Based on observations, staff interviews, record review and review of the facility's document titled, Water Management Plan, the facility failed to ensure residents were free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit (F) in seven out of 49 shared resident bathrooms (Room A-12, C-10, C-12, D-2, D-3, D-5, D-6). The deficient practice had the potential to cause injury to residents residing in these rooms.Findings include:Review of the facility's document titled Water Management Plan, dated 8/23/2024, Under the section titled Risk Factor: Water Heater revealed that the lower control limit for hot water heaters should not be below 122 F, and the upper control limit should not exceed 140 F.During observation on 7/29/2025 from 1:15 pm to 1:40 pm with the Environmental Manager, water temperature checks were conducted on A, B, and D corridors using a non-digital meat thermometer that revealed the following water temperatures: Room A-12: 130 F, Room C-10: 117 F, Room C-12: 120 F, Room D-2: 130 F, Room D-3: 140 F, Room D-5: 138 F, and Room D-6: 128 F. A follow-up observation was conducted on 7/29/2025 at 5:40 pm revealed, the following adjusted water temperatures: Room A-12: 100.3 F, Room C-10: 100 F, Room C-12: 100 F, Room D-2: 85 F, Room D-3: 95 F, Room D-5: 106 F, and Room D-6: 87 F.A review of facility water temperature logs showed that the water temperature checks had not been completed during the weeks of 7/21/2025 and 7/14/2025. Water temperature logs from earlier weeks (7/7/2025, 6/30/2025, 6/23/2025, 6/9/2025, 5/19/2025, and 5/12/2025) indicated temperature ranges between 105 F and 110 F. An interview conducted on 7/29/2025 at 1:25 pm with the Environmental Manager confirmed that weekly water temperature checks had not been conducted for two weeks. Further review of the facility's records confirmed that no residents sustained burn injuries related to hot water temperatures. In addition, the facility implemented new procedures to ensure compliance and resident safety: Thermometers were provided to housekeeping staff for regular temperature checks; Shower rooms were equipped with thermometers for monitoring water temperatures before use; In-service education on water temperature management was conducted on 7/29/2025 for the shower team, housekeeping, and laundry staff. A service invoice dated 7/31/2025 from Rapid Flow Plumbing revealed repairs to the water heaters. The invoice noted that water heater # (number) 1 could not be adjusted below 120 F and was temporarily connected to water heater #2. New copper water lines and ball valve cut-off valves were installed, and the water temperature was set to 110 F. Further review revealed, the plumber planned to return to install a new mixing valve at water heater #1 during week of 8/4/2025. Until this time the Administrator stated all showers would be conducted in shower room on front hall. Hot water to rooms served by this mixing valve was turned off until repair was completed.During an interview on 7/30/2025 at 3:30 pm, with the Administrator revealed that a new hire to fill the role of Maintenance Director at the facility should start during the week of 8/4/2025.

Based on staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to develop a comprehensive care plan that addressed activity preferences and accurately reflect the level of assistance required with transfers for one out of 37 sampled Residents (R) (R#17) reviewed for care plans. Findings include: A review of the facility's policy titled Care Plans, dated 7/27/2023, under the section titled admission Comprehensive Plan of Care revealed, 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following- The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Under the section titled Care Plan Review and Update revealed, 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change occurred. For MatrixCare [electronic medical record] users, all updates are made electronically. Further review revealed, 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. A review of R #17's Resident Face Sheet revealed the facility admitted R#17 with diagnoses that included type 2 diabetes mellitus, polyneuropathy, anxiety disorders, dysuria, and muscle weakness. A review of R#17's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/29/2024, revealed R#17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed R#17 was dependent on staff for transfers, toileting hygiene, going from sitting to standing, and from lying to sitting on the side of the bed. A review of R#17's Care Plan revealed a Problem statement dated 5/24/2023, which indicated that R #17 required assistance with activities of daily living related to impaired mobility and generalized weakness. Further review of the care plan revealed nothing was indicated for the level of assistance required with transferring and no problem or goal statements were written that addressed activities. A review of R#17's Activity Assessment dated 1/30/2024 revealed the resident preferred activities in their own room with the most common use of the resident's time being spent watching TV and visiting with family. Per the activity assessment, barriers to participation included the ability to understand, ambulation/mobility, and physical endurance. During an interview on 3/6/2024 at 4:04 pm, Certified Nurse Aide (CNA) #1 stated he knew what type of assistance residents required from their care plan. CNA #1 stated R#17 required total assistance with a mechanical lift, and he did not see anything in the care plan addressing how the resident was transferred. During an interview on 3/7/2024 at 7:55 am, CNA #5 stated she would find out what care a resident needed from reviewing the residents' care plan and from communication with other staff. During an interview on 3/7/2024 at 9:12 am, the Activity Director (AD) stated the MDS Coordinator was responsible for the care plans. During an interview on 3/7/2024 at 10:24 am, CNA #6 stated staff were to read the care plan for the amount of assistance a resident required and if the care plan were wrong the resident could get hurt. During an interview on 3/7/2024 at 10:30 am, Licensed Practical Nurse (LPN) #2 stated the amount of care and assistance required for a resident should be in their care plan. LPN #2 stated if something was not written in the care plan, the CNAs should ask a nurse and if the care plan was incorrect, the nurse should correct it. LPN #2 confirmed that R#17 required a mechanical lift to be transferred. LPN #2 stated she did not know what R#17's care plan had written on it but if care plans were inaccurate residents could be hurt. During an interview on 3/7/2024 at 10:35 am, LPN #7 stated the CNAs knew the amount of assistance a resident needed from reviewing the care plan. LPN #7 stated if a care plan was incorrect, the MDS Coordinator was responsible for correcting the care plans. LPN #7 stated if a care plan were inaccurate a resident injury could occur. During an interview on 3/7/2024 at 10:49 am, LPN #8 stated the amount of assistance a resident required was in their care plan. LPN #8 stated if the care plan was missing information or incorrect it was a problem and either a nurse or the MDS Coordinator should have corrected it immediately. During an interview on 3/7/2024 at 11:02 am, the MDS Coordinator stated she developed and updated care plans based on MDS assessments and from visiting with the resident. The MDS Coordinator stated the care plan should be developed or updated as care needs changed but at least quarterly. The MDS Coordinator stated she had been helping with the activity care plans and all residents should have an activity care plan, so staff knew what activities a resident liked. The MDS Coordinator stated care plans indicated the amount of assistance a resident required. The MDS Coordinator confirmed that R#17's care plan did not reveal the amount of assistance required for transfers. The MDS Coordinator stated it was important for care plans to be accurate, so staff knew if a resident had a decline. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated her expectation was that care plans were based on the MDS assessment and developed or updated whenever a resident had a change in condition. The DHS stated a nurse, a department head, or the MDS Coordinator could have updated a care plan. The DHS stated that CNAs used care plans to provide care to residents and if the care plan was incorrect a resident could have received the wrong care. The DHS confirmed that Resident #17's care plan did not address transfer status or activities. The DHS stated the care plan should address transfer status and activities. During an interview on 3/7/2024 at 11:57 am, the Administrator stated he expected the DHS to manage care plans.

