**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a sanitary and clean environment including air conditioning filters for 4 residents' rooms, Rooms 238-B, 235-D, 226-W and 232-B, reviewed for homelike clean environment. The census at the time of survey was 48. The findings included: 1. During an initial tour observation conducted on 09/23/24 at 9:55 AM of room [ROOM NUMBER]-B, it was observed that the air conditioning (AC) filters and vents with black mold-like substance. Photographic Evidence Obtained. An interview was conducted on 09/25/24 at 10:25 AM with the resident residing in this room who stated she always needs O2 and feels short of breath all the time. 2. During an initial tour observation conducted on 09/23/24 at 9:55 AM of room [ROOM NUMBER]-D revealed the AC vent and filters were observed with black mold-like substance. Photographic Evidence Obtained. During an interview conducted on 09/23/24 at 10:10 AM with the resident who resides in this room revealed she is on oxygen most of the time. During an environmental tour conducted on 09/26/24 at 11:30 AM, Staff E, Maintenance Assistant, stated he usually cleans the air-conditioning filers once a week. The surveyor pointed out the black mold-like substance material that was located on top of the air conditioning unit's slits. He further acknowledged all the findings in the rooms. 3. On 09/23/24 at 9:55 AM, during the initial tour to the facility, observation revealed in room [ROOM NUMBER] that the air conditioner's (A/C) vent / slats were observed with multiple black color moist matter. The A/C unit was next to a resident bed, turned on and the resident was in bed asleep. Photographic Evidence Obtained. 4. On 09/23/24 at 10:08 AM, during the initial tour to the facility, observation revealed in room [ROOM NUMBER] the A/C vent / slats and it's filters had multiple black color moist matter observed on the vents and crusted black matter on the filters. The A/C unit was turned on, next to a resident bed, and the resident was in bed asleep. Photographic Evidence Obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to monitor weights and provide adequate nutritional interventions in a timely manner for 1 of 3 sampled residents reviewed for nutrition, Resident #17. The findings included: Record review revealed Resident #17 was readmitted to the facility on [DATE] with diagnoses to include Generalized Anxiety Disorder, Parkinsons Disease, and Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Section GG of the MDS for eating showed Resident #17 needed substantial / maximum assistance with eating. In an observation conducted on 09/25/24 at 8:39 AM, Resident #17 was in her room eating breakfast. The tray consisted of oatmeal, juice, banana, and a muffin. Resident #17 was observed attempting to drink the oatmeal in the cup. No staff was noted at the time of this observation. A continued observation at 9:00 AM revealed staff sitting near Resident #17 assisting her with her breakfast meal. The breakfast tray was observed to be consumed 100%. Review of the Physician's orders showed an order for Ensure (nutritional supplement) 3 times a day dated 12/04/23. Review of the Weights log showed the following weight for Resident #17: On 05/02/24, a weight of 128 pounds. On 06/05/24, a weight of 125 pounds. On 07/02/24 a weight of 123 pounds. On 08/01/24, a weight of 122 pounds On 09/03/24, a weight of 121 pounds. This showed a weight loss trend from 128 pounds to 121 pounds, as above. Review of the nutrition progress note, dated 07/03/24, revealed the following: The Resident lost 2 pounds in one month. Oral intake of meals ranges from 50% to 75% of all meals. In this note, Staff L, Certified Dietary Manager, discontinued the Magic cup (nutritional supplements) twice a day, which provided an additional 580 calories and 18 grams of protein. Review of the dietary progress note dated 09/03/24 showed the following: current weight of 121 pounds with a 3.2% weight loss. Oral intake fluctuates between 50% to 75% of meals that are assisted. To continue encouraging high caloric foods and monitor weights. In this note, no additional nutritional recommendations were made or changes to the current nutritional supplements (Ensure). The surveyor requested a new weight on 09/25/24 at 10:00 AM, which showed a new weight for Resident #17 of 118 pounds. This showed an additional weight loss of 10 pounds from 05/02/24 to 09/25/24. Record review under the tasks section of the electronic charting, documented by the Certified Nursing Assistants (CNAs), revealed that for the last 14 days, Resident #17 ate 54% to 77% of her meals. An interview was conducted on 09/25/24 at 10:35 AM with Staff D, Registered Nurse, who stated when there is an order for Ensure nutritional supplements three times a day, it is usually given at 10:00 AM, 2:00 PM, and 6:00 PM. When asked what time the Ensure was given to Resident #17 this morning, she said that she refused it this morning. She further said that Resident #17 gets the Ensure twice a day at 10:00 AM and 6:00 PM. Review of the Medication Administration Audit Report showed the following: On 09/11/24, an Ensure was supposed to be given at 2:00 PM and was given at 4:02 PM. On 09/14/24, an Ensure was supposed to given at 10:00 AM and was given at 12:16 PM. On 09/15/24, an Ensure was supposed to be given at 6:00 PM and was given at 7:45 PM. On 09/16/24, an Ensure was supposed to be given at 6:00 PM and was given at 7:59 PM. On 09/17/24, an Ensure was supposed to given at 6:00 PM and was given at 8:31 PM. On 09/21/24, an Ensure was supposed to be given at 2:00 PM and was given at 4:37 PM. On 09/22/24, an Ensure was supposed to be given at 10:00 AM and was given at 11:58 AM. A phone interview was conducted on 09/25/24 at 11:00 AM with the facility's Clinical Dietitian, who stated that Staff L, the Certified Dietary Manager, oversees the nutritional monitoring and documenting on the long-term care residents. She is in charge of attending the care plan meetings and reviewing any weight changes. The facility's Clinical Dietitian watches the weight trends to prevent residents from loosing weight. She would review the intake of meals and ensure the residents are receiving the nutritional supplements as ordered. An interview was conducted on 09/25/24 at 11:20 AM with Staff L, who stated she removed the Magic Cup nutritional supplement for Resident #17 on 07/03/24 because she wanted to improve her oral intake with food and not fill her up with nutritional supplements. When asked why she removed the nutritional supplements for Resident #17 in spite of the resident losing 5 pounds from 05/02/24, she did not know.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy reviews, the facility failed to ensure that 1 of 1 sampled resident reviewed for dialysis, Resident #300, received care and services for the provision of hemodialysis consistent with the professional standards of practice, as evidenced by lack of ongoing communication and collaboration with the dialysis facility regarding the provision of dialysis care and services. The findings included: Review of the facility's Dialysis Policy Statement, effective 04/25/18, documented, in part, The Social Services Coordinator / designee will arrange for transporting to and from an off-site certified dialysis facility for dialysis treatments. It also documented that The care of the resident receiving dialysis services reflects ongoing communication, coordination and collaboration between the community and the dialysis staff. This communication process is established between the community and the dialysis facility to be used 24-hours a day. Communication is documented in the progress notes. Photographic Evidence Obtained. Review of the Agreement for Services between the facility and the dialysis center signed 06/05/18, documented under Section 20 Nursing Facility, (a) Use of Outside Resources: the Nursing Facility must have those services furnished to its [sig] residents by a person or agency outside the Nursing Facility under an agreement described in 42 CFR s 483.75. According to this provision, the Nursing Facility assumes responsibility for (i) obtaining services that meet professional standards and principles that apply to professional providing services in the Nursing Facility; and (ii) the timeliness of the services. Notwithstanding the foregoing, Contractor remains liable for its own acts and omissions and the acts and omissions of any person providing services pursuant to this Agreement and 42 CFR s 483.75 shall not be construed to limit such liability. Photographic Evidence Obtained. The Agreement for Services also included Schedule A Services that listed transportation arrangements under the coordination of the resident's plan of care. It specified The Contractor and Nursing Facility will coordinate the plan of care of dialysis residents. Such coordination shall include but not be limited to: iii) transportation arrangements. It documented, The medical management of the dialysis resident will be under the direction of the resident's attending physician. Record review revealed Resident #300 was admitted to the facility on [DATE], and discharged to the hospital on [DATE] to receive dialysis treatment for End Stage Renal Disease (ESRD). Prior to his admission to the facility, Resident #300 had surgery for a fractured right hip that resulted from a fall. The resident's diagnoses included Dependence on Renal Dialysis, Heart Failure, Nondisplaced Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Acute Kidney Failure, and Major Depressive Disorder. Review of the resident's Brief Interview for Mental Status (BIMS) assessment performed on 09/17/24, documented a BIMS score of 14 indicating Resident #300 was cognitively intact. An interview was conducted with Resident #300 on 09/23/24 at 12:45 PM. The surveyor observed the resident in bed and upset because he missed his appointment earlier for dialysis. He explained he did not go because the transportation arrived with the wrong equipment. He said that he fell and broke his hip, and that he was in a lot of pain. He added that the transportation company came with a chair, and that he needed a stretcher for the transportation because of the pain in his hip. Resident #300 also stated the transportation company was supposed to come back today with the appropriate equipment. Review of Resident #300's medical record showed a physician's order dated 09/17/24 for dialysis on Tuesdays, Thursdays, and Saturdays. During Resident #300's first week at the facility, this included Tuesday 09/17/24, Thursday 09/19/24, and Saturday 09/21/24. Review of the dialysis communication forms revealed no evidence that dialysis occurred on Tuesday 09/17/24 and on Thursday 09/19/24. There was no dialysis communication form provided for Saturday, 09/21/24. A phone interview was conducted on 09/24/24 at 10:05 AM, the Dialysis Outpatient Representative who stated that on Saturday, 09/21/24, Resident #300 didn't show up at the dialysis center due to transportation issues. She added he was supposed to go to the dialysis center on Monday, 09/23/24, to make up for the missed appointment, but when he arrived, he was unable to be transferred to the treatment