Based on record review and interview, the facility failed to ensure a change of condition assessment was completed no later than 14 days after the significant change for 1 (Resident #30) of 1 sampled resident. The findings are: 1. Resident #30 had a diagnosis of Unspecified dementia without behavioral disturbance. a. The resident's medical record revealed a Physician's Order for admission to Hospice was received on 03/26/2024. The last Minimum Data Set (MDS) completed was a Quarterly assessment with an Assessment Reference Date (ARD) of 12/04/2023. No Significant Change assessment was present in the medical record. b. On 04/11/2024 at 08:20 AM, the MDS Coordinator was asked if she was aware Resident #30 was admitted to Hospice. The MDS Coordinator reported that she hadn't reviewed the dates and claimed responsibility for the oversight. The MDS Coordinator was asked how she was made aware of changes in a resident's status. The MDS Coordinator described reviewing the orders every day along with the 24 hour reports. The MDS Coordinator confirmed that the facility does not have a daily stand up meeting to discuss changes in resident status. c. The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 2.0 manual documented, .Chapter 2: The assessment Schedule for RAI .Significant change in status assessments (SCSA)-Comprehensive Assessment .If the condition does not return to baseline, the assessment should be completed as soon as needed to provide appropriate care to the resident, but in no case later than 14 days after the determination was made that a significant change occurred .

According to observation, interview and record review, the facility failed to ensure incontinence care waste was disposed of properly for one (Resident #26) sampled resident. The findings are: 1. A Face Sheet documented Resident #26 had diagnoses of Dementia, Delusional disorder, and Cognitive communication deficit. 2. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/2024 documented Resident #26 scored a 2 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). 3. A Care Plan for Resident #26 documented, Behavior, [Resident #26] wanders thru [through] out the facility, [Resident #26] will remove urostomy and emptied in different places, rummages through clothes in [Resident #26's] room. 4. On 04/09/2024 at 10:25 AM, the Surveyor observed Resident #26 wandering the halls, then enter the resident's room and began to rifle through the trash. The Surveyor observed that in the trash can was a soiled brief with a blue wetness indicator visible. Resident #26 touched the soiled brief. The Surveyor then observed Resident #26 leave the room and walk down the hall. Resident #26 touched the handrails in the hallways being utilized by other residents, interacted with staff members, and touched a chair by the nurse's station before sitting in it. The Surveyor observed two residents going by in wheelchairs, stopped to take breaks and touch the handrails in the hallway. Registered Nurse (RN #1) redirected Resident #26 to the resident's room, holding the Resident ' s hand while walking down the hall. 5. On 04/09/2024 at 10:30 AM, the Surveyor asked Registered Nurse (RN) #1 what was in Resident #26's trash can by the bed. RN #1 said there is a brief in the trash can and it should have been changed already after incontinence care was performed. The Surveyor observed RN #1 pulling the trash bag containing the soiled brief out and put a new one in. The Surveyor asked what the issue could be for soiled incontinence care products being left in the room with a cognitively impaired resident. RN #1 said the resident could get into it; the resident has severe dementia. 6. On 04/10/2024 at 01:35 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2 if soiled briefs should be left in the trash can after incontinence care was performed. CNA #2 said that the brief should not have been left in there, as it's an infection control issue. 7. A facility training titled Incontinent Care/Foley Care Observation documented, .21. Clean-up workstation and place everything in appropriate bags .

Based on interview and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS) was transmitted in a timely manner to promote individualized care for 2 (Residents #7 and #13) of 2 sampled residents. The findings are: On 04/10/2024 at 11:10 AM, a Quarterly Minimum Data Set (MDS) for Resident #7 and Resident #13 were identified as being 120 days late. On 04/10/2024 at 01:30 PM, the MDS Coordinator was asked to review the last MDS assessments which were submitted for Resident #7 and #13. The MDS Coordinator reported Resident #7 had a Quarterly MDS which was submitted on 02/01/2024 and Resident #13 had a Quarterly assessment submitted on 02/21/2024. The MDS Coordinator describes the facility computer system as revealing the assessments were submitted and received. The MDS Coordinator displayed paper confirmation which confirmed the submission and receipt. The MDS Coordinator shared that another person was responsible for completion and submission of MDS assessments during the month of February. The MDS Coordinator verbalized her plan to look on the CMS website to ensure the submissions were complete. On 04/11/2024 at 08:10 AM, the MDS Coordinator reported that CMS (Centers for Medicare & Medicaid Services) was contacted, and it was determined that the MDS assessments in question were not submitted/accepted as previously thought. The MDS Coordinator confirmed that the assessments were late and were resubmitted on the evening of 04/10/2024. The MDS Coordinator provided an MDS 3.0 NH (Nursing Home) Final Validation Report which confirmed reception, receipt, and acceptance on 04/11/2024. When the MDS Coordinator was asked how the facility would have known that there had been an issue with the transmission of assessments completed in February. The MDS Coordinator stated that she wouldn't have known until the next assessment was completed had it not been for the attention called to the problem during this survey. On 04/11/2024 at 02:21 PM, the Director of Nursing (DON) provided, Ch [Chapter] 5: Submission and Correction of the MDS Assessments, page 5-3. It documented, Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS Assessments must be submitted within 14 days of the MDS completion Date.