Based on staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure that resident care plans were revised to include appropriate interventions for two out of 37 sampled Residents (R) (R#10 and R #17) reviewed for care plans. Findings include: A review of the facility's policy titled Care Plans, dated 7/27/2023 under the section titled Care Plan Review and Update revealed, 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA [Omnibus Budget Reconciliation Act] MDS [Minimum Data Set] schedule, following the completion of the assessment. Care plan updates/ reviews will be performed within 7 days of each quarterly assessment, each acute change, and as needed following each hospital stay. 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. For MatrixCare users, all updates are made electronically. 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. 1. A review of a facility policy titled Occurrences, dated 1/11/2024 under the section titled Policy Statement revealed, The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risk. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Under the section titled Investigation and Follow-up revealed, 5. The licensed nurse will be responsible for updating the patient/resident's care plan with appropriate occurrence prevention interventions. 6. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. A review of R#10's Resident Face Sheet revealed the facility admitted R #10 with diagnoses which included Alzheimer's disease, primary generalized (osteoporosis) arthritis, unspecified dementia with behavioral disturbance, polyneuropathy, muscle weakness, anxiety disorder, and difficulty in walking. A review of R #10's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/24/2024, revealed a Staff Assessment for Mental Status (SAMS) that indicated the resident had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. A review of R #10's Care Plan, with a Problem statement dated 12/24/2021, revealed that R#10 was at risk for falls related to impaired mobility, impaired cognition, and a history of falls. An intervention initiated on 1/24/2024 directed staff to keep the resident's call light within reach. Further review of the Care Plan revealed an intervention dated 12/14/2022 that revealed R#10 was unable to be educated on using a call light for assistance due to their cognitive impairment. A review of an Event Report dated 1/23/2024 revealed R#10 had an unwitnessed fall in their room without injury. Per the report, an intervention measure was check marked, which denoted the box other-up into BRODA CHAIR [type of geriatric wheelchair] was the measure taken. A review of a Resident Progress Notes dated 1/22/2024 at 7:21 pm revealed R#10 had an unwitnessed fall and was found sitting on the floor at the foot of their bed. Per the note, the Certified Nurse Aide (CNAs) had not gotten R #10 up because they were waiting for the resident to get a shower. A review of an Event Report dated 1/12/2024 revealed R#10 had an unwitnessed fall in their room without injury. Per the report, intervention measures taken had a check-marked box that denoted None of Above measures were implemented. The report revealed that under the section titled Describe measures, if necessary, staff had documented N/A [not applicable]. A review of Resident Progress Notes dated 1/12/2024 at 5:55 pm revealed that a CNA had assisted the resident on the toilet to help with incontinence care. The note revealed that the CNA went to get the resident's incontinence supplies and clothes when the resident tried to stand up and walk. Per the note, the resident then fell on the floor. A review of R#10's Care Plan revealed interventions for falls were not updated after the resident's fall on 1/12/2024. During an interview on 3/7/2024 at 10:10 am, Licensed Practical Nurse (LPN) #9 stated that when a resident had a fall, she updated the care plan with an intervention to prevent a future fall. LPN #9 stated that changes regarding the residents' care plans were communicated to CNAs verbally, or they looked at the residents' care plans. LPN #9 stated she worked on 1/12/2024 and had responded to R#10's fall. LPN #9 stated CNA #18 had stepped away from the resident to gather supplies when R#10 fell. LPN #9 stated the intervention that was put into place following R#10's fall on 1/12/2024 was when CNAs assisted the resident to the bathroom; they had to make sure supplies were within reach and not leave the resident alone. LPN #9 stated she did not put that new intervention in R#10's care plan. LPN #9 stated she also worked on 1/22/2024 and was called to R#10's room to assess the resident, who was found lying on a floor mat. LPN #9 stated it was R#10's shower day, and an intervention after the 1/22/2024 fall was to make sure if the resident was awake to get the resident up and out of bed on shower days. LPN #9 stated that follow-up after the fall consisted of ensuring R #10's bed was in a low position, and a floor mat was put in place. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) stated that following a resident fall, it was expected that licensed nursing staff added an intervention to the resident's care plan. DHS stated that each resident's fall was investigated and reviewed with the clinical team to ensure that any follow-up interventions needed were added to the resident's care plan. The DHS stated that R #10's care plan was not updated with an intervention following the 1/12/2024 fall. The DHS stated that R#10's care plan was updated with an intervention of having a call light within reach, but that was not a good intervention for R#10 as the resident was unable to use a call light. During an interview on 3/7/2024 at 3:55 pm, The Administrator stated he expected interventions to be determined after a resident falls, and interventions should be added to a resident's care plan. Cross Reference F689 2. A review of R#17's Resident Face Sheet revealed the facility admitted R #17 with diagnoses that included type 2 diabetes mellitus, polyneuropathy, anxiety disorders, dysuria, and muscle weakness. A review of R#17's Quarterly MDS, with an Assessment Reference Date (ARD) of 1/29/2024, revealed R #17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed R#17 was dependent on staff for transfers, toileting hygiene, going from sitting to standing, and from lying to sitting on the side of the bed. The MDS further revealed R#17 was always incontinent of bowel and bladder. A review of R #17's Care Plan revealed a Problem statement dated 5/24/2023, which indicated that R #17 had occasional incontinence episodes and required assistance with toileting and toileting hygiene. The Care Plan revealed a Problem statement dated 5/24/2023 which indicated that the resident was at risk for falls. Interventions directed staff to ensure the resident was wearing nonskid socks when ambulating. During an interview on 3/6/2024 at 4:04 pm, Certified Nursing Assistant (CNA) #1 stated he knew what type of assistance residents required from their care plan. CNA #1 confirmed that R#17's care plan revealed the resident had occasional incontinence and needed assistance with toileting. CNA #1 stated R #17 was always incontinent of bowel and bladder. CNA #1 stated the care plan for R #17 had not been updated because the plan listed non-skid socks and the resident no longer ambulated. During an interview on 3/7/2024 at 7:55 am, CNA #5 stated she would find out what care a resident needed from reviewing the residents' care plan and from communication with other staff. During an interview on 3/7/2024 at 10:30 am, Licensed Practical Nurse (LPN) #2 stated the amount of care and assistance required for a resident should be in their care plan. LPN #2 confirmed that R #17 was always incontinent of bowel and bladder. LPN #2 stated she did not know what R#17's care plan had written on it but if care plans were inaccurate residents could be hurt. During an interview on 3/7/2024 at 10:35 am, LPN #7 stated the CNAs knew the amount of assistance a resident needed from reviewing the care plan. LPN #7 stated if a care plan was incorrect, the MDS Coordinator was responsible for correcting the care plans. LPN #7 stated if a care plan were inaccurate a resident injury could occur. During an interview on 3/7/2024 at 10:49 am, LPN #8 stated the amount of assistance a resident required was in their care plan. LPN #8 stated if the care plan was missing information or incorrect it was a problem and either a nurse or the MDS Coordinator should have corrected it immediately. During an interview on 3/7/2024 at 11:02 am, the MDS Coordinator stated she developed and updated care plans based on MDS assessments and from visiting with the resident. The MDS Coordinator stated the care plan should be updated as care needs changed but at least quarterly. The MDS Coordinator stated care plans indicated the amount of assistance a resident required. The MDS Coordinator confirmed that R #17's care plan was listed inaccurately for the resident's incontinence status. The MDS Coordinator stated it was important for care plans to be accurate, so staff knew if a resident had a decline. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated her expectation was that care plans were based on the MDS assessment and updated whenever a resident had a change in condition. The DHS stated a nurse, a department head, or the MDS Coordinator could have updated a care plan. The DHS stated that CNAs used care plans to provide care to residents and if the care plan was incorrect a resident could have received the wrong care. The DHS confirmed that R#17's care plan was incorrect regarding their incontinence status. During an interview on 3/7/2024 at 11:57 am, the Administrator stated he expected the DHS to manage care plans.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Medication Administration: General Guidelines, the facility failed to ensure that care and services were provided according to accepted standards of clinical practice. The facility failed to document medication administration of an as-needed (PRN) pain medication in a timely manner for one out of 37 sampled Residents (R) (R#8) reviewed for medication administration. Findings include: A review of the facility's policy titled Medication Administration: General Guidelines, dated 4/10/2019, under the section titled Policy Statement revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices. Under the section titled Procedure revealed, 9. Only the licensed or legally authorized personnel that prepare a medication may administer it. This individual records the administration on the patient/resident's MAR [Medication Administration Record] at the time the medication is given. 12. When PRN [pro re nata; as needed] medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. A review of a facility Inservice Education Program Summary Record Form, dated 4/10/2023, revealed, MARS must match your narcotic books, when you administer a narcotic you must sign it off on the MAR immediately as well as sign it out in the narcotic book. A review of R#8's Resident Face Sheet revealed the facility admitted with diagnoses that included osteoarthritis and chronic pain. A review of R#8's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident had an active diagnosis of arthritis. The MDS revealed the resident had experienced occasional pain and received PRN pain medication within five days of the assessment. A review of R#8's Care Plan revealed a Problem area with a start date of 9/28/2023 that indicated the resident had pain related to diagnoses of osteoarthritis (OA), diabetes mellitus type two (DMII), muscle weakness, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Interventions included the administration of pain medications per physician's orders. A review of R#8's Physician Order Report revealed an order dated 12/30/2023 for hydrocodone-acetaminophen (a narcotic pain medication) 7.5-325 milligrams (mg) one tablet by mouth every six hours as needed for chronic pain. During an observation and interview on 3/5/2024 at 1:30 pm, Licensed Practical Nurse (LPN) #9 placed a round white pill into a medication cup. LPN #9 then took this medication into R#8's room and administered the medication to the resident. LPN #9 said the medication was a pain medication for R#8. During an interview on 3/5/2024 at 3:13 pm, R#8 said they received hydrocodone from LPN #9 earlier that day. A review of the MAR for R#8 revealed LPN #9 had documented the administration of hydrocodone-acetaminophen 7.5/325 milligram (mg) at 9:51 pm on 3/5/2024. This was the only documented administration of hydrocodone to R#8 on 3/5/2024. A review of the Controlled Drug Record revealed LPN #9 had documented the administration of R#8's prescribed hydrocodone 7.5/325 mg at 6:00 pm on 3/5/2024. There was no additional documentation indicating any other doses of hydrocodone were removed from the medication cart on 3/5/2024. During an interview on 3/6/2024 at 8:31 am, the Director of Health Services (DHS) said the time written in the Controlled Drug Record should be the time the medication was given. She said she expected the nurse to document the actual time the medication was given on the MAR. The DHS said LPN #9 had issues with documentation in the past. She said LPN #9 stayed late on 3/5/2024 to document and said that was why the MAR showed a 9:51 pm administration time. She said the MAR showed the time the documentation was completed but should have reflected the actual time the medication was given. During a phone interview on 3/6/2024 at 8:32 am, LPN #9 said the medication given to R#8 on 3/5/2024 at 1:30 pm was hydrocodone. She said she thought she documented the administration of hydrocodone in the MAR. She said she could not document in the computer located on the medication cart and documented the administration of the medication later that day. Regarding the Controlled Drug Record, which showed the only time hydrocodone was given on 3/5/2024 was at 6:00 pm, LPN #9 said that was a new sheet and said there was a completed Controlled Drug Record that may show the documentation of the observed 1:30 pm dose. She said completed Controlled Drug Record sheets were placed in the unit manager box at the nurse's desk. During an observation and interview on 3/6/2024 at 8:42 am, the DHS looked in the unit manager box for a completed Controlled Drug Record for R#8's prescribed hydrocodone-acetaminophen. She could not find the record. An additional staff member, LPN #8, said she would continue looking for the document. During an interview on 3/6/2024 at 10:12 am, LPN #8 said they were not able to find the completed Controlled Drug Record for R#8's hydrocodone. During an observation and interview on 3/6/2024 at 10:22 am, LPN #7 compared R#8's hydrocodone tablet count in the medication cart to the documentation found on the available Controlled Drug Record with only two entries. LPN #7 verified that the count was correct at 57. She said she would document the administration of a medication in the MAR when the medication was given. She said when administering a controlled medication, the nurse should document the time the medication was administered in the MAR and the Controlled Drug Record. LPN #7 said the MAR and the Controlled Drug Record should match. She said the MAR would automatically timestamp the document at the time the documentation was completed. LPN #7 said there was no option to document a late entry for a PRN medication, only for scheduled medications, which prompted the nurse to document a reason for administering a scheduled medication late. She said that could throw things off. LPN #7 said if an administered pain medication was documented late, it could cause confusion when nurses on the night shift look to see if enough time had passed since the last dose to administer another needed dose. She said if a resident requested a PRN pain medication, she would look in the MAR for the last time the medication was documented as given. LPN #7 said she would give the completed Controlled Drug Records to the unit manager. During an interview on 3/7/2024 at 9:35 am, the Administrator said the timeliness of medication administration was important. The Administrator said documentation of medication administration should be done shortly after the medication was given. During an interview on 3/7/2024 at 10:40 am, LPN #9 added that she administered a second dose of hydrocodone to R#8 on 3/5/2024 in the evening between 6:30 pm and 7:00 pm. She said she only documented the second dose of hydrocodone given and completed the documentation later that day. LPN #9 said the documentation was in the MAR and that she should have documented the first dose of hydrocodone after administering it as well. LPN #9 stated the documentation found in the MAR for 9:51 pm on 3/5/2024 and the documented time of 6:00 pm on 3/5/2024 on the Controlled Drug Record was for the second dose of hydrocodone given. Cross Reference F880