chair because he needed two people to transfer him. The Dialysis Outpatient Representative said he required a stretcher because of his hip surgery. She stated the facility knew Resident #300 needed to come to his dialysis treatments with a stretcher since they did not have the resources to accommodate other transportation methods. An in-person interview with the facility's Concierge, conducted on 09/24/24 at 2:53 PM, revealed that she was aware that Resident #300 was scheduled for dialysis three times each week and that he did not receive dialysis on Tuesday, 09/17/24, because he could not be transferred to the treatment chair. The Concierge said she called the Staff Director of Sales in the admissions department and explained the problem with the transportation. After the Staff Director of Sales was notified, she arranged for transportation to the dialysis center, on the following day. This transportation included a stretcher for an appointment on Wednesday, 09/18/24, to make up for the missed session. A dialysis communication form documented evidence that the dialysis treatment occurred on 09/18/24. In a phone interview on 09/24/24 at 3:17 PM, the facility's Staff Director of Sales said that when Resident #300 was first admitted , they thought he could go to dialysis by wheelchair. After she was notified that the dialysis center was unable to transfer the resident to the treatment chair on 09/17/24, she set up an appointment for the following day with a different transportation company. Resident #300 was transported to the dialysis center and was dialyzed on 09/18/24. According to the Staff Director of Sales, she arranged for a transportation company to go to the facility on Saturday, 09/21/24, to conduct a site survey to determine if this resident would qualify for emergency services. She was told that they thought his services would qualify, and that they needed a form to be signed by the dialysis center. The Staff Director of Sales said that a representative from the transportation company brought a paper to the dialysis center to be signed. She was made aware that the resident was not transported to the dialysis center on Saturday, 09/21/24. When the Staff Director of Sales followed up with the dialysis center, she was informed that Resident #300 needed to arrive by 11:00 AM to receive dialysis. The Staff Director of Sales asked the dialysis center representative if he should go to the hospital to get dialysis, and she said she was told that he could wait until Monday morning. The Staff Director of Sales set up transportation for Monday morning and expected the transportation company to arrive with a stretcher. On Monday morning, instead of arriving with a stretcher, the transportation company arrived with a Broda chair (which is like a transportable recliner chair). The transportation company transported the resident in the Broda chair and after they arrived at the dialysis center, they were told that the dialysis center could not transfer the resident from the Broda chair to the dialysis treatment chair. The Staff Director of Sales said she requested a new chair time for the dialysis treatment and that she arranged for another transportation company to bring the resident to a later dialysis appointment on Monday 09/23/24. When the Staff Director of Sales was asked why Resident #300 didn't go to the later appointment at the dialysis center, she said that a Covid-19 test was performed on Resident #300 and the results were positive. The Staff Director of Sales said that Resident #300 was not able to go to dialysis because he tested positive for Covid-19. She added that they sent him out to the hospital because they knew he would miss the dialysis treatment. In a phone interview, on 09/24/24 at 3:46 PM, the Dialysis Outpatient Representative was asked what the usual protocol for a missed dialysis treatment was. She said that when a patient cannot make it to the dialysis center on one day, they are rescheduled for an appointment on the next day. She explained that three days would have been too many days for him to wait for the next day for dialysis treatment. She added that it all depends on the patient and at times it is a nurse's call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to properly destroy a controlled substance patch for 1 of 1 sampled resident reviewed during the controlled substance record review, Resident #8, and failed to ensure controlled substance medications reconciliation was accurate for 2 of 5 sampled residents, Resident #8 and #37. The findings included: Review of the facility's policy, undated, titled, Narcotic Reconciliation, provided by the Director of Nursing (DON) documented, in part, the licensed nurse is responsible to sign the administration of the controlled medication on the Medication Administration Record and the Controlled Substance Declining Inventory Record at the time of the administration to the resident . 1. Review of Resident #8's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included Chronic Pain, Heart Failure and Osteoarthritis. Review of Resident #8's clinical record documented an active physician order dated 04/22/24 for Buprenorphine Transdermal Patch (controlled substance) weekly 5 microgram per hour (mcg/hr.), apply 1 patch transdermally in the morning every Tuesday for Non Acute Pain and remove per schedule. Review of Resident #8's September 2024 Medication Administration record (MAR) documented, Buprenorphine Transdermal Patch weekly 5 mcg/hr., apply 1 patch transdermally in the morning every Tuesday for Non-Acute Pain and remove per schedule start date 04/23/24. Further review revealed Staff H, Registered Nurse (RN), signed off that Buprenorphine patch was removed on 09/24/24 at 5:59 AM and applied on 09/24/24 at 6:00 AM. On 09/24/24 at 11:33 AM, a joint side by side review of Medication Cart #1 was conducted with the Assistant Director of Nursing (ADON) and Staff F, Registered Nurse (RN). The review revealed an opened Buprenorphine Transdermal System, a single package, that was opened with the patch dated 09/10/24 and was located on the top drawer of the cart. Staff F stated the patch belonged to Resident #8 and it was supposed to be discarded and signed by two nurses. A side-by-side review of Resident #8's Controlled Drug Declining Inventory Sheet for the resident's drug Buprenorphine was conducted with the ADON and Staff F, RN. The inventory sheet documented an entry that a patch for Buprenorphine was removed from the controlled box on 09/10/24 at 6:00 AM. The inventory sheet also documented above patch was destroyed by nurse (A) and witness (B) who signed and dated to the left. Further review revealed another entry signed off by Staff H, RN. The entry was not dated, and the patch was not destroyed and witness by (B) as per the inventory sheet. On 09/24/24 at 12:28 PM, an interview was conducted with the Director of Nursing (DON) who stated that on 09/17/24, the night nurse went to Resident #8's room and asked the resident if she wanted the Buprenorphine patch and the resident refused it. The DON was apprised that the night nurse left the removed patch dated 09/10/24 in the medication cart and did not discard it as per inventory sheet. The DON stated the resident's patch was administered on 09/24/24 at 6:00 AM. The DON was asked to arrange for an interview with Staff H, RN. On 09/24/24 at 1:45 PM, a joint interview was conducted with the DON and Staff H, RN. Staff H stated he works the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shift. Staff H stated that on 09/24/24, he removed Resident #8's Buprenorphine patch dated 09/10/24 and applied a new one on her right forearm and added that two nurses should sign when dropping the old patch into the drug buster. Staff H stated the other nurse was busy and he was waiting 'to waste'. He stated, my mistake, I forgot. Staff H was apprised that he did not date the controlled substance inventory sheet either. 2. Review of Resident #37's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's diagnoses included Displaced Fracture of Base of Neck of Right Femur, Acute Kidney Failure and Dementia. Review of Resident #37's clinical record documented a discontinued physician order dated 08/02/24 for Oxycodone-Acetaminophen tablet 5-325 mg every 8 hours as needed for pain. On 09/24/24 at 12:12 PM, a side-by-side review of Resident #37's Controlled Drug Declining Inventory Sheet for Oxycodone-Acetaminophen (controlled substance) tablet 5-325 mg every 8 hours as needed for 2 days, received on 07/17/24, was conducted with Staff G, RN and the ADON. The review revealed two tablets of Oxycodone-Acetaminophen 5-325 mg in the controlled box. The inventory sheet documented that on 08/30/24 at 8:00 PM, one tablet was removed from the controlled substance box. Further review revealed that the Oxycodone-Acetaminophen 5-325 mg tablet removed from the box on 08/30/24 was not documented as administered on Resident's #37's August 2024 MAR. There was not a written physician order to administer Oxycodone-Acetaminophen 5-325 mg on 08/30/24. On 09/25/24 at 9:45 AM, during an interview, the DON confirmed Resident #37's Oxycodone-Acetaminophen 5-325 mg was discontinued on 08/02/24 and the tablet had been removed on 08/30/24 without a physician order and it was not documented on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure medication error rates was below 5 percent; a total of 29 opportunities were observed with 3 medication errors identified which yield a medication error rate of 10.34 percent, affecting 2 of 5 sampled residents reviewed for medication administration, Resident #249 and Resident #250. The findings included: Review of the facility's policy, titled, Medication Administration General Guidelines, dated 01/2023, included the following: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. Documentation: 1. The individual who administers the medication dose records the administration on the resident's MAR immediately following the medication being given. 