Based on observation, interview and record review, the facility failed to ensure hand rolls were applied to prevent further decline in range of motion (ROM) for 2 (Residents #13 and #28) of 3 sampled residents. The findings are: 1. A review of Resident #13's Care Plan dated 05/26/2023 did not document the contracture to the left hand. a. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was impaired on one side of the upper extremities. b. On 04/09/2024 at 11:17 AM, the Surveyor observed Resident #13 lying in bed at a fifteen (15) degree angle on his/her left side with legs elevated under the blanket. Resident #13 had a left hand contracture with no device present. c. On 04/09/2024 at 02:24 PM, the Surveyor observed Resident #13 lying on his/her back in bed at a fifteen (15) degree angle. The left hand remained contracted with no device present. d. On 04/10/2024 at 12:58 PM, the Surveyor observed Resident #13 lying in bed. The left hand was contracted with no device present. e. On 04/10/2024 at 01:04 PM, Certified Nurse Assistant (CNA) #3 confirmed that Resident #13's left hand was contracted with no device present to prevent the contracture from getting worse. f. On 04/10/2024 at 01:17 PM, the Director of Nursing (DON) confirmed that Resident 13's left hand was contracted with no device present to prevent the contracture from getting worse. 2. A review of Resident #28's Care Plan dated 12/19/2023 did not document the contracture to the left hand. a. A review of Resident #28's Quarterly MDS with an ARD of 02/14/2024 noted the resident was impaired on both sides of the upper extremities. b. On 04/10/2024 at 01:10 PM, the Surveyor interviewed CNA #3 at Resident #28's bedside and had her pull the residents blanket back to expose the extremities. CNA #3 confirmed the resident had a left hand contracture with no device present to prevent the contracture from getting worse. c. On 04/10/2024 at 01:20 PM, the Surveyor interviewed the DON at Resident #28's bedside. The DON confirmed the resident had a left hand contracture with no device present to prevent the contracture from getting worse. d. On 04/11/2024 at 09:22 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator and asked, If a resident is admitted to the facility with a contracture should it be documented on their comprehensive care plan? She stated, Yes, ma'am. When asked, Why should a contracture be on the care plan? She stated, It has to do with ADLs [activities of daily living] and help they may need. They may need a hand roll to prevent it from getting worse.

3. Resident #30 had a diagnosis of Unspecified dementia without behavioral disturbance. a. A Physician's Order for admission to Hospice was received on 03/26/2024. The order also included the discontinuation of all medications except PRN (as needed) and comfort. On 04/10/2024, a review of Resident #30's medical record revealed a physician's order for admission to Hospice was received on 03/26/2024. A review of Resident #30's care plan revealed that the care plan had not been revised to include Hospice services. b. On 04/11/2024 at 08:20 AM, the MDS Coordinator was asked when a care plan should be updated. The MDS Coordinator reported that a comprehensive care plan should be updated quarterly and as needed. When asked for as needed examples, the MDS Coordinator cited falls, major medication changes. When asked if the discontinuation of all medications which included antidepressants and antipsychotics would be considered a major medication change, the MDS Coordinator confirmed it would. When asked why updating the care plan would be important in this instance, the MDS Coordinator described that the staff would need to know to look for changes in mood or behavior. 4. The facility provided a policy titled, 'CMS's [Centers for Medicare & Medicaid Services] RAI [Resident Assessment Instrument] Version 3.0 Manual,' dated October 2023, that documented, .Following the decision to address a triggered condition on the care plan, key staff or the IDT [Interdisciplinary Team] should subsequently: Review and revise the current care plan, as needed; and Communicate with the resident or their family or representative regarding the resident, care plans, and their wishes . Based on interview and record review, the facility failed to ensure a resident's individualized plan of care was revised to reflect the current needs of the resident and updated to include falls for 1 (Resident #13); oxygen therapy for 1 (Resident #19); and Hospice services for 1 (Resident #30) sampled residents. The findings are: 1. Resident #13's Care Plan dated 05/26/2023 did not document the contracture to Resident #13's left hand. a. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was impaired on one side of both the upper and lower extremities and had had no falls. b. An Incident report dated 03/05/2024 noted Resident #13 was found lying on the floor next to the bed. 2. A review of Resident #19's Care Plan dated 05/19/2023 did not document oxygen use. a. A review of Resident #19's Physician Orders dated 02/06/2024 noted oxygen saturation QS (as frequently as needed) keep at or above 93%. No specific order for quantity of oxygen in liters. b. A review of Resident #19's Medication Administration Record (MAR) for April 2024 documented oxygen usage at two (2) liters as needed for shortness of breath or below 93% O2 (oxygen) on 04/01/2024; 04/02/2024; 04/05/2024; 04/06/2024; 04/08/2024; and 04/09/2024.