Based on observations, staff and resident interviews, record review, review of the facility's policy titled Resident Rights, the facility failed to provide incontinence care for a resident who requested it. Specifically, the facility failed to provide incontinence care during mealtime for one out of 37 sampled Residents (R) (R#17) reviewed for activities of daily living. Findings Include: A review of the facility's policy titled Resident Rights, dated 12/1/2023, Under the section titled RESPECT AND DIGNITY revealed, You have the right to be treated with respect and dignity, including, c. The right to reside and receive services in the center with reasonable accommodation of your needs and preferences except when to do so would endanger your health and safety or that of other patients. A review of R#17's Resident Face Sheet revealed the facility admitted R#17 with diagnoses that included type 2 diabetes mellitus, polyneuropathy, anxiety disorders, dysuria, and muscle weakness. A review of R#17's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/29/2024, revealed R#17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed that R#17 depended on staff for transfers, toileting hygiene, going from sitting to standing, and from lying to sitting on the side of the bed. The MDS further revealed R#17 was always incontinent of bowel and bladder. A review of R#17's Care Plan revealed a Problem statement dated 5/24/2023, which indicated that R#17 had occasional incontinence episodes and required assistance with toileting and toileting hygiene. Further review revealed a Problem statement dated 5/24/2023, which indicated that R#17 required assistance with activities of daily living related to impaired mobility and generalized weakness. During an interview on 3/6/2024 at 12:53 pm, R#17 stated they had told staff not to bring in their lunch tray until after staff provided incontinence care. During an observation on 3/6/2024 at 12:55 pm, Certified Nurse Aide (CNA) #1 took R#17's tray into the resident's room. R#17 was heard telling CNA #1 that they did not want their tray until after someone had provided incontinence care. CNA #1 left the meal tray on the overbed table and exited the room. During an observation on 3/6/2024 at 1:03 pm, R#17's call light was on, and CNA #1 entered the resident's room at 1:04 pm, turned the call light off, and exited the room. During an interview on 3/6/2024 at 1:05 pm,, CNA #1 stated he had checked on R#17's roommate when he entered the room. CNA #1 stated they could not provide incontinence care during meals. CNA #1 stated he would have to wait until R#17's roommate was done eating before he could provide incontinence care to R#17. During an interview on 3/6/2024 at 1:07 pm,, Licensed Practical Nurse (LPN) #2 stated incontinence care could not be provided while meal trays were in the room. LPN #2 stated a CNA had gone in to change R#17 before the meal. LPN #2 stated once R#17's roommate was done eating, they could remove R#17's tray, provide incontinence care, and then take the meal tray back in the room. During an observation and interview on 3/6/2024 at 1:45 pm,, CNA #3 was observed leaving R#17's room. CNA #3 stated she had provided incontinence care to R#17 before lunch and did not know if they needed incontinence care at that time, but the resident was eating. During the interview, CNA #3 opened R#17's door and asked if they needed incontinence care, and R#17 stated they did not need it now. CNA #3 stated that if a resident needed incontinence care during a meal, she removed the food from the area, closed both curtains and provided care. During an interview on 3/7/2024 at 7:48 am, CNA #4 stated staff were not supposed to provide incontinence care during mealtimes while someone else was eating. CNA #4 stated if someone requested incontinence care, she would ask them to wait until everyone was done eating. During an interview on 3/7/2024 at 7:55 am, CNA #5 stated if a resident needed incontinence care during a meal, she removed the food tray and provided the care. CNA #5 stated if a resident had a roommate, she would ask the roommate if they wanted to leave the room or move to the dining room while the roommate received incontinence care. CNA #5 stated she tried to make sure everyone was provided incontinence care before meals, so this issue did not happen frequently. During an interview on 3/7/2024 at 10:24 am, CNA #6 stated if a resident requested incontinence care during mealtime and the food trays were not in the room, she would provide the care. CNA #6 stated if the resident had a roommate who was eating, the resident would have to wait for incontinence care until the roommate was done eating because of cross-contamination. CNA #6 stated she was not sure how long a resident would have to wait for incontinence care during mealtime. During an interview on 3/7/2024 at 11:36 am, LPN #7 stated there was no specific policy on providing incontinence care during mealtime. LPN #7 stated staff should remove the tray from the resident who needed incontinence care, close the curtain, and then provide care to the resident. LPN #7 stated staff should provide incontinence care before meals to avoid this becoming an issue. During an interview on 3/7/2024 at 10:49 am, LPN #8 stated if a resident required incontinence care during meals and there were no trays in the room, staff could have provided care before the meal tray was delivered. LPN #8 stated that if a meal tray had already been delivered, staff could ask the roommate to step out, go to the dining room, or just cover their food, but staff should never deny a resident incontinence care. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated it was the resident's right not to sit in a bowel movement. The DHS stated if food was already in the room and the resident had a roommate, the roommate should be asked if they would like to leave the room or get permission to provide incontinence care to their roommate during their meal. The DHS stated she educated the staff on providing incontinence care before mealtimes to minimize this issue. During an interview on 3/7/2024 at 11:57 am, the Administrator stated his expectation for incontinence care during meals was that either the roommate could leave the room or the resident who required incontinence care could be taken out of the room for care. The Administrator stated residents should not have to wait for incontinence care.

Based on staff interviews, record review, and review of the facility's document titled Position Description, the facility failed to ensure they employed a qualified Activity Director (AD) for the facility. This deficient practice had the potential to affect all the residents residing in the facility. The facility census was 67 residents. Findings include: A review of the facility's document titled Position Description for the Activities Director dated November 2016, under the section titled, JOB PURPOSE revealed, Assumes administrative authority, responsibility, and accountability for the provision of a program of activities designed to meet the interest and enhance the functional abilities and self-esteem of each Resident. Manages employees to provide Recreation Services according to the facility's philosophy. In collaboration with the Administrator, allocates resources in an efficient and economic [sic] manner to ensure each resident achieves the highest practicable physical, mental, and psychosocial well-being. MINIMUM EDUCATION REQUIRED: Minimum two (2) years college education with courses in recreation, education, social work, other behavioral sciences or clinical services. MINIMUM EXPERIENCE REQUIRED: Two (2) years' [sic] experience in a social or recreational program within the past five years, with one (1) year full-time employment in a resident activities program in a long term [sic] health care [sic] setting; or, One (1) year in a supervisory role within a recreation program. MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW: Eligible for certification as therapeutic Recreational Specialist or as an Activities professional by a recognized accrediting body. ADDITIONAL QUALIFICATIONS: (preferred qualifications) Qualified as an Occupational Therapist or Occupational Therapist Assistant, or satisfactory completion of an approved training course in state [sic] of employment. Under the section titled KNOWLEDGE, SKILLS, ABILITIES revealed, Attend and participate in continuing education programs to keep abreast of changes in your field as well as to maintain current license/certification, as required. A review of the facility's AD personnel file revealed a document titled New Hire, Rehire and/or Transfer, effective 6/29/2023. During an interview on 3/7/2024 at 12:09 pm, the AD indicated that she had worked in the AD role since July 2023 but had to take off for three months (October, November, and December 2023) for personal reasons. The AD stated that she had worked in a social or recreation role in a nursing home setting for a total of five months. The AD stated that she had no formalized training pertaining to the AD role. During an interview on 3/7/2024 at 12:44 pm, the AD stated that there was no plan in place for her to receive formal training for her role. The AD stated that she was unaware of the regulations pertaining to the activity department; however, she was aware that food brought in and served to the residents needed to be store-bought. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) stated that she was unaware of the requirements for an AD. The DHS stated that there was no plan for the AD to receive formalized training for the AD role. During an interview on 3/7/2024 at 3:40 pm, the Administrator stated that he was not 100% [percent] sure of the requirements for an AD. The Administrator stated that he would expect the qualifications, experiences, and education of the facilities AD to match the regulation requirements.