1. Record review for Resident #250 revealed she was re-admitted to the facility on [DATE] with the following diagnoses: Fracture of Sacrum, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Stage 3, and Paroxysmal Atrial Fibrillation. Review of Section C of the Minimum Data Set (MDS) dated [DATE] Admissions MDS revealed Resident #250 had a Brief Interview for Mental Status (BIMS) score of 10, indicating she was moderately cognitively impaired. On 09/24/24 at 9:25 AM, a medication administration observation was conducted with Staff F, Registered Nurse (RN), for Resident #250. Staff F was observed preparing Resident #250's medications to include 8 oral medications: Allopurinol 100mg 2x daily Colchicine 0.6mg tab daily Gabapentin 300 mg cap 2x daily Pilocarpine 5mg 2x daily Prednisone 2.5mg, give 7.5mg daily (3 tabs) daily Docusate Sodium cap 100mg 2x daily Magnesium Gluconate 250mg daily Vitamin B-12 500 mcg daily. Reconciliation of Resident #250's physician's orders and medications administered above revealed Resident #250 was scheduled to receive the above medication at 10:00 AM, plus 2 other medications: Ferrous Sulfate Oral Tab 45 mg daily and Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 mcg/ACT, 1 puff inhale daily. These 2 medications were omitted in the medication administration observation at 9:25 AM. During an interview conducted on 09/24/24 at 10:45 AM with Staff F, she stated she has been working at the facility for almost 2 years. She stated she administered the Trelegy Ellipta and the Ferrous sulfate prior to the medication administration observation with the surveyor. When asked to see the medications, Staff F remembered that the Ferrous Sulfate 45mg was not in the medication cart or the medication storage room, therefore she did not administer it. She noted that she did administer Trelegy prior to the medication administration observation at 9:25 AM. Review of the Medication audit report (time stamp) revealed Staff F documented that Resident #250 received the 8 oral medications between 9:53 and 9:54 AM including the Trelegy (9:54 AM) and not prior to the start of the medication administration observation at 9:25 AM as Staff F stated. In addition, Staff F signed for the Ferrous sulfate 45mg and then changed it at 10:47 AM after the surveyor brought it to her attention. Review of the nursing progress notes dated 09/24/24 at 12:24 PM revealed Resident #250's physician was contacted and an order received for a one-time dose of Slow Fe 45mg, which was administered at 12:47 PM. In addition, there was no further documentation of the Trelegy Ellipta administration. An interview was conducted on 09/24/24 at 2:59 PM with Resident #250's private aide. She stated she does not recall seeing the nurse give the resident the Trelegy Ellipta inhaler today, however, the nurse could of given the inhaler prior to her coming in at 7:30 AM. She also stated that she stepped out around 11:30 AM to pick up something from downstairs and the nurse could have administered the inhaler then. 2. Review of Resident #249's clinical record documented an admission on [DATE] with a diagnosis to include Sepsis, Extended Spectrum Beta Lactamase (ESBL) Resistance (a bacteria), Escherichia (E) Coli (a bacteria) and Urinary Tract Infection (UTI). On 09/24/24 at 9:54 AM, medication administration observation for Resident #249 performed by Staff G, RN started. The RN prepared the followings meds: Aspirin 81 mg(milligram) one tablet Multivitamin without minerals one tablet Metoprolol Tartrate 50 mg one tablet On 09/24/24 at 10:22 AM, Staff G stated she had finished the medication administration for the time for Resident #249. Review of Resident #249's clinical record documented an active physician order dated 09/20/24 for Multivitamin-Minerals Oral Tablet (Multiple Vitamins with Minerals) give 1 tablet by mouth one time a day for supplement. Review of Resident #249's September 2024 Medication Administration Record (MAR) documented Multivitamin-Minerals Oral Tablet (Multiple Vitamins with Minerals) give 1 tablet by mouth one time a day for supplement, start date 09/20/24 at 10:00 AM. On 09/24/24 at 12:12 PM, a side-by-side review of Medication Cart #2 and the Multivitamins bottle in the cart was conducted with Staff G, RN and the Assistant Director of Nursing (ADON). The cart had one opened bottle of Multivitamins without minerals. Staff G stated that was the only Multivitamin bottle she had in Medication Cart #2 and added she had not seen a bottle of Multivitamins bottle with minerals and did not give Multivitamin with mineral to Resident #249. On 09/24/24 at 12:39 PM, a side-by-side review of Multivitamins supply located at the facility's Central supply room was conducted with the Central Supply Clerk (CSC) and the ADON. The CSC stated the most popular over the counter Multivitamins she ordered was the one used by Staff G, Multivitamins without minerals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the correct diet consistency for the Pureed diet during 1 of 3 dining observations for Resident #20 and Resident #6. This had the potential to affect 5 of 48 residents on a Pureed diet. The findings included: Review of the Purred Diet-NDD Level 1 taken from the 2014 Nutrition Care Manual, Academy of Nutrition and Dietetics, showed the following: pureed foods must be smooth and thick enough to mound on the plate. No coarse textures, chunks, lumps, or particles are allowed in the food. Record review revealed Resident #20 was admitted on [DATE] with a diagnosis of Dysphagia, Repeated Falls, and Weakness. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 02, indicting severe cognitive impairment. Review of the physician's orders showed an order, dated 07/24/20, for a Regular diet, Pureed texture, and Nectar consistency for dysphagia. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder and Parkinsons Disease. Review of the physician's orders, dated 11/12/23, showed an order for a Concentrated Carbohydrate diet, Pureed texture, and Honey consistency. The MDS assessment dated [DATE] revealed a BIMS score of 02, indicating severe cognitive impairment. Review of the menu cycle for 09/24/24 showed the following for the lunch meal: Cream of Mushroom shop, Fried Chicken, Steamed rice, and Stir-Fried Vegetables. In an observation conducted on 09/24/24 at 12:15 PM, Resident #6 was observed in the dining room eating her lunch meal. The meal ticket was noted to have L1 Puree Concentrated Carbohydrates and a Honey Thickened diet. Resident #6 was observed eating a Cream of Mushroom soup, which was observed to be lumpy and thick with an oatmeal-like consistency. Photographic Evidence Obtained. Resident #6 was observed coughing while attempting to drink the soup. Resident #20 was observed sitting at the same table, eating her lunch. Her meal ticket was noted to be on a Pureed diet with nectar-thickened liquids. Resident #20 was eating her Cream of Mushroom soup which was noted with the same consistency as Resident #6. In an interview conducted on 09/24/24 at 1:06 PM with Staff B, the Executive Chef stated that Cream of Mushroom soup was placed in an Emersion blender, and a thickener was added to it. When asked how much of the thickener was placed into the soup portion of the pureed diet, he said, We just eyeball it. An interview was conducted on 09/25/24 at 11:23 AM with the facility's Speech Pathologist who stated the Cream of Mushroom soup is considered food and needs to be made into three consistencies: Regular, Pureed, and Mechanical soft. For the Pureed consistency, the soup needs to be smooth with no lumps. When looking at Pureed foods, you should not be able to see pieces and should see one uniform texture. When shown a picture of the Cream of Mushroom soup taken earlier by the surveyor, she said that it was not smooth enough to be considered Pureed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure they had implemented an infection control program that ensured a resident with a bacterial Urinary Tract Infection (UTI) was placed on contact precautions for 1 of 3 sampled residents reviewed for Transmission Based Precautions (TBP), Resident #249; and failed to perform hand washing between gloves change during wound care observation for 1 of 1 sampled resident reviewed for pressure ulcers, Resident #34. The findings included: Review of the facility's policy, titled, Infection Prevention and Control Program for Skilled Communities -Transmission-Based Precautions, revised on 07/2024, provided by the Director of Nursing (DON), documented, in part, Transmission-based precautions are used for residents with documented .infection .with highly transmissible pathogens for which additional precautions are needed to prevent transmission .Contact Precautions-use contact precautions for residents with known .infections that are at an increased risk of being transmitted by direct contact with the residents or the resident's environment .use the following guidelines to manage the care of resident's on contact precautions: PPE [personal protective equipment] - use gloves and gown when in contact with the resident or the resident's environment. Put on PPE prior entering the resident's room . 1. Review of Resident #249's clinical record documented an admission on [DATE] with a diagnosis that included Sepsis, Extended Spectrum Beta Lactamase (ESBL) Resistance [a bacteria], Escherichia (E) Coli (a bacteria) [E-Coli] and Urinary Tract Infection (UTI). Review of Resident #249's hospital discharge instructions listed a diagnosis of Bacterial UTI and Sepsis, discharge to Skilled Nursing Facility (SNF) on 09/19/24. Review of Resident #249's clinical record documented an active physician order dated 09/20/24 for Meropenem Solution (an antibiotic) 1 GM (Gram) intravenously (IV) every 12 hours for ESBL/ E.Coli - UTI until 09/26/24. Review of Resident #249's September 2024 Medication Administration Record (MAR) documented Meropenem Solution 1 GM (Gram) intravenously every 12 hours for ESBL/ E.Coli-UTI, as administered for the first time on 09/20/24 at 10:00 AM. Review of the facility's resident's census list provided by the Director of Nursing (DON) on 09/23/24 documented ISO above Resident #249's name. On 09/23/24 at 8:49 AM, an interview was conducted with the DON who stated that ISO means isolation, and stated that Resident #249 was on isolation. On 09/23/24 at 9:41 AM, during an initial tour, observation revealed Resident #249 in her room being helped to walk to the bathroom by the Assistant Director of Nursing (ADON). The ADON was holding the resident by her arm. Observation revealed the ADON was not wearing PPE (gown or gloves). Further observations revealed the resident's room did not have signage or any indications that Resident #249 was on Isolation or Contact Precautions due to a bacterial infection. There were no PPE supplies readily available for the staff to care for Resident #249. On 09/24/24 at 8:45 AM, observation revealed Resident #249 door with a Contact Precautions signage on the door and PPE supplies cart outside the room. On 09/24/24 at 9:52 AM, an interview was conducted with Staff G, Registered Nurse (RN), assigned to Resident #249, who stated the resident had ESBL in the urine and was placed on contact precautions on 09/24/24. Staff G stated the resident was on intravenous antibiotic for the ESBL infection since admission. On 09/24/24 at 10:04 AM, an interview was conducted with Resident #249 who stated she has had an UTI four (4) times and added she told the hospital to treat her before she was sent home. The resident added she was told she had the UTI and was sent to the nursing home for antibiotic and will not go back home until clear. On 09/24 24 at 11:33 AM, an interview was conducted with the ADON / Infection Preventionist (IP) who stated they missed placing Resident #249 on contact precautions for ESBL on admission on [DATE]. The ADON added that contact precautions were started last night on 09/24/24. The ADON was apprised of the surveyor observation of taking the resident to bathroom without her wearing a gown or gloves on 09/23/24 morning, and that the census indicated the resident was on isolation but there was not a sign or PPE supplies in the room. The ADON confirmed findings. 