Based on observation, interview and record review, the facility failed to ensure residents were shaved to promote good personal hygiene for 2 (Residents #13 and #3) of 2 sampled residents and residents' fingernails were kept clean for 1 (Residents #3) of 1 sampled resident. The findings are: 1. A review of Resident #13's Plan of Care dated 05/26/2023 noted the resident required total assistance with activities of daily living (ADLs). a. The facility provided a policy titled, 'Please Be Careful When Shaving Residents. Do Not Rush Through, As This Can Lead To Nicks & Cuts', dated 12/15/2023, which documented, Overview: Shaving may help a person feel good. b. A review of Resident #13's Physician Orders dated 02/09/2024 documented, Shower 6-2 bed baths daily may give shower if needed/ as tolerated. c. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was dependent for showers/baths. d. On 04/09/2024 at 11:17 AM, the Surveyor observed Resident #13 lying in bed. The resident needed to be shaved. e. On 04/09/2024 at 02:24 PM, the Surveyor observed Resident #13 lying in bed. The resident's face was not shaven. f. On 04/10/2024 at 12:57 PM, the Surveyor observed Resident #13 lying in bed. Resident #13 was unshaven. g. On 04/10/2024 at 01:04 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) #3 at Resident #13's bedside. CNA #3 confirmed the resident was not clean shaven and should have been shaved on bath day. h. On 04/10/2024 at 01:15 PM, the Surveyor interviewed the Director of Nursing (DON) who confirmed the resident was not clean shaven and should have been shaved on bath day. 2. Resident #3 had diagnoses of Unspecified sequelae of cerebrovascular accident and Unspecified atrial fibrillation. a. A Quarterly MDS with an ARD of 01/15/2024 documented Resident #3 scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was dependent for care. b. Resident #3's Care Plan documented, The resident is at risk of developing complication r/t [related to] needing total assistance in the following ADLS [activities of daily living]: bed mobility, transfer, locomotion, dressing, personal hygiene, bathing, and toilet use . Approaches. Nailcare every two weeks per nurse . c. On 04/09/2024 at 12:26 PM, Resident #3's chin had hair that was stubble like in appearance. The Surveyor observed the fingernails of both hands had a brown substance under them, and the nails were long, jagged, and chipped in appearance. Resident #3 said they do not pluck my hair on bath days, and I would like that. Resident #3 also stated that the resident would like their fingernails cleaned and clipped. e. On 04/09/2024 at 02:21 PM, the Surveyor asked Resident #3 if nail care and plucking had been provided. Resident #3 showed the Surveyor the resident's chin and hands. The Surveyor observed no changes. Resident #3 stated it had not. f. On 04/10/2024 at 01:34 PM, the Surveyor asked CNA #2 to described Resident #3's hands. CNA #2 said that the nails were long and dirty and that they needed to be clipped. The Surveyor asked for CNA #2 to describe Resident #3's chin. CNA #2 said that the hair needs to be plucked or shaved. The Surveyor asked what the issue for the resident could be. CNA #2 said that it could be a dignity issue. The Surveyor asked when should nail care and shaving be done. CNA #2 said as needed, and to tell the nurse if the resident is diabetic. g. On 04/10/2024 at 01:43 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to describe Resident #3's hands. LPN #1 said that the nails need clipping and are dirty. The Surveyor asked what the issue for the resident could be. LPN #1 said that the resident could scratch herself. The Surveyor asked LPN #1 to describe Resident #3's chin. LPN #1 said that yes, they need plucked or shaved. The Surveyor asked when should nail care and shaving be done. LPN #1 said when you see it and bathe them.

3. A review of the facility policy titled, Restorative/Rehab [Rehabilitation] Care stated in part, the goals of rehab/restorative care are to maintain the present level of function and to improve or restore physical function. Based on observation, interview and record review, the facility failed to ensure hand rolls were applied to prevent further decline in range of motion (ROM) for 2 (Residents #13 and #28 ) of 3 sampled residents. The findings are: 1. A review of Resident #13's Care Plan dated 05/26/2023 did not document the contracture to the left hand. a. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was impaired on one side of the upper extremities. b. On 04/09/2024 at 11:17 AM, the Surveyor observed Resident #13 lying in bed. Resident #13 had a left hand contracture with no device present. c. On 04/09/2024 at 02:24 PM, the Surveyor observed Resident #13 lying in bed. The left hand was contracted with no device. d. On 04/10/2024 at 12:58 PM, the Surveyor observed Resident #13 lying in bed. The left hand was contracted with no device present. e. On 04/10/2024 at 01:04 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) #3 at Resident #13's bedside. CNA #3 confirmed the resident's left hand was contracted with no device present to prevent the contracture from getting worse. f. On 04/10/2024 at 01:17 PM, the Surveyor interviewed the Director of Nursing (DON) at Resident #13's bedside. The DON confirmed the resident's left hand was contracted with no device present to prevent the contracture from getting worse. 