Based on staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to develop, implement, and document appropriate interventions to prevent further falls for one out of 37 sampled Residents (R) (R#10) reviewed for accidents. Findings include: A review of the facility's policy titled Occurrences, dated 1/11/2024, under the section titled Policy Statement revealed, The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risk. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Under the section titled Investigation and Follow-up revealed, 1. Occurrence investigation and follow-up is a joint responsibility within the healthcare center. 2. Communication between all parties is essential for identifying the events and circumstances that resulted in the occurrence and for identifying interventions that limit the risk of the occurrence being repeated. 4. The licensed nurse will be responsible for notifying the Director of Health Services and the Occurrence Reduction Coordinator of all occurrences. 5. The licensed nurse will be responsible for updating the patient/resident's care plan with appropriate occurrence prevention interventions. 6. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. A review of the Resident Face Sheet for R#10 revealed the resident was admitted with diagnoses which included Alzheimer's disease, primary generalized (osteoporosis) arthritis, unspecified dementia with behavioral disturbance, polyneuropathy, muscle weakness, anxiety disorder, and difficulty in walking. A review of the Quarterly Minimum Data Set (MDS) for R#10, with an Assessment Reference Date (ARD) of 1/24/2024, revealed a Staff Assessment for Mental Status (SAMS) that indicated the resident had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. A review of the Care Plan, with a Problem statement dated 12/24/2021 for R#10, revealed that R#10's was at risk for falls related to impaired mobility, impaired cognition, and a history of falls. Interventions included: - Initiated 1/24/2024, staff were directed to keep the resident's call light within reach, - Initiated 9/18/2023, staff were directed to place a mat at bedside, - Initiated 7/23/2023, staff were directed to have the resident up in a geriatric wheelchair for comfort/positioning, - Initiated 6/19/2023, staff were directed to assist the resident to position away from the edge of the bed as needed, - Initiated 6/10/2023, staff were directed to keep the resident within sight when noted to be more active during the day, - Initiated 3/15/2023, staff were directed to assist in keeping the resident's bed in a lower position, and -Initiated 12/14/2022, staff were directed to observe the resident frequently for performing unassisted activities of daily living and to assist with activities of daily living as needed. Further review of the Care Plan revealed an intervention dated 12/14/2022 that revealed she was unable to be educated on using a call light for assistance due to their cognitive impairment. A review of an Event Report dated 1/12/2024 revealed R#10 had an unwitnessed fall in their room without injury. Per the report, intervention measures taken had a check-marked box that denoted None of Above measures were implemented. The report revealed that under the section titled Describe measures, if necessary, staff had documented N/A [not applicable]. A review of Resident Progress Notes dated 1/12/2024 at 5:55 pm revealed that a CNA had assisted the resident on the toilet to help with incontinence care. The note revealed that the CNA went to get the resident's incontinence supplies and clothes when the resident tried to stand up and walk. Per the note, the resident then fell on the floor. A review of a Resident Progress Notes dated 1/22/2024 at 7:21 pm revealed she had an unwitnessed fall and was found sitting on the floor at the foot of their bed. Per the note, the Certified Nurse Aide (CNAs) had not gotten R#10 up because they were waiting for the resident to get a shower. A review of an Event Report dated 1/23/2024 revealed she had an unwitnessed fall in their room without injury. Per the report, an intervention measure was check marked, which denoted the box other-up into BRODA CHAIR [type of geriatric wheelchair] was the measure taken. During a telephone interview on 3/7/2024 at 9:40 am, CNA #18 stated she was in the room with R#10 when the resident fell on 1/12/2024. CNA #18 stated she was assisting R#10 to the bathroom and the resident became agitated and fell. CNA #18 stated she notified a nurse that R#10 had fallen. CNA #18 stated fall interventions in place prior to R#10's fall on 1/12/2024 included a fall mat and putting the resident in a Broda chair so the resident could relax. During an interview on 3/7/2024 at 10:10 am, Licensed Practical Nurse (LPN) #9 stated that when a resident had a fall, she assessed the resident, took vitals, looked for an injury, got the resident off the floor, notified the doctor and the Director of Health Services (DHS), called the resident representative, entered a progress note or event note/fall report, and updated the care plan with an intervention to prevent a future fall. LPN #9 stated that changes regarding the residents' care plans were communicated to CNAs verbally, or they looked at the residents' care plans. LPN #9 stated she worked on 1/12/2024 and had responded to R#10's fall. LPN #9 stated CNA #18 had stepped away from the resident to gather supplies when R#10 fell. LPN #9 stated the intervention that was put into place following R#10's fall on 1/12/2024 was when CNAs assisted the resident to the bathroom; they had to make sure supplies were within reach and not leave the resident alone. LPN #9 stated she did not put that new intervention in R#10's care plan. LPN #9 stated she was unsure of other interventions for assisting R#10 to the bathroom except to ensure the resident had grippy socks on. LPN #9 stated she also worked on 1/22/2024 and was called to R#10's room to assess the resident, who was found lying on a floor mat. LPN #9 stated it was R#10's shower day, and an intervention after the 1/22/2024 fall was to make sure if the resident was awake to get the resident up and out of bed on shower days. LPN #9 stated that follow-up after the fall consisted of ensuring R#10's bed was in a low position, and a floor mat was put in place. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) stated that following a resident fall, it was expected that licensed nursing staff assessed residents, performed neurological checks, notified the medical doctor and resident representative, got the resident off the floor, created a fall report/event, entered a progress note, and added an intervention to the resident's care plan. DHS stated that each resident's fall was investigated and reviewed with the clinical team to ensure that any follow-up interventions needed were added to the resident's care plan. The DHS stated that R#10's care plan was not updated with an intervention following the 1/12/2024 fall. The DHS stated that R#10's care plan was updated with an intervention of having a call light within reach, but that was not a good intervention for R#10 as the resident was unable to use a call light. During an interview on 3/7/2024 at 3:55 pm, The Administrator stated resident falls are discussed in risk meetings and during interdisciplinary team reviews to determine root causes for a fall. The Administrator stated he expected interventions to be determined after a resident falls, and interventions should be added to a resident's care plan. Cross Reference F657

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Infection Prevention - Hand Hygiene, and Medication Administration: General Guidelines, the facility failed to follow standard precautions during the administration of medications. In addition, the facility failed to ensure that staff demonstrated proper use of gloves and hand hygiene during medication administration for one out of 37 sampled Residents (R) (R#8) reviewed for medication administration. Findings include: A review of the facility's policy titled Infection Prevention - Hand Hygiene, dated 3/8/2019, under the section titled Definition revealed, Indication for Hand Hygiene is the moment during health care when hand hygiene must be performed to prevent harmful germ transmission and/or infection. Under the section titled Indications Requiring Hand Wash or Hand Rub revealed, 1. Before and after contact with the resident. A review of the facility's policy titled Medication Administration: General Guidelines dated 4/10/2019, under the section titled Policy Statement revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices. A review of the Resident Face Sheet for R#8 revealed, the resident admitted with diagnoses that included osteoarthritis and chronic pain. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/2023 for R#8, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident had an active diagnosis of arthritis. The MDS revealed the resident had experienced occasional pain and received as needed (PRN) pain medication within five days of the assessment. A review of the Physician Order Report for R#8 revealed an order dated 12/30/2023 for hydrocodone-acetaminophen (a narcotic pain medication) 7.5-325 milligrams (mg) one tablet by mouth every six hours as needed for chronic pain. A review of the Care Plan for R#8 revealed a Problem area with a start date of 9/28/2023 that indicated the resident had pain related to diagnoses of osteoarthritis (OA), diabetes mellitus type two (DMII), muscle weakness, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Interventions included the administration of pain medications per physician's orders. During an observation and interview on 3/5/2024 at 1:30 pm, Licensed Practical Nurse (LPN) #9 placed a round white pill she was holding in her ungloved hand into a medication cup. LPN #9 then took the medication into R#8's room and administered the medication without gloves on. LPN #9 did not perform hand hygiene prior to or after administering the medication. LPN #9 said the medication was a pain medication for R#8. She said she did not know why she had the medication in her bare hand and said she should have dispensed the medication straight from the package into the medication cup without touching it. LPN #9 said she was rushing and that she usually did not wear gloves while dispensing medications because she would dispense the medication directly into the medication cup from the package. During an interview on 3/5/2024 at 3:13 pm, R#8 said they received hydrocodone from LPN #9 earlier that day. During an interview on 3/6/2024 at 8:31 am, the Director of Health Services (DHS) said she expected staff to avoid touching oral medications with bare hands and said staff should use gloves if handling medications. She said if staff touched a medication with bare hands, they should waste the medication and dispense a new