2. Review of the facility's undated document provided by the DON, titled, Shadowing and Skills - Team Member Hand Hygiene, documented, in part, Standard: all steps in the procedure must be completely and properly performed by the team member .skill procedure - handwashing .state when handwashing is required after removing gloves . Review of Resident #34's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Lymphedema, Dementia, Benign Prostatic Hyperplasia, Difficulty in Walking, and Muscle Weakness. Review of Resident #34's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3, indicating that the resident had severe cognitive impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete the activities of daily living (ADLs) including turning and repositioning. Review of Resident #34's physician order dated 09/17/24 documented Santyl Ointment 250 unit/gram (Collagenase), apply to Left ischium topically every night shift, cleanse with normal saline, apply Santyl then alginate calcium with skin prep around periwound and cover with gauze island daily. On 09/26/24 at 1:49 PM, wound care observation for Resident #34 performed by Staff F, RN and assisted by Staff D, RN started. Staff F removed the resident's wound's previous dressing, removed her pair of gloves and without performing hand hygiene, opened the room door, retrieved the treatment cart's key from her pocket and opened the treatment cart to retrieve wound care supplies. Staff F returned to Resident #43's beside, placed the wound care supplies on top of the table and donned gloves without performing hand hygiene prior to care. Staff F cleaned the surrounding wound skin with skin prep pads, removed her pair of gloves and without performing hand hygiene donned a pair of gloves and was not able to open the normal saline vial to clean the wound with. Observation revealed Staff F removed her pair of gloves, opened the room door, pulled the treatment cart keys from her pocket, opened the cart and retrieved more normal saline vials from the cart. Staff F returned to the resident's bedside, donned gloves without performing hand hygiene, and cleaned the resident's wound, removed her pair of gloves and again without performing hand hygiene donned another pair of gloves. Staff F then applied the Santyl ointment with a tongue depressor, removed her gloves and donned gloves again without performing hand hygiene, applied a Calcium alginate dressing, and with her gloved hand, Staff F reached for a marker in her pocket to label the dressing. At the end of the observation, a joint interview was conducted with Staff D and Staff F, who both stated that they are supposed to do hand hygiene / washing between gloves changing. Staff F confirmed she did hand hygiene only once. Staff D confirmed that Staff F did not perform hand hygiene between gloves changes.

Based on interviews, observations, and record, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially affect 48 residents in the facility. The findings included: 1. In a tour of the main kitchen conducted on 09/23/24 at 9:15 AM, accompanied by the Kitchen Manager, the following issues were observed: a. Three large round garbage bins were opened without lids in the food production area. Thirty minutes later, at 9:45 AM, this was still observed. b. A small Styrofoam cup, with an employee's name written on it, was noted in the food production area. c. The Traulsen reach-in refrigerators was noted with dirt and debris on the bottom. d. The commercial charcoal grills were noted with an old sticky-like black dried substance attached. Staff A, Cook, stated the grill is supposed to be cleaned the night before and that it is usually clean when he arrives for his shift in the morning. When asked when it was last cleaned, he did not know. e. A rectangular silver tray with some debris and dirt inside it was noted underneath the tray line. f. The walk-in refrigerator had two boxes (10.5 pounds) each, with ready to cook boneless, skinless chicken breast filets. No date was noted on the boxes indicating the time and date that the boxes were placed in the walk-in refrigerator. Further observation revealed that the chicken filets were sitting in a pool of red fluid. The boneless, skinless chicken breast filets were also in an open plastic bag and not sealed appropriately. In this observation, Staff A was asked when the two boxes were placed in the walk-in refrigerator, and he did not know. g. The reach-in refrigerator contained a 16-ounce round container of clam base, dated 09/13/24, which was ten days ago. Staff A reported that the 16-ounce container of clam base should have been used and discarded after 3 days. h.The walk-in refrigerator had a box of 8 servings (2.5 pounds each) of oven roasted chicken halves with no dated on the box indicating when the box was placed in the walk-in refrigerator. i. A large metal container was noted with multiple pieces of raw fish that were in the walk-in refrigerator. Further observation revealed the container was placed there on 09/16/24 which was 7 days later. j. Four large boxes of frozen Swai fillets were noted in the walk-in refrigerator. The fillet boxes did not have a date on them indicating when they were placed in the refrigerator. In this observation, Staff B, Executive Chef, said that the boxes were placed in the walk-in refrigerator on Saturday. He acknowledged that the date that the boxes were placed in the walk-in refrigerator should have been marked on the boxes. k.A large box of frozen Swai fillets was in the walk-in refrigerator. The fillet box did not have a date on the box indicating when the boxes were placed in the walk-in refrigerator, and it was opened and not sealed. l. The floor in the dry storage area noted with debris and dirt on the floor. Continued observation showed a live insect on the wall in the dry storage area. 2. In an observation conducted on 09/23/24 at 10:30 AM on the 2nd floor satellite kitchen, an opened round garbage container with no lid was noted. At 10:45 AM, the round garbage container was still opened with no lid. 3. In an observation conducted on 09/25/24 at 11:56 AM on the 2ndfloor Satellite Kitchen, the following were noted: a. Using a facility-calibrated thermometer, Staff C, Dietary Aid, measured the internal temperature of a small square metal container with blue cheese. The temperature was 44.2 degrees Fahrenheit (F), not the recommended 40 degrees and below Fahrenheit. b. Using a facility-calibrated thermometer, Staff C, Dietary Aid, measured the internal temperature of 12 individuals' Ham and Cheese Sandwiches. The internal temperature was 45.8 degrees Fahrenheit, not the recommended 40 degrees and below Fahrenheit. In an interview conducted on 09/26/24 at 2:00 PM with the facility's Administrator, he acknowledged all findings.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, homelike environment in the facility and in the laundry area. The findings included: Review of the facility policy, titled, Dryer Fire Prevention Policy, review date 10/12/15, revealed the following directions for dryer lint maintenance: Clean lint screens in commercial dryers after each use. 1. Observation by 3 of 3 surveyors during tours of the facility conducted during the survey week (07/31/23 to 08/03/23) noted that the 230-240 hallway had an offensive, urinary, molded, musty smell throughout the hallway. The surveyors informed the facility administration about the issue on 08/01/23. 2. Observation by 3 of 3 surveyors during tours of the facility conducted during the survey week (07/31/23 to 08/03/23) noted that large stains were present on the carpet of the second-floor lobby area and in the entrances of the dining room and activities room. The surveyors informed the facility administration about the issue on 08/01/23. 3. Tours of the facility's laundry areas were conducted on 08/01/23 at 11:10 AM with the Housekeeping Supervisor, the facility's Administrator, and the Director of Housekeeping. Observation on the second floor revealed there was a Laundry Room which contained one washing machine. The Housekeeping Supervisor stated this washing machine is used for the aprons worn by the staff. Please note, there was no dryer in this room. When asked where the aprons are dried, the Housekeeping Supervisor stated she did not know. Next to the washing machine leaned against the wall was a mop, bucket, broom, dustpan, and garbage can without a lid. In the first-floor laundry room, there were four washing machines, three of which had rectangular lids on the tops. Under these rectangular lids were trays. The Director of Housekeeping stated she thought they were detergent dispensing trays. Inside these dispensing trays and on the undersides of the lids was a large amount of black, slimy, mold-like substance and standing water which could contaminate the clean laundry inside the machines. The Director of Housekeeping stated these dispensing trays were not used, but rather the detergent was auto filled through another mechanism. When asked how often the trays are cleaned, the Director of Housekeeping stated she did not know. When asked if the black, slimy, mold-like substance was contaminating the inside of the washing machines, she again stated she did not know. Hanging on the laundry room wall was a dryer lint trap record sheet, which showed three time slots for the staff to fill out for lint removal each day. When asked how often the dryer lint traps are cleaned out each day, the Director of Housekeeping stated three times per day. When asked what the hours are for laundry operation each day, the Director of Housekeeping stated 6:00 AM to 1:30 PM. When asked why the lint traps are not cleaned every 2 hours or after each use, the Director of Housekeeping and the facility Administrator stated they did not know. When asked to see the lint traps, it was observed that four of four dryer lint traps had a large buildup of lint and debris in each lint trap. One of the four dryers also had a gasket which was torn. The surveyor explained that it is a fire hazard to have a buildup of lint in the dryer lint traps and that the lint traps. In the clean linen folding room, the floor was noted to be dirty and worn. One of three clothing racks was worn and rusted all over. The surveyor explained that both of these areas of concern could cause contamination of clean clothing and linens. 4. In the Soiled Linen Room on the second floor, there were two dirty linen carts both of which had dirt and debris located in the bottoms of the carts. One of the two carts also had a broken-down cardboard box lying in the bottom of the cart. In the Soiled Linen Room near the hand washing sink was a paper towel dispenser that was noted to be lacking paper towels. Further observation revealed the paper towel dispenser was filled with condensation which was dripping from the bottom of the dispenser. When asked why this paper towel dispenser was empty and filled with condensation, the Housekeeping Supervisor stated, I don't know. We never use this one. 5. In the Central Supply Room located on the second floor, the surveyor observed two purses sitting on top of a table which contained care supplies for residents. There were two employees working in this room, as it is also used as the Medical Records Department. Both employees had food and beverages out among the supplies. The surveyor explained that purses, food, and beverages can contaminate the care supplies in the room.

