/22 at 9:45 AM documented Resident #78 was scheduled to receive showers/bathing 3 times per week on Tuesdays, Thursdays, and Saturdays. On 02/04/23, 02/11/23 and 02/14/23 documented code 98. The Surveyor asked the DON what code 98 meant. She said it is for refused. The key at the bottom of the document documented, .98-Resident Refused . c. On 02/21/23 at 1:51 PM, Resident #78 was in her room. She stated I haven't had a bath in a week. Resident #78's hair was oily and matted. d. On 02/22/23 at 8:50 AM, Resident #78 was in bed. The Surveyor asked if she had received a shower since yesterday. She stated No. Her hair continued to be oily and matted. e. On 02/24/23 at 8:45 AM, the Surveyor asked CNA #2 how often Resident #78 received a shower and shampoo. CNA #2 stated, Three times a week, but sometimes she refuses. The Surveyor asked him to look at the survey report provided by the DON and asked him, Has the resident received a shower or shampoo since 02/09/23? He stated, I give my showers when they are scheduled but I am not always good at getting them documented. The Surveyor asked what no documentation of the bathing being complete meant. He stated, If it isn't documented it isn't done. f. On 02/24/23 at 9:00 AM, the Surveyor asked the DON to look at Resident #78's ADL Survey Report for bathing and asked if Resident #78 had had a shower and shampoo since 02/09/23. The DON stated, I can tell you it was completed on 02/09/23 and refused on 02/11/23 and 02/14/22. The showers may not have been documented since then and we have to look at resident right to refuse. 3. Resident #16 had diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis - Right Side Effected, Alzheimer's Dementia and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required set up assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. a. The Care Plan with a revision date of 11/27/18 documented, .I'm at risk for an ADL [activities of daily living] self-care performance deficit r/t [related to] HIV, neuropathy, major depression and noncompliance with care . Nail Care was not addressed on the Care Plan. b. On 02/23/23 at 8:50 AM, the Surveyor asked the DON where nailcare was documented. The DON replied, Nailcare is not documented on the ADL sheets, it's not documented anywhere. The Surveyor asked when nailcare was done. The DON replied, On Sundays. The Surveyor asked the DON for policy and procedures for nailcare and ADLs. The DON replied, There is no policy and procedure for ADLs or nailcare . They train their staff on nailcare . The Resident is often resistive to care. c. On 02/23/23 at 1:42 PM, Resident #16 was sitting in his wheelchair outside of his room in the hallway. The fingernails on both hands extended approximately 1/4 inch beyond the fingertips. The Surveyor asked Resident #16 if he liked his fingernails that long. Resident #16 replied, No. The Surveyor asked if he would like to have them trimmed. Resident #16 replied, Yes. d. On 02/23/23 at 3:45 PM, the Surveyor requested the Bathing and/or Activities of Daily Living policy and procedure from the Administrator. At 4:40 PM, the Nurse Consultant entered the Conference Room and stated, We do not have a policy on bathing or ADLs.