one. During a phone interview on 3/6/2024 at 8:32 am, LPN #9 said the medication that was observed to be given to R#8 was hydrocodone. During an interview on 3/6/2024 at 10:22 am, LPN #7 said medications came to the facility from the pharmacy in individual packets. She said that when administering medications, she would open the packet and dispense the medication directly into the medication cup. LPN #7 said she would not touch the pill with bare hands. She said if she was going to handle the medication with her hands, it should be with gloves on. During an interview on 3/6/2024 at 2:43 pm, the Infection Preventionist (IP) said she had completed in-service training with staff on the topic of hand hygiene and glove use within the past two months. She said other than verbally reminding staff to use gloves when handling medications, there was no in-service training specific to hand hygiene during medication administration. The IP said the only time staff would need to touch a pill was if they had to separate a capsule. She said staff should wear gloves when handling medications. She said if a staff member touched a medication with bare hands, they should dispose of the medication and dispense a new one. The IP said there were no specific policies related to hand hygiene and medication administration and said that was why they were verbally reminding staff to use gloves and perform hand hygiene during medication pass. During an interview on 3/7/2024 at 9:35 am, the Administrator said he was somewhat familiar with the medication administration process. He said the timeliness of medication administration was important, as was following physician's orders and infection control procedures. He said he expected staff to dispense medications without touching them with ungloved hands. During an interview on 3/7/2024 at 9:40 am, the IP said the conversations she had with staff in the past regarding hand hygiene during medication administration were not official in-services and said that was because the medication administration policy did not contain anything regarding hand hygiene or glove use during medication administration. She said those conversations were not documented. She said she could recall having that conversation with LPN #9. She said she thought there was an additional policy that addressed the need for staff to avoid touching medications during administration. This policy was requested from the IP but was not provided. Cross Reference F658

2. A review of a facility's policy titled Resident Rights, dated 12/1/2023, under the section titled Policy Statement revealed, It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. In addition, all patients/residents and their responsible parties must sign a written statement of acknowledgment and be given a copy of the center's patient/resident rights and responsibilities. Under the section titled Procedure revealed, 1. Patients/residents are entitled to fully exercise their personal and legal rights and privileges if possible. 2. The center will make every effort to assist the patient/resident in understanding and exercising his/her rights to assure the patient/resident is always treated with respect, kindness, and dignity. A review of an untitled list of the number of sets of silverware on hand at the facility, dated 3/6/2024, provided by the Registered Dietician (RD), revealed that the facility had a census of 67, and per the dietary staff, they usually ran out of silverware around the second to last meal cart. The document revealed they estimated they had 47 sets of silverware. A review of R #28's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. During an observation and interview on 3/4/2024 at 8:56 am, R#28's meal tray had a plastic spoon on it. R#28 stated they hated plasticware and could not use it as well as silverware. A review of R #49's admission MDS, with an ARD of 2/12/2024, revealed the resident had a BIMS score of five, which indicated the resident had severe cognitive impairment. An observation on 3/5/2024 at 1:00 pm revealed R#49 was eating their lunch using plasticware. A review of R#21's quarterly MDS, with an ARD of 1/12/2024, revealed R #21 had a BIMS score of 15, which indicated the resident was cognitively intact. An observation and interview on 3/5/2024 at 1:05 pm, revealed R #21 ate the noon meal. R#21 stated that they could not cut up the porkchop with the plasticware. A review of R#55's quarterly MDS, with an ARD of 1/12/2024, revealed the resident had a BIMS score of 14, which indicated the resident was cognately intact. During an interview on 3/5/2024 at 1:20 pm, R#55 stated that they had often been given plastic silverware with lunch and dinner. R#55 stated that they had been given paper plates recently as well. R #55 stated that they kept metal silverware in their room and used them when staff brought them plasticware. During an interview on 3/5/2024 at 2:30 pm, R #55 stated that they had notified staff about the kitchen staff sending out plasticware. R #55 stated that they despised using disposable silverware and plates. R#55 stated that they were told by staff that they were short on silverware. R#55 stated that when staff brought them plasticware, they told staff that they did not want disposable plasticware. An observation on 3/6/2024 at 12:49 pm revealed that staff passed meal trays to residents on the D-hall, and each tray included a package of plasticware. During an interview with Dietary Aide (DA) #13 and the Registered Dietician (RD) on 3/6/2024 at 10:17 am, DA #13 stated that they gave silverware for one meal and then did not have any for the rest of the day. The RD stated that they seemed to lose silverware as fast as they replaced it. During an interview on 3/7/2024 at 9:36 am, the RD stated that it had not been brought to her attention that the residents did not like the plastic silverware. She stated that she could imagine that they did not like using the plasticware. She stated that forks and spoons were ordered last in December 2023. During an interview on 3/7/2024 at 10:51 am, the Director of Health Services (DHS) stated that residents should not use plastic utensils or paper plates. She said there had been a problem with this, that it was terrible for residents to use plasticware, and that it was a dignity issue. During an interview on 3/7/2024 at 11:36 am, the Administrator stated that the RD told him about the issues with residents using plasticware. He stated that typically the plasticware and paper plates should only be used in an emergency when they had dishwasher concerns. He stated that for the most part, they should use silverware. Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Patient/Resident Voting, the facility failed to support three out of 37 sampled Residents (R) (R#54, R#55, and R#56) with their rights to vote. In addition, the facility failed to promote dignity by using disposable cutlery at meals for four out of 37 sampled Residents (R) (R#28, R#49, R#41, and R#55) observed during dining. Findings include: 1. A review of a facility's policy titled Patient/Resident Voting, dated 1/5/2015, under the Policy Statement revealed, It is the policy of this Healthcare Center for each patient/resident's civil right to vote be promoted and opportunities will be provided within the healthcare center for patients/residents to exercise this right. Under the section titled Procedure revealed, 1. All patients/residents who are registered to vote and have a desire to vote and have the ability to make such a decision will be identified through the initial assessment process. 3. Each patient/resident will be informed in advance of voting procedures and schedules. A review of R#54's Resident Face Sheet indicated the facility admitted Resident #54 on 8/10/2023. A review of R#54's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/2024, revealed R#54 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #54's electronic health record did not reveal a completed activity assessment. During an interview on 3/4/2024 at 1:07 pm, R#54 stated that they were interested in voting but was not aware they could ask staff for assistance with voting. A review of R#55's Resident Face Sheet revealed the facility admitted Resident #55 on 8/11/2023. A review of R#55's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/2024, revealed R#55 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of R#55's Activity Assessment, completed on 1/24/2024, indicated that R#55 wished to vote. A review of R#56's Resident Face Sheet indicated the facility admitted R#56 on 8/11/2023. A review of R#56's quarterly MDS, with an ARD of 2/19/2024, revealed R#56 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of R#56's Activity Assessment, completed on 2/12/2024, indicated that R#56 wished to vote. During a Resident Council meeting on 3/5/2024 at 2:30 pm, the following residents had concerns about voting: -R#55 stated that they wanted to vote but had not voted since their admission to the facility. --R#55 stated that no one at the facility had assisted them with changing their address, receiving an absentee ballot, or going to a polling place to vote. - R#56 stated they had voted since they were the legal age to vote. R#56 stated it was important for them to vote, but they had not voted since they were admitted to the facility in the summer of 2023. R#56 stated that no one at the facility had assisted them with changing their address, receiving an absentee ballot, or going to a polling place to vote. During an interview on 3/7/2024 at 9:12 am, the Activity Director (AD) stated that she asked residents quarterly if they wanted to vote. The AD stated that if a resident wanted to vote, she would discuss it with the Social Services Director (SSD) to determine if the resident was competent to vote. She stated that as far as she was aware, after asking a resident if they wanted to vote, there had not been any follow-up until recently. The AD confirmed that no one had come to the facility to assist residents with voting. The AD stated she was unsure if R#54 had a completed activity assessment that addressed the resident's wishes regarding voting. During an interview on 3/7/2024 at 10:55 am, the Social Services Director (SSD) stated that he and the AD had contacted the county registrar on 3/6/2024 to confirm which residents were registered to vote. The SSD stated he was unaware of any residents voting in the three years he had worked at the facility. The SSD stated that he did not know what happened with the activity assessment when a resident indicated they wanted to vote. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated it was the residents' right to vote, and the facility staff should assist residents with voting. During an interview on 3/7/2024 at 11:57 am, the Administrator stated that residents had the right to vote, and the facility staff should assist with that process.