Based on observation, interview, and record review, the facility failed to follow the approved menus and failed to provide a variety of foods to the residents on the L3/Mechnical Soft Diet, for 2 of 6 sampled residents, Resident's #9 and #27; and for residents on the L1/Pureed Diet, for 2 of 3 sampled residents, Resident's #5 and #18. The census at the time of the survey was 40. The findings included: 1. Review of the approved menu for the lunch meal of 07/31/21 for the L1/Pureed Diets noted the following to be served: - Broccoli Shape with Lemon Sauce - Peach Shaped Ice Cream. Observation of the lunch meal in the satellite kitchen on 07/31/23 at 12:00 PM noted the following for the L1/Pureed Diets: -Pureed Broccoli Shapes w (with) Lemon Sauce not available -Peach Shape Ice cream not available. Residents receiving the pureed diet received vanilla ice cream. 2. Review of the approved menu for the brealfast meal of 08/01/23 for the L3/Mechnaical Soft diets noted the following to be served: -Cold Cereal Slurry -Ground Sunrise Omelet -Crustless Bread. Observation of brealfast meal in the satellite kitchen on 08/01/23 at 7:45 AM noted the following for residents on the L3/Mechnaical Soft Diet: -Cold Cereal Slurry was not preprared or served -Ground Sunrise Omelet not preprared or served -Crustless Bread not preprared or served. 3. Review of the approved menu for the breakfast meal of 08/02/23 for the L3/Mechanical Soft Diet noted the following to be served: -Sunny Ground Omelet -Crustless Bread -Slurry Cinnamon Roll. Observation of the breakfast meal in the satellite kitchen on 08/02/23 at 8:15 AM noted the following for residents on the L3/Mechanical Soft Diet: -Sunny Ground Omelet - not prepared or served -Crustless bread - not prepared or served. -Slurry Cinnamon Roll - not prepared or served. 4. Review of the approved menu for the lunch meal of 08/02/23 for the L3/Mechanical Soft Diet noted the following to be served: -Ground Turkey Ala King -Crustless Bread -Vegetable Juice -Assorted Pudding. Review of the approved menu for the lunch meal of 08/02/23 for the L1/Pureed Diet noted the following to be served: -Vegetable Juice -Assorted Pudding -Pureed Asparagus Shape. During the observation of the lunch meal in the satellite kitchen on 08/02/23 at 12:00 PM, the following were noted: a. L3/Mechanical Soft Diet: -The Turkey Ala King entrée was not prepared for as per the menu. Ground turkey with gravy was served as the entrée -Crustless bread was not prepared or served -Vegetable Juice was not available -The regular diets were served Coconut Cream Pie. The Mechanical Soft diets were served vanilla pudding. The menu should have included Coconut Pudding. b. L1/Pureed Diet: -The vegetable juice was not available -The regular diets were served Coconut Cream Pie. The Pureed Diet was served vanilla pudding. The menu should have included Coconut Pudding -The L1/Pureed Deit should have included Pureed mushrooms that were documented to be served to the Regular Diet. 4. During the review of the facility's diet and census for 07/31/23, the following were noted: -Six facility residents had physician ordered L3/Mechanically Soft Diet that included sampled Residents #9 and #27. -Three facility residents had physician ordered L1/Pureed Deit that included sampled Residents #5 and #18.

Based on observation and interview, the facility failed to store, prepare, distribute an serve food in accordance with professional standards for food service safety that included labeling and dating of perishable food, proper cleaning of food preparation equipment on a scheduled basis, proper maintenance of refrigeration equipment on a regular scheduled basis, holding of hot foods at regulatory, temperatures, and proper maintenance of dish machine equipment. The findings included: 1. During the initial Kitchen / Food Service Observation Tour of the Main Kitchen conducted on 07/31/223 at 9:00 AM, and accompanied with the facility's Certified Dietary Manager (CDM), the following were noted: (a) The main service hallway was noted to be heavily soiled and stained throughout. It was noted that recent food deliveries were being stored in the hallway. It was also discussed with the CDM that resident food transportation carts are travelled through the soiled hallways on the way to the Skilled Nursing Unit. The surveyor requested the hallways be cleaned and sanitized prior to the next food deliveries and food prior to the next food cart transportation. Photographic Evidence Obtained. (b) Observation of the walk-in refrigerator noted that there were 4 large containers of raw chicken (approximately 40 pounds) located on the food shelves. Further observation noted that none of the 4 boxes were labeled with a date that they were stored or thawed. The CDM stated that the containers of chicken required a documented storage date. Photographic Evidence Obtained. (c) The main service hallway was noted to have a large, uncovered trash bin stored within the area. Further observation of the bin noted open food containers and soiled cleaning cloths. The surveyor informed the CDM that all trash / garbage must have a secured lid when not in use. Photographic Evidence Obtained. (d) The entrance / exit service hallway door that leads to the main kitchen and laundry areas was noted not to shut properly leaving large open areas to the outside. It was discussed with the CDM that the opening could allow potential pests, dirt and debris into the facility. Photographic Evidence Obtained. (e) Observation of the walk-in freezer noted that the commercial unit is located outside due to the facility's interior freezer unit being under repair. Upon entering, it was noted that the 2 refrigeration units located inside were completely covered in ice. Further observation noted that all of the foods located within unit were covered in a thick layer of ice. It was discussed with the CDM that the ice could cause food freezer burn and result in food borne illness. Photographic Evidence Obtained. (f) Observation and chemical testing of the cleaning cloth buckets noted that 1 of the buckets failed to be filled with a chemical solution that meets regulatory requirement. Photographic Evidence Obtained. (g) The convection oven was noted to be heavily soiled with a thick black layer of carbon. It was discussed with the CDM that the oven is not being cleaned on a regular basis. The CDM confirmed the surveyor's findings. Photographic Evidence Obtained. (h) Observation of the dish machine noted that 1 of the 3 internal separation curtains was broken. It was discussed with the CDM that the internal separation curtains are necessary to prevent contamination of dishware while moving through the machine. The CDM stated that a new curtain would be ordered immediately. Photographic Evidence Obtained. (i) Observation of the ceiling mounted lights noted that a set of lights that was located over a food preparation area did not have a protective covering. It was discussed with the CDM that there was the potential for the light to crack or brake causing small piece of glass to fall into prepared foods. Photographic Evidence Obtained. 2. During the observation of the satellite kitchen located with the second floor SNF (Skilled Nursing Facility) unit noted that the six shelves within the unit were in disrepair that included being rust ladened. The CDM confirmed the surveyor's findings and stated that new shelving would be ordered. Photographic Evidence Obtained. 3. During the observation of the breakfast meal conducted on 08/01/23 in the satellite kitchen located on the second floor of the SNF, the following ws noted: a. The floor drain located in the far corner of the kitchen was noted to have a thick layer of black mold type substance. b. The ceiling mounted air-conditioning vents located above the stem table was laden with dirt and dust. The air steam from the unit was noted to blow directly over and onto foods located in the steam table. The issues were confirmed with the CDM at the time of the observation. Photographic Evidence Obtained. 4. During the observation of the lunch meal service in the satellite kitchen on 08/01/23 at 12 PM, temperatures of hot located in the hot storage hold box were taken with the facility's calibrated digital thermometer. The finding noted that hot foods were not kept at the regulatory requirement of 135 degrees Fahrenheit (F) as per the following: a. Individual Pureed Fish Molds (4) = 125 degrees F. b. Individual Pureed Turkey Molds (4) = 128 degrees F. The findings of the observations conducted on 07/31/23 and 08/01/23 were confirmed with the Administrator on 08/01/23.