2. Resident #28's Care Plan dated 12/19/2023 did not document the contracture to the left hand. a. A review of Resident #28's Quarterly MDS with an ARD of 02/14/2024 noted the resident was impaired on both sides of the upper and lower extremities. b. On 04/10/2024 at 01:10 PM, the Surveyor interviewed CNA #3 at the resident's bedside and had her pull the residents blanket back to expose the extremities. CNA #3 confirmed Resident #28 had a left hand contracture with no device present to prevent the contracture from getting worse. c. On 04/10/2024 at 01:20 PM, the Surveyor interviewed the DON at the resident's bedside. The DON confirmed that Resident #28 had a left hand contracture with no device present to prevent the contracture from getting worse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 04/09/2024 at 12:48 AM, the Surveyor observed a gray call light laying across Resident #11's bed, part of the plastic was missing exposing wires. The Surveyor then observed a cable cord hanging from the right-hand corner near the bathroom door. The cable was touching the floor. a. On 04/09/2024 at 02:22 PM, the Surveyor observed the resident moving around the room, no changes had been made to observations earlier. b. On 04/09/2024 at 02:33 PM, the Surveyor asked CNA #1 to describe the call light and what the issue could be for the resident. CNA #1 said that a plastic piece is missing, and that it could be a fire hazard. The Surveyor asked what the protocol for reporting issues like this was. CNA #1 said it should be written down on the maintenance log. The Surveyor then observed the CNA #1walk to the maintenance log for east hall and state it had not been reported, the Surveyor then observed them writing in it about the call light having wires exposed. c. On 04/09/2024 at 02:37 PM, the Surveyor asked the Maintenance Employee to observe the call light and asked what the issue could be for the resident. The Maintenance Employee said it has plastic broken off, and that it's an electrical issue. The Surveyor asked if it had been reported to them. The Maintenance Employee said it had not. The Surveyor asked about the cable in the corner of the room. The Maintenance Employee said that it was supposed to be covered and tucked into the ceiling. The Surveyor asked what the issue is with the cable being down. The Maintenance Employee said that it could be hazardous as they believe it's a live wire. The Surveyor asked if it has been reported to them. The Maintenance Employee said no it has not been reported. d. A facility policy titled Maintaining Call Lights documented, .Maintenance is responsible for ensuring that call lights are working/functioning properly. Call lights should be checked once a week. Staff should report any call lights that are not functioning properly to maintenance so that the issue can be resolved. Call light Checklist: C. Call light cords in good condition-no fraying or tears on cord . Based on observation, interview, and record review, the facility failed to ensure fall mats at the bedside were properly positioned for 1 (Resident #13) of 1 sampled resident who required fall mats and call lights were maintained with no exposed wires for 1 (Resident #11) of 1 sampled resident. The findings are: 1. Resident #13 was admitted on [DATE] with a diagnosis of Alzheimer's disease and Convulsions. a. A facility in-service titled, 'Falls: Reduce the Risks' dated 05/19/2023 documented, .Intervention & Documentation Tickler for Falls . Padding on floor- landing mat(s) . b. The facility provided an Incident and Accident (I&A) Report dated 03/05/2024 that noted Resident #13 had fallen and hit the right side of their forehead on the floor. The twenty-four (24) hours follow up noted fall mat placed, staff re-educated to lower head of bed (HOB). c. Review of Resident #13's Care Plan dated 05/26/2023 did not document a fall. d. On 04/09/24 at 11:17 AM, the Surveyor observed Resident #13 lying in bed. Resident #13 had a fall mat that was positioned underneath the bed. e. On 04/10/2024 at 12:55 PM, the Surveyor observed Resident #13 lying in bed. Resident #13's fall mat was underneath the bed. f. On 04/10/2024 at 01:04 PM, Certified Nursing Assistant (CNA) #3 confirmed the resident was at risk for falls and the fall mat was underneath Resident #13's bed and should be located on the side of the resident ' s bed. g. On 04/10/2024 at 01:13 PM, the Director of Nursing (DON) confirmed the resident was a fall risk and the fall mat was underneath Resident #13's bed and should be located on the side of the resident's bed. h. A facility policy titled 'Accidents' documented, .The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: Identifying hazard(s) and risk(s); evaluating and analyzing hazard(s) and risk(s); Implementing interventions to reduce hazard(s) and risk(s) .

Based on observation, interview, and record review, the facility failed to ensure food items were sealed after opening, food items were used prior to their use by date, equipment was maintained in good condition, and pans and other containers were stored in a manner to minimize the risk of contamination. The findings are: On 04/09/2024 at 10:27 AM, a carton of potato flakes was observed on the top shelf, above the worktable in the kitchen. The mouth of the carton was open, exposing the food product to air and contaminants. On the lowest shelf a container of paprika was observed with the top open exposing the product to air and contaminants. On 04/09/2024 at 10:35 AM, 1 package of hot dog buns and 1 package of hamburger buns were observed on the top tray of the bread rack with a use by date of 04/05/2024. On the second tray there were 4 full loaves of sliced bread with a use by date of 04/05/2024. On 04/09/2024 at 10:40 AM, 4 stainless steel mixing bowls, 5 skillets, 4 sheet trays, 7 large trays, 3 1/2 steam table pans, 2 1/4 steam table pans and 9 large steam table pans