Based on observations, staff interviews, record review, and review of the facility's policy titled Patient/Resident Council, the facility failed to complete an investigation, response, and resolution to the residents' concerns that attended the Resident Council Meetings. The facility census was 67 residents. Findings include: A review of a facility policy titled Patient/Resident Council, dated 10/20/2017, under the section titled Procedure revealed, 1. The Patient/Resident Council will meet as a group to: Discuss and offer suggestions about healthcare center policies and procedures affecting patients/residents' care, treatment, and quality of life. 2. Issues raised/discussed, and recommendations made by the Patient/Resident Council will be communicated to the healthcare center administration, considered in center planning, and responded to promptly. 10. Issues, concerns, ideas or complaints of the Council will be transferred to the Patient/Resident Council/Family Council Department Response Form by the staff liaison person and given to the Administrator for distribution and response by the appropriate department. The response/action will be documented on this form, returned to the Administrator for review and signature and returned to the Council staff liaison for communication back to the Council Presiding Officer and presentation at the next council meeting. The department response form will be attached to the minutes of the meeting in which the issue was brought up. During a Resident Council meeting on 3/5/2024 at 2:30 pm, Residents (R) R#9, R#41, R#55, and R#56 expressed concerns about staff giving the residents disposable silverware and plates with meals, food temperatures, food seasoning, meat being served too tough, staff not following the dietary menu, and the font on the activity calendar being too small to read. A review of Patient/Resident Council Minutes/Report, dated 1/1/2024, indicated that the Resident Council brought forth their concerns that Certified Nurse Aide (CNAs) needed to bring seasonings with trays, the chicken was still too tough, they wanted more alternative options for diabetic residents, and calendars needed to be on bigger paper. A review of the Patient/Resident Council/Family Council Department Response Form for the 1/1/2024 Resident Council meeting concerns revealed that the nursing Department Investigation, Response, and Resolution indicated that the nursing department educated CNAs and nurses delivering trays to residents were to ask, Would you like any additional seasonings for your meal? The dietary Department Investigation, Response, and Resolution revealed staff failed to investigate and respond to the concern that the chicken was still too tough and that there needed to be more alternative options for diabetic residents. The activity Department Investigation, Response, and Resolution indicated that the activity department was working on February's calendars and getting them printed on bigger paper. A review of Patient/Resident Council Minutes/Report, dated 2/19/2024, indicated that the Resident Council brought forth their concerns of keeping food warm. A review of the Patient/Resident Council/Family Council Department Response Form for the 2/19/2024 Resident Council meeting concerns revealed that the nursing Department Investigation, Response, and Resolution indicated that as soon as trays were on the hall's food was delivered to each resident. A review of Patient/Resident Council Minutes/Report dated 12/6/2023 indicated that the Resident Council brought forth their concerns, including that plastic silverware did not work. A review of the Patient/Resident Council/Family Council Department Response Form for the 12/6/2023 Resident Council meeting concerns revealed that residents identified concerns that included food was often over or undercooked, trays were often cold, the food needed more seasoning, and staff were not serving what was on the facility menus. The dietary Department Investigation, Response, and Resolution indicated that the facility would educate on the importance of silverware, timing while cooking, and the menus. The dietary Department Investigation, Response, and Resolution revealed that the facility failed to respond to the concerns regarding the trays often being cold and the food needing more seasoning. A review of Patient/Resident Council Minutes/Report, dated 11/8/2023, indicated that the Resident Council brought forth their concerns, including no salt packets on meal trays. A review of the Patient/Resident Council/Family Council Department Response Form for the 11/08/2023 Resident Council meeting concerns revealed staff failed to indicate that the Resident Council had identified a concern with not receiving salt packets on meal trays. The form revealed the facility failed to respond to the Resident Council's concern about no salt packets on trays. A review of Patient/Resident Council Minutes/Report dated 10/2/2023 indicated that residents in attendance brought forth their concerns, including staff not providing salt with meals and menus not being followed. A review of the Patient/Resident Council/Family Council Department Response Form for the 10/2/2023 Resident Council meeting concerns revealed that the dietary Department Investigation, Response, And Resolution failed to address and respond to the dietary concern about salt with meals and menus not being followed. A review of Patient/Resident Council Minutes/Report dated 9/4/2023 indicated that the Resident Council brought forth their concerns, including food coming out of the kitchen being cold and raw and the facility serving tough meat that was hard to cut and chew. A review of the Patient/Resident Council/Family Council Department Response Form for the 9/4/2023 Resident Council meeting concerns revealed that the facility's Department Investigation, Response, and Resolution to the identified concerns was new covers and carts were ordered. A review of the form revealed the facility failed to complete an investigation, response, and resolution to the Resident Council's concern that the tough meat was hard to cut and chew. On 3/5/2024 at 1:01 pm, dining observations were conducted. Plastic silverware was observed being passed on residents' lunch trays delivered to residents on the D Hall. During an interview on 3/5/2024 at 9:31 am, the Activity Director (AD) indicated that they assisted with the Resident Council and scheduled the Resident Council meetings. During an interview on 3/6/2024 at 10:17 am with the Registered Dietitian (RD) and Dietary Aide (DA) #13, DA #13 indicated that they gave the residents one set of regular silverware a day, and the facility did not have enough regular silverware for the rest of the day. DA #13 stated that she felt like the residents would rather have the plasticware instead of the real stuff. The RD also stated that she felt like the residents would rather have the plasticware instead of the real stuff. During an interview on 3/6/2024 at 1:30 pm, the RD stated that she imagined that the chicken that was served to the residents the day prior was not great based on how it was cooked. The RD stated that the staff put frozen chicken patties in the oven with no seasoning, cooked them for a bit, and then put some seasoning on them. The RD stated cooking the chicken that way dried it out. During an interview on 3/7/2024 at 9:36 am, the RD stated the dietary staff had been putting seasoning packets in cups on top of the carts, and the nursing staff were supposed to grab them when they passed the tray. The RD stated they had to throw out any extra packets that had been in the cups on the hall. The RD stated that if they posted the menu too early, the residents would be disappointed if they had to replace menu items; if they posted it at least the night before, the dietary staff would know they had all the items listed on the menu. The RD stated that there were complaints with the Resident Council regarding alternative meal choices. The RD indicated that the facility staff should be meeting with residents to determine preferences and then adding preferences in the meal tracker. During an interview on 3/7/2024 at 12:09 pm, the AD stated that the residents hold Resident Council meetings on the first Monday of every month, and they encourage the residents to come. The AD indicated she was given directions from the facility to take notes and report problems. The AD stated that she never knew what her role was in the Resident Council. The AD stated that the concerns that the Resident Council brought forward were given to the appropriate department managers, and at the following Resident Council meeting, the residents would report if the concerns were resolved. The AD stated that last month, the Resident Council identified that the activity calendars in residents' rooms needed to be bigger. The AD stated that they had not been able to print calendars on larger paper and were still being printed on 8.5-inch by 11-inch paper. During an interview on 3/7/2024 at 10:51 pm, the Director of Health Services (DHS) stated that she expected the facility to have and be able to use regular utensils. The DHS stated that it was terrible for residents to use plasticware and that it was a dignity issue. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) indicated that the AD was responsible for overseeing the Resident Council meetings, including bringing the Resident Council's concerns to the department heads by writing a grievance for each concern. The DHS indicated that every topic/concern was worth an investigation. The DHS indicated that they had addressed reoccurring food concerns with current and prior administrators, the social worker, the facility consultant, and the ombudsman. During an interview on 3/7/2024 at 3:32 pm, the Administrator indicated that he expected all concerns brought forth by the Resident Council to be documented on the forms (Patient/Resident Council Minutes/Report and the Patient/Resident Council/Family Council Department Response Form) following a Resident Council meeting. The Administrator indicated that repetitive Resident Council concerns raised a bigger concern.