Based on observation and interview, the facility failed to dispose of garbage and refuse properly. The findings included: During the observation of the garbage / refuse area on 07/31/23 at 10:00 AM and accompanied with the the facility's Certified Dietary Manager (CDM), the following were noted: 1. The ground areas surrounding the commercial dumpster was noted to be covered with numerous soiled PPE (personal protective equipment) such as gloves, masks, gowns, etc., trash and food garbage debris, soiled food containers and an old tire. 2. Two 55-gallon drums, of which old cooking oil was being stored, were noted to be leaking. It was noted that a large thick layer of oil surrounded one of the dumpster ground areas. The CDM confirmed the dumpster findings and stated that the environmental service would be notified of the issues. The findings and photographs were reviewed with the facility's Administrator. Photographic Evidence Obtained of the garbage / dumpster areas.

Based on observation and interview, the facility failed to provide a homelike environment for a clean and debris-free flooring for 9 of 40 rooms (211, 212, 214, 218, 225, 226, 234, 237, and 240). The findings included: An observation of the facility was conducted throughout the survey from 03/28/22- 04/01/22. The flooring at the doorway entry to the resident's rooms were noted with dirty, peeling, black duct tape in the following rooms: 211, 212, 214, 218, 225, 226, 234, 237, and 240. An interview was conducted with the Director of Maintenance on 04/01/22 at 2:00 PM. The Director of Maintenance acknowledged the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to place nutrition orders and obtain weights in a timely manner for 1 of 4 sampled residents reviewed for nutrition (Resident #2); and failed to conduct nutrition assessments in a timely manner for 1 of 4 sampled residents reviewed for nutrition (Resident #24). The findings included: Review of the facility's policy, titled, Nutrition and Weight Management Program, version 1.0, documented the following: Ongoing monitoring of weight is integral to the plan to manage the resident's weight. Residents are upon admission, weekly for 4 weeks, then monthly to evaluate trends or in accordance with physician's orders. Residents who are not cognitively impaired may choose not to be weighed. Document this preference in the resident's care plan. All weights are recorded in the resident's electronic health record. Review of the facility's policy, titled, Nutritional Care Planning Process, revised on 04/30/21, documented the following: Quarterly, each resident is nutritionally reviewed and problems, goals, and approaches on the care plan are updated. Dietary Progress notes may be used for notations needed between reviews. Review of the facility's policy, titled, Nutritional Quarterly Review, revised on 07/02/18, documented the following: Quarterly Nutritional Risk Review and Quarterly Minimum Data Set should be done at least quarterly on those residents for whom dietary goals have been established through the interdisciplinary care planning process. The quarterly reviews need to correlate with the quarterly Minimum Data Set. 1. Review of the record documented Resident #2 was re-admitted to the facility on [DATE] with diagnoses that included, in part: Protein-Calorie Malnutrition, Irritable Bowel Syndrome, Anemia, Gastroesophageal Reflux Disease, and Hypertension. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated that she was moderately cognitively impaired. Review of the weights showed that Resident #2 weighed 108 pounds on 12/27/21 and 116 pounds on 03/03/22. Further review showed that there were no weights taken between 12/27/21 and 03/03/22. Review of the Care Plan, revised on 03/28/22, documented Resident #2 was at risk for compromised nutritional status and significant weight fluctuation. Interventions were to obtain and document resident weights as ordered for additional nutritional intervention. Review of the Nutrition Progress Note, dated 12/29/21, showed that the Registered Dietitian (RD) documented the following: Recommend to resume previously recommended oral supplements including Ensure and appetite stimulant Eldertonic. Review of all Physician's Orders showed that Eldertonic had not been ordered following the RD's recommendation on 12/29/21. In an interview conducted on 03/31/22 at 3:47 PM, the Certified Dietary Manager / Dietetic Technician Registered (CDM/DTR) was asked about the timing of weights upon admission and stated, I would have to check the policy for weights. According to her, all weights were documented in PointClickCare (electronic charting system). She stated that if a resident refused to be weighed, it would be documented under progress notes in PointClickCare. When asked about the weights for Resident #2, she confirmed the resident's weight was taken on 12/27/21 and on 03/03/22. When asked about nutrition supplements, the CDM/DTR stated that she and the RD were responsible for placing orders. The CDM/DTR then stated that if she recommended a nutrition supplement, she would check the orders to see if it went through. When asked about the order for Eldertonic for Resident #2 following the RD's recommendation on 12/29/21, the CDM/DTR reviewed PointClickCare and stated, I don't see that it was placed. In an interview conducted on 04/01/22 at 7:19 PM, the RD stated that upon admission, residents are to be weighed once per week for the first 4 weeks and then monthly thereafter. When asked about re-admissions, the RD stated that residents who are re-admitted to the facility would also be weighed once per week for the first 4 weeks and then monthly thereafter. According to her, weights were documented in PointClickCare. When asked about weight refusals, the RD stated, Weight refusals should be documented. I would ask the Director of Nursing (DON) where they would document that. When asked about nutrition supplements, the RD stated that the CDM or nurses would be responsible for placing the orders from her recommendations. The surveyor then informed the RD of the findings, and the RD acknowledged the findings. In an interview conducted on 04/01/22 at 10:23 AM, the DON stated that weight refusals would be documented under Health Status Progress Notes or Nutrition Progress Notes. The DON then reviewed Resident #2's Health Status and Nutrition Progress Notes from 12/27/21 to 03/03/22 and confirmed that there were no weight refusals documented. The DON acknowledged the surveyor's findings. 2. Review of the record documented that Resident #24 was admitted to the facility on [DATE] with diagnoses that included, in part: Hyperlipidemia, Hypertensive Heart Disease, Osteoarthritis, Dementia and Parkinson's Disease. Review of Section C of the MDS, dated [DATE], documented Resident #24 had a BIMS score of 03, which indicated that she was severely cognitively impaired. Review of Section G of the MDS, dated [DATE], documented that Resident #24 required limited assistance with one-person physical assist for eating. Review of the Care Plan, revised on 03/28/22, documented Resident #24 was at risk for compromised nutritional status. Interventions were for the RD to assess nutritional and hydration needs as indicated. Review of all Nutrition Progress Notes in PointClickCare showed that there was only one RD note, which was dated 05/14/21. In an interview conducted on 03/31/22 at 3:47 PM, the CDM/DTR stated that nutrition assessments were conducted according to the policy used by the facility. According to her, she was responsible for quarterly and significant change assessments, and the RD was responsible for conducting initial assessments and following up with high-risk residents. When asked where nutrition assessments were documented, the CDM/DTR stated that all notes would be documented in PointClickCare. She further stated that initial assessments, quarterly assessments, and significant change assessments would be documented under progress notes. When asked about the nutrition assessments for Resident #24, the CDM/DTR stated, I see there's one 05/14/21 from the RD. I do not see anything else. In an interview conducted on 04/01/22 at 7:19 PM, the RD stated that she conducted initial assessments and monthly assessments to check on residents with wounds, tube feeding or dialysis. When asked about the timing of assessments upon admission, the RD stated, If they are high risk, tube feeding, dialysis, or significant change, they need to be seen within 72 hours. Otherwise, I would have 7 days. Then I believe they should be seen quarterly. The RD stated that nutrition assessments would be documented in PointClickCare. When asked about the assessments for Resident #24, the RD stated, We monitor our patients at least monthly. If there's no issue, there's no reason to write a note. The RD then acknowledged that there was no documentation to show that Resident #24 had been assessed since 05/14/21. In an interview conducted on 04/01/22 at 10:23 AM, the DON acknowledged the surveyor's findings.

Based on observation and interview, the facility failed to ensure that an oxygen concentrator's (a device that delivers oxygen) filter was clean and debris free for 1 of 2 sampled residents reviewed for oxygen (Resident #7). The findings included: An observation of Resident #7 was conducted on 03/28/22 at 3:00 PM. The resident was observed awake in bed receiving oxygen therapy. Further observation of the resident's oxygen concentrator revealed a filter laden with a large amount of dust and debris. A side-by-side observation of Resident #7's oxygen concentrator with the Director of Maintenance on 04/01/22 at 12:00 PM revealed a filter laden with a large amount of dust and debris. An interview was conducted with the Director of Maintenance during the side-by-side observation. The Director of Maintenance stated he did not know who was responsible for maintaining / cleaning the oxygen filters. The Director of Maintenance stated that housekeeping cleans the oxygen concentrator when the resident is discharged / leaves the facility.