Based on observation, and interview, the facility failed to ensure all mechanical and electrical equipment in the kitchen was maintained in safe operating condition. The failed practice had the ability to affect 92 residents who receive their meals from the kitchen according to a list provided by the Administrator on 02/24/23 at 9:00 AM. The findings are: 1. On 02/21/23 at 10:50 AM, during a tour of the kitchen, there was frozen water on the floor of the walk-in freezer. The water came from the motor/condenser located on the top of the unit. The water had traveled down the wall and accumulated on the top of a case of previously opened hamburger buns. 2. On 02/22/23 at 8:40 AM, the floor of the walk-in freezer continued to have water frozen on the floor. The water on the floor was located directly beneath the motor/condenser attached to the top of the freezer. An area directly under one leak extended from the floor of the freezer up approximately 6 inches. The water had run down the wall, freezing on the wall and on top of an opened box of hamburger buns. The ice on top of the box had accumulated and formed an area of ice approximately 1/4 inch to 1 and 1/2 inches thick. The running water had also frozen on the front of the box. The Surveyor asked the Dietary Manager if she had reported the issue of the water to the Maintenance Department. She stated, .No, it ' s been doing that since I got here so I really didn't think anything about it . The Dietary Consultant stated that the issue with the water dripping will be reported on this date. 3. On 02/22/23 at 1:45 PM, the Dietary Manager and Dietary Consultant approached this Surveyor. The Dietary Consultant reported that the Dietary Manager misspoke on 02/21/23 when she stated that she had not spoken to the Maintenance Department about the water in the freezer. The Dietary Consultant described that the Dietary Manager was simply unaware that action had been taken previously. The Dietary Consultant described that the administration had written a Performance Improvement Plan (PIP). Review of the plan revealed that the plan was written in August 2021. The August 2021 PIP provided by the Dietary Consultant on 02/22/23 documented, Observation during routine inspection there was ice buildup noted in different areas of the freezer. A handwritten note in the observation section documented, Can't come due to COVID. Notation was not signed or dated. Action the unit has been looked at for repair at different times. Supply chain issues as well as labor issues have prevented timely repair. Will continue to discuss repair time with vendor. Maintenance immediately removed built up ice. Dietary staff will keep the ice chipped away as needed until vendor can make repairs. Dietary personnel will contact maintenance if there are any issues noted to temperatures. A handwritten note in this section documented, Oct. [October] 2022 Maint. [Maintenance] repaired. Person Responsible Dietary, Maintenance. Evaluation Method Observations. Multiple hand written notations made in this section documented, Holding temp-no negative outcomes; dietary keeps ice chipped-temps [temperatures] good. Notations were not dated. On 12/22 a handwritten notation documented, Some buildup, temps good. Goal or Measure of Success and Date No ice buildup in unit. Evaluation Date/Results On-going. An Invoice dated 08/25/2021 provided by the Dietary Consultant documented service had been provided to the freezer on 8/02/21. 4. On 02/23/23 at 8:30 AM, the Surveyor asked the Administrator to review the PIP that was provided on 02/22/23 and to address the Goal or Measure of Success and Date. The Surveyor asked, for the date of the PIP completion, as one was not listed. The Administrator stated, With COVID and everything, I couldn't put in a date. Because of COVID and staffing and not knowing when I could get someone in here, I couldn't put down a date. Do you want me to make one up? The Surveyor asked the Administrator for a policy concerning the QA [Quality Assurance]/QAPI [Quality Assurance and Performance Improvement] program including the completion of the PIP. Administrator stated, Let me look. At 9:40 AM, the Nurse Consultant reported that there was no policy for the PIP process. 5. On 02/23/23 at 3:55 PM, the Surveyor asked the Maintenance Director if he was aware of the problem with dripping water in the freezer. The Maintenance Director stated, .I didn't really know that it was happening all the time . I know we have had people out here before . The Surveyor asked when was the last time he worked on the freezer. The Maintenance Director stated, .A month or two ago I was called because I think the temperature was dropping a little bit . I defrosted the coil . The Surveyor asked if there was a maintenance log which would provide a record of reported issues and when they were addressed. The Maintenance Director stated, They just started that log system again about a month ago. So, before that I wouldn't be able to tell you . The Maintenance Director stated that he was out during November and December of 2022 and thought that an outside repair service had been called in to fix a problem during this time. However, he was uncertain of the exact nature of the problem. The Surveyor asked the Maintenance Director to provide an invoice of this service call. 6. An Invoice dated 02/24/23 provided by the Administrator documented service had been provided to the freezer on 02/23/23.