were stored right side up in a manner which allow dust and contaminants to collect prior to use. The shelf was observed to contain multiple food particles which extended down the length of the shelf and were beside the pots, trays, and other items on the shelf. On the upper shelves a stack of 11 divided plates, 5 gallon pitchers and one large beverage dispenser were observed to be right side up allowing for the collection of dust and contaminants. On 04/08/2023 at 10:45 AM, 2 wire baskets used for deep frying were observed hanging from a pot rack in the middle of the room. The entire circumference of each basket was coated in a tan substance that was thick and sticky to touch. The substance extended 1 to 1.5 inches down the side and all the way up the handle of each basket. Several pots were observed to be dented and blackened on the bottom. On 04/08/2024 at 11:36 AM, Dietary Aide #1 was observed inserting a digital thermometer into a full steam table pan of baked beans. The thermometer was inserted into the beans all the way to the handle of the thermometer, the plastic end extending into the bean mixture 1/2 inch. On 04/08/2024 at 12:00 PM, seven tables were observed in the dining room. The legs of each table were observed to be covered in varying amounts of rust. On 04/11/2024 at 10:45 AM, the Director of Nursing (DON) provided a Food Safety and Sanitation Policy and Procedure. On page 2, the policy directs that stored food is handled to prevent contamination and growth of pathogenic organisms. When a food package is opened, the food item should be marked to indicate the open date; perishable foods with expiration dates are used prior to the use by date on the package. Note: .all food and dining areas should be inspected on a regular basis. On 04/11/2024 at 11:15 AM, the Dietary Manager (DM) was asked how pots, pans and utensils should be stored. She replied that the items would typically be stored face down but the facility has a large rack for storing pots and pans. The DM was asked about the items on the bottom shelf and confirmed that the items are stored right side up but stated that the items should be face down. The DM identified the risk of gathering debris as the reason for storing these items bottom up. When asked how long the rust had been present on the shelves and legs of the worktables, the DM reported that the rust was present when she started working in the facility 11 years ago. The DM described how the staff took several pieces outside last year and painted the rusted shelves with paint designed for metal. However, the attempt at refurbishing isn't holding up as they had expected. She continued that the primary worktable located in the middle of the room that had the heaviest rust coverage, they were not able to get the table outside because the screws which hold the pot rack started to break when they attempted to take the rack down. The screws were corroded with grease and rust. When addressing the rack located beside the steam table that was rusted, the DM expressed that they would have been better served with a rubber coated rack versus the rack that is all metal. The DM confirmed that she was aware of the rust on the tables in the dining room. She was uncertain as to when the rust had developed, just that the rust had covered the legs of the tables for some time. When asked to describe the substance covering the circumference of the deep fryer the DM said the substance was a buildup of grease, a little crusty and slick. The DM reports that the facility has never had a deep fryer, as that would require the hood to be enlarged. Ensuring an item is dated and sealed was identified by the DM as the primary task when a food item is brought into the kitchen. On 04/12/2024 at 08:24 AM, the Administrator was asked if she was aware of the issues concerning the presence of rust on the kitchen equipment and on the legs of the dining room tables. The Administrator reported that they have been intending to take the tables outside to paint the legs. The Administrator was asked how long the tables had been in the facility, and the Administrator reported as long as she had been here, 14 years.

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 8 residents who received pureed diets as documented on the Diet List provided by the Dietary Supervisor on 03/14/23 at 11:42 AM. The findings are: 1. On 03/13/23 at 11:11 AM, Dietary Employee (DE) #1 placed 8 servings of ham into a blender, added broth and pureed. She added thickener and pureed the mixture some more. At 11:15 AM, she poured the pureed meat into a pan on the steam table. The consistency of the pureed meat was lumpy and not smooth. There were pieces of ham in the mixture. 2. On 03/13/23 at 11:40 AM, DE #1 placed 8 servings of cornbread into a blender and added 2 cartons of whole milk and pureed. DE #1 used a #16 scoop (blue) to portion pureed cornbread into 8 individual bowls. The consistency of the pureed cornbread was thick. 3. On 03/13/23 at 12:19 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents for the lunch meal. She stated, The pureed ham has pieces of ham in it and the pureed cornbread was thick. 4. On 03/14/23 at 7:44 AM, the pureed sausage served to the residents on pureed diets for the breakfast meal, was gritty and not smooth. The Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the consistency of the pureed sausage served to the residents for the breakfast meal. She stated, It was ground up. 5. On 03/14/23 at 7:51 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed sausage served to the residents who required pureed diets. She stated, It needed to be pureed a little longer.