Based on observations, interviews and record review, the facility failed to follow the approved menu for 1 of 3 residents on pureed diets, which included sampled resident (Resident #37). The findings included: Review of the approved breakfast menu for pureed diets for 03/29/22 documented that the following items were to be served: pureed pancakes, pureed bread and pureed oatmeal. During an observation of the breakfast tray line conducted on 03/29/22 at approximately 7:30 AM, it was noted that the pureed bread and the pureed oatmeal were missing from the breakfast tray line. When asked about the pureed bread, Staff B, Cook, stated that pureed pancakes were to be served in place of pureed bread. The surveyor showed Staff B the approved breakfast menu which documented that both pureed bread and pureed pancakes were to be served. When asked again about the pureed bread, Staff B acknowledged that it was missing from the breakfast tray line. When asked about the pureed oatmeal, Staff B stated that she only made pureed oatmeal on Mondays, Wednesday, and Fridays, and confirmed that she did not make pureed oatmeal for the breakfast tray line on 03/29/22. The Certified Dietary Manager (CDM) acknowledged that the approved breakfast menu for the pureed diets was not being followed. Review of the facility diet census, dated 03/29/22, documented that 3 residents were on pureed diets, which included Resident #37.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide restorative nursing services as care planned for 1 of 3 sampled residents reviewed for rehabilitation (rehab), Resident #9. The findings included: Review of the record documented that Resident #9 was admitted to the facility on [DATE] with diagnoses that included: Osteoarthritis, Muscle Weakness, Dislocation of Left Shoulder, and Spinal Stenosis. Review of Section C of the Minimum Data Set, dated [DATE], documented Resident #9 had a Brief Interview for Mental Status score of 15, which indicated that she was cognitively intact. Review of the Care Plan, dated 02/07/22, documented Resident #9 was in the restorative program due to muscle weakness. Interventions included: Nursing Restorative Program for active assisted range of motion for both lower extremities, hips, knees, and ankles; both upper extremities, elbows, wrists, fingers, in all available planes of movement for 3 sets of 20 two times daily for 6-7 times weekly. In an interview conducted on 03/28/22 at approximately 12:40 PM, Resident #9 stated that she was supposed to get therapy 5 times per week but was only getting therapy 2 times per week. In an interview conducted on 04/01/22 at 8:55 AM, the Director of Rehab stated that Resident #9 was to receive restorative nursing therapy. When asked how often Resident #9 was to receive restorative nursing therapy, the Director of Rehab provided the surveyor with the Restorative Program Training Documentation form, dated 09/03/21, which documented Resident #9 was to receive restorative nursing therapy two times per day for 6-7 days per week. Review of the Nursing Restorative Program - Active Range of Motion Tasks, dated 03/03/22 - 03/31/22, showed that there was no documentation to show that therapy was provided to Resident #9 on the following days: 03/05/22, 03/07/22, 03/09/22, 03/12/22, 03/13/22, 03/14/22, 03/18/22, 03/19/22, 03/20/22, 03/21/22, 03/24/22, 03/25/22, 03/26/22, 03/27/22, and 03/28/22. Further review of the Nursing Restorative Program - Active Range of Motion Tasks, dated 03/03/22 - 03/31/22, showed that there was no documentation to show that therapy was provided to Resident #9 two times per day on the following days: 03/03/22, 03/04/22, 03/06/22, 03/08/22, 03/10/22, 03/11/22, 03/15/22, 03/16/22, 03/17/22, 03/22/22, 03/23/22, 03/29/22, and on 03/30/22. In an interview conducted on 04/01/22 at 9:07 AM, Staff C, Restorative Certified Nursing Assistant, and the Assistant Director of Nursing (ADON) stated that restorative nursing was documented under the Nursing Restorative Program - Active Range of Motion Tasks in PointClickCare (electronic charting system). According to them, this is where completion or refusal of restorative nursing services would be documented. They further stated that if a resident were to receive multiple sessions within the same day, this is also where completion or refusal of each session would be documented. Staff C and the ADON reviewed the Nursing Restorative Program - Active Range of Motion Tasks dated 03/03/22 - 03/31/22 and acknowledged that documentation to show that Resident #9 had received or refused therapy was missing. In an interview conducted on 04/01/22 at 9:30 AM, the Director of Nursing (DON) stated that Resident #9 would often refuse restorative nursing therapy. When asked for documentation of refusals, the DON stated that refusals should have been documented under the Nursing Restorative Program - Active Range of Motion Tasks. The DON acknowledged that documentation showing Resident #9 had refused restorative nursing therapy was missing. The DON then reviewed Resident #9's Care Plan, dated 02/07/22, and confirmed that there was no documentation showing Resident #9 had refused restorative nursing. The DON acknowledged that documentation to show that Resident #9 had received or refused restorative nursing therapy was missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have provisions of eggs cooked to order as menu suggests with the potential to affect all 45 residents, and the facility failed to honor a resident's choice of a lactose free diet for 1 of 18 sampled residents (Resident #154). The findings included: 1. Review of the approved 7-week cycle menus showed that egg of choice was offered as a daily breakfast option. During an observation conducted on 03/29/22 at 1:22 PM, it was noted that the walk-in cooler contained pasteurized liquid eggs and unpasteurized shell eggs. The Sous Chef stated that the pasteurized liquid eggs were used for the nursing home and that the unpasteurized shell eggs were used for the assisted living facility / independent living sections within the campus. In an interview conducted on 03/29/22 at 1:25 PM, the Certified Dietary Manager (CDM) stated that egg of choice would include the following options: sunny side up, scrambled or hardboiled. In an interview conducted on 03/29/22 at 1:59 PM, the Executive Chef stated that the facility has been unable to obtain pasteurized shell eggs. According to him, the residents would only receive pasteurized liquid eggs as they were not sending the unpasteurized shell eggs to the Nursing Home residents. The Executive Chef stated, We used to send them eggs sunny side up when we had pasteurized shell eggs, but we are not sending things like that now. If someone ordered sunny side up eggs, then we tell them that they can't order things like that now. In an interview conducted on 03/30/22 at 12:00 PM, the Executive Chef was asked when he last received pasteurized shell eggs. The Executive Chef stated, I last received them 1 truck delivery or so ago. He further stated that he usually gets 2 truck deliveries per week. According to him, if Staff B, Cook, received an order for undercooked eggs, she would not provide the resident with their choice and would send the eggs to the resident fully cooked. In an interview conducted on 03/30/22 at 12:08 PM, Staff D, Dietary Aide (DA), stated that when delivering meal trays, the dietary aides would tell the residents that they were out of their selected egg of choice. She further stated that an alternate would be provided instead. Review of the Sysco Purchase Order showed that large pasteurized shell eggs were delivered to the facility on [DATE]. Review of the Sysco (wholesale food distributor) invoice dated 03/25/22 showed that medium unpasteurized shell eggs were ordered and out of stock. Further review of the Sysco invoice dated 03/25/22 showed that large unpasteurized shell eggs were substituted and delivered to the facility on [DATE]. During an interview conducted on 03/30/22 at 12:16 PM, the Executive Chef stated that he last received pasteurized shell eggs on 03/01/22. When asked why unpasteurized shell eggs were ordered on 03/25/22, the Executive Chef stated that pasteurized shell eggs were ordered and that Sysco was out of pasteurized shell eggs and provided them with unpasteurized shell eggs instead. During an interview conducted on 03/30/22 at 12:39 PM, the Registered Dietitian (RD) stated, I think they only do scrambled eggs and omelets. I've been working for the facility since 2014 and I've never seen them undercooked. During an interview conducted on 03/31/22 at 7:27 AM, Staff B stated that she worked in the facility Monday through Friday and was responsible for preparing breakfast and lunch for the nursing home. Staff B-Cook further stated that she did not use unpasteurized shell eggs and that the facility used liquid pasteurized eggs for their recipes. Staff B stated that she was aware the unpasteurized shell eggs were in the walk-in cooler but only used liquid pasteurized eggs. She further stated, I know I'm only supposed to use pasteurized eggs for upstairs. When asked what egg of choice meant, Staff B stated it meant boiled, scrambled, or omelet. At this time, the Dining Services Director stated that they did not prepare or offer undercooked egg options even with pasteurized shell eggs. He further stated, We do not do soft boiled eggs either. The Dining Services Director then acknowledged that the approved breakfast menus needed to be updated. During an interview conducted on 03/31/22 at 8:18 AM, the Dining Services Director stated, We do not do sunny side up eggs in healthcare. We do not use unpasteurized eggs, we use liquid eggs. In an interview conducted on 03/31/22 at 10:05 AM, the RD stated that she approved the facility's menus annually. When asked what egg of choice meant, she stated, It should be egg chef choice because we don't allow long term care residents to choose eggs, we only provide them with scrambled. I don't know why it's signed with egg of choice when we offer scrambled. Our menus have always been like that. When asked about her expectations