Based on observation, record review and interview, the facility failed to ensure kitchen equipment was clean and in good condition, dietary staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and opened containers of food were refrigerated after opening when required. The failed practices had the ability to effect 96 residents who received their meals from 1 of 1 kitchen as documented on a list provided by the Dietary Consultant on 02/23/23 at 3:02 PM. The findings are: 1. On 02/21/23 at 10:55 AM, the Dry Storage Room had paper and other debris on the floor, under the storage racks. Rusted areas were noted on multiple shelves on each rack. 2. On 02/21/23 at 10:58 AM, on the top shelf of a rack in the Dry Storage Room was a gallon, plastic container of picante sauce. Approximately 1 cup of the picante Sauce had been removed from the container. The label on the container stated, Refrigerate after opening. 3. On 02/21/23 at 11:05 AM, in the walk-in refrigerator three quarters of the wire shelves were covered in rust. 4. On 02/21/23 at 11:20 AM, Dietary Aide (DA) #1 assembled the items necessary to puree the lunch meal. DA #1 placed a bowl on the Robo-coupe and attached the blade. DA #1 gathered a plastic pitcher of chicken broth. He applied a hot mitt to his hand, opened the steamer and obtained a steam table pan. DA #1 picked up a box of plastic wrap and placed it on the worktable. He picked up the steamtable pan and covered it with plastic wrap and placed it in the steamer. The bowl, blade, and lid were taken to the 3-compartment sink, rinsed, and returned to the work area. He placed his hand inside a hot mitt, opened the door to the steamer and brought out a steam table pan of Sausage and Chicken Jambalaya. Upon completion of the blending process, the food was returned to the steamtable pan and the pan was carried to the worktable which housed the plastic wrap. The pan was covered and returned to the steamer. The Robo-coup was returned to the 3-compartment sink for cleaning. Each time DA #1 moved from a clean task to a dirty task he did not wash his hands. 5. On 02/21/23 at 11:35 AM, DA #2 was rolling flatware in napkins for lunch. A resident knocked on the kitchen door and requested that someone prepare her (Brand) noodles. The resident presented with a red plastic bowl containing a packet of noodles. DA #2 took the bowl and placed it on the counter in front of the microwave oven. DA #2 obtained gloves and without washing her hands put the glove on. DA #2 emptied the noodles into the bowl, added water and placed them in the microwave. She them took off her gloves and washed her hands and returned to roll flatware. DA #2 left the station and rolled a 3-tiered cart to the preparation room. Without washing her hands, she returned to the microwave, removed the bowl, carried it to the sink, and poured the excess water into the sink. She returned the bowl to the microwave for additional time. Without washing her hands, DA #2 retrieved the bowl from the microwave a second time, poured off the excess water and placed the noodles into the red bowl. Without washing her hands, she applied gloves, obtained plastic wrap, covered the red bowl, placed it on a tray and delivered it to the resident. 6. On 2/22/23 at 11:55 AM, insulated carts were brought into the kitchen for lunch. Pieces of what appeared to be dried food was littering the bottom of two carts. The outside ledge of the carts just over the wheels were littered with debris of various colors, shapes, and sizes. 7. On 02/22/23 at 12:00 PM, DA #1 obtained the temperatures of the food items for lunch. Prior to completing his tasks DA #1 left the tray line, donned a heat mitt, opened the door to the steamer and removed a steamtable pan containing baked fish. Without washing his hands, he returned to assessing food temperatures. 8. On 02/22/23 at 8:45 AM, the shelving units in the walk-in refrigerator contained multiple areas of rust. The middle shelf was covered with a white powdery substance. The Surveyor asked the Dietary Consultant to identify the white substance. He stated, .It almost feels like powdered sugar . 9. On 02/22/23 at 8:48 AM, two racks designed to hold the insulated dome cover and/or base that surrounds the plates were standing in the kitchen. The inner portion of each tier on the rack was covered in a layer of brownish, black buildup in various depths. The substance had food particles of various shapes and sizes adhered to it and a French Fry of indeterminate age on the bottom tier. 10. On 02/23/23 at 10:15 AM, the Surveyor asked the Dietary Manager when hand should be washed when working in the kitchen. The Dietary Manager stated, .Whenever you have been outside. When you have gone to the restroom. When you have touched yourself or your clothes. When you have been working with something that isn't cooked . 11. On 02/24/23 at 8:40 AM, the Surveyor asked DA #1 when hands should be washed while working in the kitchen. DA #1 stated, .When I prepare a ready to eat food such as lettuce or tomato or right before I serve. I wash my hands a lot . 12. On 02/24/23 at 8:43 AM, , the Surveyor asked DA #3 when should hands be washed while working in the kitchen. DA #3 stated, .Any time you change stations or touch something dirty . 13. The facility policy and procedure titled, Hand Washing, provided by the Dietary Consultant on 02/23/23 at 3:02 PM documented, .Procedure: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands: .f. After handling soiled equipment or utensils. g. During food preparations, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks . i. Before donning disposable gloves for working with food and after gloves are removed. j. After engaging in other activities that contaminate the hands .