Based on interview, and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents to help protect against pneumococcal bacteria which can cause serious infections and is potentially fatal and immunization records were accurately documented for 5 (Residents #12, #13, #22, #31 and #189) of 5 sampled residents whose immunization records were reviewed. This failed practice had the potential to affect 38 residents as documented on the Resident Matrix provided by the Minimum Data Set (MDS) Coordinator on 03/13/23. The findings are: 1. Resident #12 had a diagnosis of Chronic Respiratory Disease. The Quarterly MDS with an Assessment Reference Date (ARD) of 02/22/23 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Health (SAMS) and was up to date on his Pneumococcal Vaccinations. a. A Vaccination Form in the medical chart documented, Vaccine not given . Pneumococcal vaccine previously immunized 11-10-11 . b. A Consent for Vaccination form dated 10/23/12 in the medical chart documented, I have had the pneumococcal vaccination within the past five years . 2. Resident #13 had diagnoses of Chronic Obstructive Pulmonary Disorder and Asthma. The admission MDS with an ARD of 02/09/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS), was not up to date on his Pneumococcal Vaccinations and the vaccination was offered and declined. a. The Resident Vaccination Status Form in the medical chart documented, .Pneumococcal Vaccination Vaccine not given due to refusal . No declination was found in the chart. 3. Resident #22 had a diagnosis of Alzheimer's Disease. The Annual MDS with an ARD of 02/14/23 documented the resident was moderately impaired in cognitive skills for daily decision-making per a SAMS and was up to date on her Pneumococcal vaccinations. a. The Flu/Pneumonia Vaccination Status at the bottom of the Face Sheet in the medical chart documented Resident #22 received a Pneumococcal vaccine on 02/27/20 and the next vaccine was due 02/28/21. 4. Resident #31 had diagnoses of Atrial fibrillation and Hyperlipidemia. The Quarterly MDS with an ARD of 12/14/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and was not up to date on her Pneumococcal Vaccinations and the vaccination was offered and declined. a. The medical chart contained a consent for a Pneumococcal vaccine. No documentation of the administration of the vaccine was found in the medical chart. 5. Resident #189 had a diagnosis of Diabetes Mellitus. The admission MDS with an ARD of 11/03/22 documented the resident scored 14 (13-15 indicates cognitively intact) and was not up to date on her Pneumococcal Vaccinations and was not eligible - medical contraindication. a. The medical chart did not contain documentation a Pneumococcal vaccine had been administered or declined. The Face Sheet documented, .Reason: Not eligible . 6. On 03/14/23 at 10:44 AM, the Surveyor asked the DON/ICP if immunization records in the resident charts should be accurate and kept up to date. The DON/ICP stated, Yes ma'am. The Surveyor asked what she utilized to know when residents needed immunizations. The DON/ICP stated, [Electronic Records System]. The Surveyor asked the DON/ICP to review Resident #12's vaccination documentation in his chart and asked if it was complete. The DON/ICP stated, No, it does not say if he wants Pneumo [Pneumococcal] or not. The Surveyor asked if Resident #12 was due for another Pneumococcal vaccine. The DON/ICP stated, I don't know. The Surveyor asked how often they are given. The DON/ICP stated, Every five years, I think. I will get a new form and have the refusal marked right. The Surveyor asked the DON/ICP to review Resident #13's vaccination documentation in his chart and asked if his Pneumococcal documentation was complete. The DON/ICP stated, No, his doesn't say it either. The Surveyor asked what was marked at the bottom of his Face Sheet. The DON/ICP stated, Offered and declined. That's got to be wrong. That's for COVID. I'll fix it. I'm sorry. The Surveyor asked if Resident #13 was due for a Pneumococcal vaccination. The DON/ICP stated, I will have to check [Immunization Information System]. He might have verbally refused. The Surveyor asked if that was documented in the nurses notes in the medical records. The DON/ICP stated, No ma'am. The Surveyor asked the DON/ICP to review Resident #22's vaccination documentation in her chart and asked if her documentation showed the correct Pneumococcal documentation. The DON stated, No, her Pneumo should not be due in 1 year. That was put in wrong too. The Surveyor asked the DON/ICP to review Resident #31's vaccination documentation in her chart and asked if there was a consent signed for the pneumococcal vaccine. The DON/ICP stated, Yes ma'am. The Surveyor asked if the DON/ICP had documentation of the Pneumococcal vaccine being administered. The DON/ICP stated, No, I do not see any. The Surveyor asked if Resident #31 was due for her Pneumococcal vaccine. The DON stated, I will have to check [Immunization Information System] for her too. The Surveyor asked the DON/ICP to review Resident #189's vaccination documentation in her chart and asked for the documentation for the reason it was documented she was not eligible for the Pneumococcal vaccine. The DON/ICP stated, I put it in wrong. I must have hurried. I will check on it and fix it. The Surveyor asked what possible negative outcomes could occur if the immunizations records were not kept accurate and up to date. The DON/ICP stated, They could be double immunized, or they could be given a shot that they don't want. 7. On 03/14/23 at 11:01 AM, the Surveyor asked the Administrator if a resident ' s immunizations should be accurate and kept up to date in the electronic records and in the resident's charts. The Administrator stated, Yes, ma'am. The Surveyor asked what a possible negative outcome could be if the records were not kept accurate and up to date. The Administrator stated, They would possibly catch the flu or get sick if we failed to provide them. If it was not accurate, they might receive a double dose. 8. On 03/14/23 at 12:16 PM, the DON/ICP informed the Surveyor that Resident #13 wanted a Pneumo vaccination and was overdue. The DON/ICP stated she would not have caught this. and thanked the Surveyor for bringing this to her attention. 9. On 03/14/23 at 1:40 PM, the DON/ICP provided the following documents: a. Resident #31 - an [Immunization Information System] printout. The printout documented a pneumococcal vaccine was due. The DON/ICP stated the [Immunization Information System] did not have any dates for Pneumococcal for Resident #31 and she had called Resident #31's Doctor's Office for the date the first one was given. If the Doctor's Office stated it was due the Pharmacy would bring it in a few days to administer. b. Resident #13 - a new completed consent form for the Pneumococcal vaccine. She stated, The pharmacy will be coming this afternoon to give it. 10. A completed vaccination status form provided by the DON/ICP on 03/14/23 at 3:41 PM for Resident #13 documented Resident #13 received a pneumococcal vaccination on 03/14/23. 11. The facility policy titled, Nursing Home Residents and Employee Requirements for Influenza, Pneumococcal and COVID-19 Vaccine Administration , provided by the DON/ICP on 03/14/23 at 9:00 AM documented, .6. If a resident is not vaccinated, the reason must be provided in the medical record . 7 .If administration of vaccine is requested by resident . facility will have 14 days to administer . Documentation: 1. After administration of a vaccine, the lot number and manufacturer name must be documented - this is done immediately after administration. 2. If a resident refuses, the refusal must be documented on the Vaccination Status form as well as documented in the nursing notes. 3. All records of documentation related to administration or refusal of . pneumococcal . vaccines must be kept in the resident's permanent medical record . 12. On 03/15/23 at 9:47 AM, the Surveyor asked the DON/ICP how often she checked the resident's immunization status. The DON/ICP stated, During Flu season once we put that [influenza immunizations] in and print that out. [Resident #31] needs hers and I found another lady too. The Surveyor asked if she checked on pneumococcal vaccinations at other times besides Flu season. The DON/ICP stated, No, I can't say that I have. The Surveyor asked how often medical records are checked for accuracy. The DON/ICP stated she did know but, I also put in my records to print a new face sheet for updated medical records.