of the menu when it says egg of choice but residents are only offered scrambled. She stated, I don't know how to answer that. I'm not sure how to answer the verbiage, I can call the corporate office and see how they would like me to answer that. When asked about ordering food items for the kitchen, she stated that the Executive Chef and Dining Services Director were responsible. When asked about the unpasteurized shell eggs, she stated, In regards to this week, I know they threw away unpasteurized eggs. They should only be purchasing pasteurized eggs. In an interview conducted on 03/31/22 at 10:39 AM, the Executive Chef stated that he must have been the one who placed the order for the unpasteurized shell eggs that were delivered on 03/25/22. When asked about ordering, he stated that they order based on the product number listed on the order guide. The surveyor informed the Executive Chef that the product number on the order guide for the shell eggs did not reflect pasteurized shell eggs. The Executive Chef then stated that he did not remember if he ordered pasteurized shell eggs. Review of the Sysco invoices dated October 2021 - March 2022 showed that unpasteurized shell eggs were delivered to the facility on [DATE], 10/26/21, 11/09/21, 11/19/21, 02/08/22, and 03/25/22. Review of the Sysco Purchase Order dated 10/15/21 showed that shell eggs had not been ordered. Review of the Sysco Purchase Order dated 10/26/21 showed that medium unpasteurized shell eggs were ordered. Review of the Sysco Purchase Order dated 11/09/21 showed that medium unpasteurized shell eggs were ordered. Review of the Sysco Purchase Order dated 11/19/21 showed that no shell eggs had been ordered. Review of the Sysco Purchase Order dated 02/08/22 showed that medium pasteurized shell eggs were ordered and substituted for large unpasteurized shell eggs. Review of the Sysco Purchase Order dated 03/25/22 documented that medium unpasteurized shell eggs were ordered and substituted for large unpasteurized shell eggs. This showed that the facility did not place orders for pasteurized shell eggs in order to accommodate egg of choice as listed on the approved breakfast menus. During an interview conducted on 03/31/22 at 4:07 PM, Staff D-DA and Staff E-Dietary Supervisor were asked what they do when a resident orders soft boiled, sunny side up, poached, or undercooked eggs. Staff E stated, We really don't serve that, it's usually just what's on the menu when it says scrambled eggs. I've never allowed them to order sunny side up or poached eggs. When asked about eggs of choice, she stated that they offered omelets and eggs with cheese. When asked what types of eggs the residents could receive, they stated, Scrambled eggs, omelet, egg and cheese. Soft boiled, poached, sunny side up is not on the menu. 2. An interview was conducted with Resident #154 on 03/28/22 at 11:35 AM. Resident #154 stated he was lactose intolerant. Resident #154 stated he likes to get the facility's fruit and cottage cheese platter, but they do not offer him a lactose-free cottage cheese as requested. Record review revealed Resident #154 was admitted to the facility on [DATE]. An admission comprehensive assessment documented Resident #154 as cognitively intact. A review of Resident #154's food preferences, dated 03/11/22, documented the resident had a dislike for dairy, and to serve menu alternate. A review of Resident #154's food preferences, dated 03/29/22, documented a supplement / preference for non-dairy foods / beverages for the resident. A review of Resident #154's orders revealed an order dated 03/31/22 for Lactaid tablet every 4 hours as needed for lactose intolerance to be given with meals that contain dairy. Further review of Resident #154's record did not reveal any documentation of why the resident's food preferences documented on 03/11/22 were not followed. An interview was conducted with the Director of Nursing (DON) on 04/01/22 at 2:00 PM. The DON did not know why the resident's food preferences documented on 03/11/22 were not followed.

Based on observation and interview, the facility failed to maintain the laundry room in a clean and sanitary manner; failed to have a dedicated clean linen utility chest for 5 of 5 clean utility chests; and failed to provide and encourage hand sanitation prior to meal intake for 2 of 20 sampled residents observed in the dining room, Resident #153 and #35. The findings included: A review of the facility's policy Infection Prevention and Control Program for Skilled Communities, dated 08/2018, documented: Hand hygiene means cleaning your hands with soap and water, antiseptic hand wash, antiseptic hand rub, or surgical hand asepsis. Key situations where hand hygiene should be performed included before eating and after handling soiled linen. 1. During Dining observation on 03/28/22 at 12:30 PM, Resident #35 was observed sitting in the dining room. Resident #153 was observed entering into the dining room and sitting at the same table as Resident #35. Resident #153 was observed eating a bowl of soup at 12:40 PM. Both residents were observed eating their lunch entrees at 1:25 PM. Resident #35 and Resident #153 were questioned if staff ensured or encouraged hand hygiene prior to eating meals. Both residents denied encouragement of hand hygiene prior to eating the meal. An interview was conducted with the Director of Nursing on 04/01/22 at 1:00 PM. The DON confirmed residents should be encouraged to perform hand hygiene prior to eating. 2. A tour of the laundry room was conducted with the Director of Housekeeping and the Nursing Home Administrator on 04/01/22, beginning at 12:00 PM. During the tour, the following was observed: a) Two light fixtures in the ceiling with dirt and debris in the storage room. b) Two laundry carts with dirt and debris on the bottom. c) Staff G, a laundry technician, was observed bringing in a dirty laundry bin, containing dirty linen. Staff G was observed leaving the laundry room without washing his hands. d) Two dirty mop heads were observed in the personal clothing dirty laundry bin. e) Chipped paint was observed on the wall directly adjacent to the clean linen folding table and clean personal clothes hamper/rack. An observation of 5 of 5 of the clean linen utility chests with the Director of Housekeeping and the Nursing Home Administrator on 04/01/22, starting at 12:15 PM revealed: miscellaneous personal socks, clothing, a metal tin with puzzle pieces inside and styrofoam cups. An interview was conducted with the Director of Housekeeping was conducted on 04/01/22 at 12:30 PM. The Director acknowledged the above. The Director stated no personal clothing or personal items should be stored in the clean linen utility chests.

Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions. The findings included: 1. During the initial tour of the kitchen conducted on 03/28/22 at 8:57 AM, accompanied by the Executive Chef, the following was noted: a. One chain lanyard with about 10 keys and one orange notebook were stored on top of the food preparation table. The Executive Chef stated that he had placed these items on top of the food preparation table prior to the surveyor's entrance to the kitchen. b. In the walk-in cooler, about 20 condiment cups containing red sauce were missing labels identifying the product name and use by date. c. In the walk-in cooler, the floor was observed with brown residue and cracked floor panels. d. One light bulb in the walk-in cooler was out. e. In the dry storage area, about 8 boxes containing food products (ice cream cones, saltine crackers, miniature marshmallows, barbecue sauce, cheesecake mix, and soda cans) were stored on top of a wooden pallet. The Executive Chef acknowledged that they should not have been stored on a wooden pallet that was not designed to be easily cleanable for shelving. f. In the dry storage area, one 46 fluid ounce carton of Imperial mildly thick nectar consistency thickened apple juice from concentrate had a use by date of 03/22/22. g. In the dry storage area, two 6.5 pound cans of whole white potatoes, one 6 pound can of apricots in light syrup, and one 105 ounce can of peach halves were dented. 2. During the tour of the second floor satellite kitchen conducted on 03/28/22 at 9:27 AM, accompanied by Staff A, Dietary Aide, and the Certified Dietary Manager (CDM), the following was noted: h. At the request of the surveyor, the CDM checked the chemical concentration of the sanitation bucket located near the handwashing sink using the facility's test strips. The concentration was recorded between 700-848 parts per million (ppm). The CDM stated that the chemical concentration should have been between 272-700 ppm. The CDM acknowledged that a high chemical concentration of 700-848 ppm would result in a toxic chemical residue that would remain on the surface of the products being cleaned. i. The reach-in freezer was observed with an approximately 4-inch tear in the gasket on the door. j. The reach-in refrigerator was observed with 2 approximately 1-inch tears in the gasket on the bottom left door. k. One metal container of thickener powder was observed with a condiment cup inside. The CDM and Staff A acknowledged that the condiment cup/scoops should not be stored inside the container with food products. l. One box of 1000 count plastic lids was stored directly on the floor of the dining room. The CDM acknowledged that the box of plastic lids should not have been stored directly on the floor. Following the tour, the surveyor informed the CDM of all findings and the CDM acknowledged all findings. 3. During an observation of the breakfast tray line conducted on 03/29/22 at approximately 7:30 AM, accompanied by Staff A and the CDM, the following was noted: m. Two clean steam table lids were observed with food residue. Staff A stated that the steam table lids were supposed to be placed in the dishwasher at the end of each meal service. Staff A further stated that she did not take the steam table lids out of the dishwasher that morning because they were already on the tray line. The CDM acknowledged that the clean steam table lids were dirty.