Based on observation, record review, and interview, the facility failed to ensure an effective pest control program was in place to keep the kitchen free of pests to prevent the potential of cross contamination or bacteria growth. The failed practice had the potential to affect 36 residents who received meals from the kitchen (total census 38), as documented on a list provided by the Dietary Supervisor on 03/14/23 at 11:42 AM. The findings are: 1. On 03/13/23 at 10:48 AM, 3 roaches were crawling on the floor by the bread rack in the Storage Room. The Surveyor showed them to the Dietary Supervisor, she stepped on them and killed them. 2. On 03/13/23 at 10:55 AM, 8 dead roaches were on the floor in the Storage Room and 12 dead roaches were in the kitchen. The Surveyor asked the Dietary Supervisor how long they have had problems with pests. She stated, Not long. We changed companies and they come more often to spray. 3. On 03/13/23 at 10:56 AM, one roach was crawling on the floor by the door close to the Mop Room. The Surveyor showed it to Dietary Employee (DE) #3, who stepped on it and killed it. 4. On 03/13/23 at 10:57 AM, one roach was crawling down the wall above the rack where the plate holders and a tray that contained clean glasses was kept. The Surveyor showed it to the Dietary Supervisor. 5. On 03/13/23 at 11:44 AM, one roach was on the floor in the kitchen. The Surveyor showed it to DE #2, who stepped on it and killed it. 6. On 03/14/23 at 7:48 AM, one roach was crawling on the outside door of the walk-in refrigerator. The Surveyor showed it the Dietary Supervisor, she pushed it down and killed it. She stated, They came last night to spray. They come out when we have a heavy rain and when it's cold. 7. On 03/14/23 at 8:08 AM, one roach was crawling on the floor in the kitchen towards the oven. The Surveyor showed it to the Dietary Supervisor, and she stepped on it and killed it. 8. On 03/14/23 at 2:13 PM, the Surveyor asked the Dietary Supervisor, How many dead roaches did you observe in the Storage Room and in the Kitchen? She stated, I will say about 20 dead roaches. 9. The Pest Elimination Service logs dated 01/04/23 to 03/03/23 provided by the Dietary Supervisor on 03/13/23 at 2:12 PM documented: a. Date 01/04/23 Time In 9:28 AM - Time Out 11:11 AM, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly Service Notes and Recommendations The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated, and bait was replaced where needed . b. Date 01/05/23: Time In 8:30 PM - Time Out 9:47 PM, .Services Provided Trouble Call. Service Notes and Recommendations Treated the kitchen for roaches will treat again next week . c. Date 01/20/23: Time In 8:56 PM - Time Out 10:10 PM, .Services Provided Trouble Call. Treated the kitchen for roaches . d. Date 02/04/23: Time In 9:14 AM - Time Out 10:39 AM, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly. The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated and bait was replaced where needed . e. Date 02/07/23: Time In 7:52 PM - Time Out 9:06 PM, .Services Provided Trouble Call Treated the kitchen for roaches . f. Date 02/22/23: Time In 7:43 PM - Time Out 8:58 PM, .Services Provided Trouble Call Treated the kitchen for roaches . g. Date 03/01/23: Time In 10:42 AM - Time out 12:03 PM, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly. The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated and bait was replaced where needed . h. Date 03/03/23: Time In 8:04 PM - Time Out 9:14 PM, .Services Provided Trouble Call. Treated the kitchen for roaches .

Based on observation and interview, the facility failed to ensure the kitchen and dry storage area floors were free of debris, dirt, and stains and the kitchen vent were maintained in clean condition to provide a clean and sanitary environment for food preparation and to prevent the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; food items were promptly removed and/or discarded on or before the expiration or use by date to prevent the growth of bacteria; food items that contained dairy products and other food items were used by its use-by date to maintain maximum freshness and taste and prevent potential food borne illness for residents who received a meal trays from 1 of 1 kitchen; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; failed to ensure 3 of 3 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages. These failed practices had the potential to affect 22 residents who received ice from the ice machine on the North Hall, 15 resident residents who received ice from the ice machine on the East Hall and 36 residents who received meals from the kitchen (total census 38), as documented on a list provided by Dietary Supervisor on 03/14/23 at 11:42 AM. The findings are: 1. On 03/13/23 at 10:17 AM, in the Kitchen, there was black residue on the panel of the ice machine. The Dietary Supervisor was asked to wipe the residue from the panel of the ice machine. The black residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor how often the ice machine was cleaned and who uses the ice from the ice machine. She stated, We clean it every week and we use it to fill beverages for the residents at mealtimes. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. 2. On 03/13/23 at 10:19 AM, the following spices were observed on a shelf above the food preparation counter: a. Ground Celery Seed. b. Ground [NAME] Pepper. c. Meat Tenderizer. d. Taco Seasoning. e. Chili Powder. f. Ground Cumin. g. Ground Black Pepper. h. Montreal Steak Seasoning. i. Ground Cinnamon. j. Lemon and Pepper Seasoning Salt. k. Rubbed Sage. l. Smoked Sweet Paprika. m. Ground Mediterranean Seasoning. n. Dillweed. o. Thyme Leaves. p. Mediterranean Seasoning q. Oregano. The spices had no date when they were opened or when received. 3. An opened bag of sandwich bread was on the food preparation counter and had an expiration date of 3/10/2023. 4. On 03/13/23 at 10:21 AM, the following were observed on the bread rack in the Storage Room: a. Eight bags of bread dated 3/4/2023. b. One bag of bread had an expiration date of 3/9/2023. c. Two bags of bread had an expiration date of 2/25/2023. d. Sixteen bags of bread had expiration date of 3/10/2023. 5. On 03/13/23 at 10:49 AM, the following food items were on a shelf in the walk-in freezer in the Storage Room: a. An opened box of sausage, had no opened date on the box. b. An opened box of biscuits had no opened date on the box. c. An opened box of okra had no opened date on the box. d. An opened box of boneless pork chop fritters. The box was not covered or sealed. 6. On 03/13/23 at 10:53 AM, the following food items were on a shelf in the walk-in refrigerator: a. An opened bag of biscuits. The bag was not completely sealed. b. An opened bag of cheese slices had no date to indicate when it was opened. 7. On 03/13/23 at 11:21 AM, Dietary Employee (DE) #1 picked up the water hose with her bare hand and used it to spray off leftover food items from the blender contaminating her hands. She placed the blender, the lid, and the blade in the dirty rack of the dishwasher and pushed it into the dish washing machine. After the dishes stopped washing, she moved to the clean side and without washing her hands picked up the clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents for lunch. At 11:26 AM, when she was ready to place cornbread into a blender to puree, the Surveyor stopped her and asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. I will go back and rewash the blade and the blender. 8. On 03/13/23 at 11:33 AM, DE #2 turned on the hand washing sink faucet and washed his hands. With his bare hands he turned off the faucet contaminating his hands. Without washing his hands he placed gloves on his hands contaminating the gloves. He untied a bread bag and used his contaminated gloved hand to remove slices of bread from the bag and placed them on the tray. He used a spatula to remove pimento cheese from the container and spread on the bread to be served to the residents for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I rewash my hands and redo the pimento cheese sandwiches. 9. On 03/13/23 at 11:39 AM, the ceiling vent leading to the dish washing machine, extending towards the plate warmer had greasy cobweb/lint inside the slats with an accumulation of corroded black residue on them. 10. On 03/13/23 at 11:41 AM, DE #3 turned on the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands contaminating her hands. She removed gloves from the glove box and placed them on her hands contaminating the gloves. She picked up bowls with her contaminated gloved fingers inside of the bowls and placed them on the counter by the steam table to be used in portioning foods to be served to the residents on for lunch. 11. On 03/13/23 at 11:55 AM, the refrigerator temperature on the East Hall was 50 degrees Fahrenheit. The freezer was set on cool. The ice cream in the freezer was soft to touch. The Surveyor asked the Dietary Supervisor if the ice cream was still frozen solid. She stated, It was soft. On a shelf in the refrigerator was a plate with a pimento cheese sandwich dated 2/18/2023. On 3/14/23 at 3:38 PM, the Surveyor asked the Dietary Supervisor how long you keep a leftover sandwich. She stated, Two days maximum. 12. On 03/14/23 at 8:14 AM, the ice machine on the North Hall had a wet black residue on the left side of the panel. The panel area where the ice forms before dropping to the ice collector had a wet brown residue on it. The Surveyor asked the Dietary Supervisor to wipe the residue from the panel of the ice machine. The black residue easily transferred to the paper towel. The Surveyor asked how often the ice machine was cleaned and who uses the ice from the ice machine. She stated, We clean it every week, That's the ice the CNAs use for the water pitchers in the residents' rooms. 13. On 03/14/23 at 8:22 AM, the ice machine on the East Hall had a wet pink residue on the panel. The Surveyor asked the Dietary Supervisor to wipe the residue from the panel of the ice machine. The pink residue easily transferred to the paper towel. The Surveyor asked how often the ice machine was cleaned and who uses the ice from the ice machine. She stated, They clean it every Thursday. That's the ice the CNAs use for the water pitchers in the residents' rooms. 14. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 03/14/23 at 11:42 PM documented, . Policy: Employees will wash hands as frequently as needed throughout the day . Procedure: 1. When to wash hands: a. When entering the kitchen at the start of a shift . f. After handling soiled equipment or utensils. g. During food preparation, 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 contaminates the hands .