Based on observations, staff and resident interviews, record review and review of the facility's policy titled How to Purée Foods, the facility failed to ensure they served food that was prepared by methods that conserved the nutritive value, flavor, and appearance, and that the foods served from the facility's kitchen was palatable and attractive. This deficiency affected three out of 37 sampled Residents (R) (R#62, R#49, and R#17) but had the potential to affect all 37 residents on a regular consistency diet and all 10 residents with orders for puréed diets. Findings include: 1. A review of the facility document titled Consistency Census Report, printed on 3/6/2024, revealed the facility had 37 residents on a regular consistency diet. A review of the facility's 2023 Diet Guide Sheet revealed the lunch menu for Tuesday, day 24, included herb baked chicken, parslied noodles, creamed spinach, and a breadstick. A review of the recipes provided by the facility staff, used for the lunch meal on Tuesday, 3/5/2024, revealed a recipe for herb-baked chicken. The recipe revealed instructions for staff to use boneless and skinless chicken thighs, salt, pepper, and ground rosemary. The recipe revealed the procedure included instructions for staff to do the following: - Wash the chicken and place pieces of the chicken on baking sheets. - Combine salt, pepper, and rosemary, and season the chicken with the herb mixture. - Cover and bake at 350 degrees Fahrenheit (F) for about one to one and a half hours. Remove cover for at least 30 minutes of baking. During an observation and interview on 3/5/2024 at 12:53 pm, R#62 was in their room eating the noon meal. The resident began having trouble swallowing their chicken and started coughing. R#62 stated that the chicken was dry. During an interview on 3/5/2024 at 1:00 pm, as R#49 ate their noon meal, R#49 stated that their meal was not good. An observation of a test tray of the noon meal on 3/5/2024 at 1:11 pm revealed the chicken was chicken breast, not a thigh, and it was very dry. The breadstick was overcooked on the bottom, and the top was wet and appeared to be undercooked. During an interview on 3/5/2024 at 1:44 pm, R#17 stated that the chicken was too tough and dry so one of the Certified Nurse Aides (CNA) got them ground chicken. R#17 stated that it was still too dry and now they felt like they had a piece stuck in their mouth. R#17 stated that there was a breadstick that was overcooked and was hard as a rock. During an interview on 3/6/2024 at 2:45 pm, [NAME] #15 stated that she did not have a lot of kitchen training. She stated that she sometimes would taste test the food, but she did not the day prior. She stated that she usually talked to the residents about the food. [NAME] #15 stated that some of the residents would tell her they liked the food and others would say they did not. During an interview on 3/6/2024 at 1:30 pm, the Registered Dietician (RD) stated that staff should taste test the food, and she usually did, but she did not test it the day prior. She stated that she imagined the chicken was not great based on how [NAME] #15 cooked it. She stated that [NAME] #15 put frozen chicken patties in the oven with no seasoning, cooked them for a bit, and then put seasoning on it. The RD stated that cooking the chicken that way would dry it out. 2. A review of an undated facility policy titled How to Purée Foods under the section titled What is the correct pureed texture revealed, Puréed foods should be soft and moist, cohesive (holds together, not runny), smooth (without lumps) and spoon-thick (does not flow or drip continuously through fork prongs). Properly puréed foods should be 'swallow ready' and not require chewing. Under the section titled Preparation Steps revealed, 1. Depending on the resident's dietary restrictions, follow the proper recipe. 5. If required, for hot foods add a small amount of hot liquid, such as gravy, sauce, or cooking liquid, to the cooked hot foods. For cold food, add cold liquid such as milk or fruit juice; Do not add water. Under the section titled Notes revealed, Some foods, typically vegetables, have a higher water content than others, such as squash, cauliflower, broccoli, carrots, tomatoes, greens, peas, green beans, etc. [et cetera]. When processing these foods, thickener may be needed. If thickener is required, use as little as possible. Use one half teaspoon at a time until proper consistency is reached. A review of a facility document titled Consistency Census Report, printed on 3/6/2024, revealed that the facility had 10 residents who received purée food. A review of the facility's 2023 Diet Guide Sheet revealed the lunch menu for Wednesday, day 25, included baked ham with chipotle peach glaze, wild rice, squash au gratin, tossed salad with dressing, and a cornbread muffin. A review of the recipes provided by the facility revealed a recipe for baked glazed ham that included ham, light brown sugar, cornstarch, light corn syrup, and pineapple juice. The recipe revealed the procedure included instructions for staff to do the following: - Place the ham in a roasting pan or on a steam table pan. - Bake the ham at 325 degrees Fahrenheit (F) for 15 minutes per pound or until the internal temperature reaches 155 degrees F for a minimum of 15 seconds. - While the ham is baking, prepare the glaze so it can be placed on top of the ham approximately 30 minutes before it is done. - Glaze: combine the brown sugar, cornstarch, light corn syrup, and pineapple juice in a small bowl. - Approximately 30 minutes before the ham is done, pull the ham from the oven and spoon the glaze over the ham. - Return the ham to the oven and bake until the internal temperature has reached. A review of the recipes provided by the facility revealed a recipe for puréed glazed baked ham. The recipe included instructions for staff to do the following: - Weigh the ham according to the recipe and place it in the food processor. - Purée the baked ham until the consistency is puréed, noting that it would not be smooth, but there would be no large pieces. - Reheat the baked ham to 165 degrees F for a minimum of 15 seconds. - Maintain the temperature of the ham at a minimum temperature of 140 degrees F or according to the policy. - Serve a #10 scoop per serving, which is 3.25 ounces (oz). Ensure a 2 oz serving of sauce or gravy is placed on top of the ham during service. A review of the recipes provided by the facility revealed a recipe for summer squash. The recipe revealed instructions for staff to use zucchini squash, margarine, black pepper, and onion powder. The recipe included instructions for staff to do the following: - Steam or boil the summer squash in water. - Do not overcook. - Drain most of the water off the summer squash. - Add the margarine, pepper, and onion powder, then toss lightly. An observation and interview on 3/6/2024, beginning at 9:40 am, revealed [NAME] #14 prepared ham, rice, squash, and cornbread. The ham and cornbread were in the oven and ready to be served. A small pan of ham was on the counter. Observation at this time showed [NAME] #14 cut up squash and added salt and pepper to the pan with the squash. She cut up more squash, put it in a smaller pan, and left it on the counter. She did not put any seasoning on the small pan. She did not have any recipes out. [NAME] #14 pulled a small pan of ham out of the steamer and added the smaller pan of squash to the steamer. She put the ham from the steamer into the food processor and ground the meat. [NAME] #14 then added an unmeasured amount of ham and an unmeasured amount of broth to the food processor, added more broth, and then used the food processor to purée the ham. She checked the consistency and asked the Certified Dietary Manager (CDM) #16 to look at the purée. [NAME] #14 then added an unmeasured amount of water to the food processor. CDM #16 told [NAME] #14 she needed to add thickener to the ham to thicken it up. [NAME] #14 added one tablespoon of thickener. [NAME] #14 then pulled the squash out of the steamer and added a pan of rice into the steamer. The squash had a large amount of pepper on it. [NAME] #14 placed the steamed squash in a smaller pan and put it on the steam table. At 11:23 am, [NAME] #14 placed an unmeasured amount of squash in the food processor and blended it. She placed two tablespoons of thickener in the food processor, then sprinkled the remainder of the thickener from the can into the food processor and continued to blend. She then checked the temperature of the puréed squash and put it back in the steamer. During an interview on 3/6/2024 at 1:25 pm, [NAME] #14 stated she found out Monday, 3/4/2024, that she was coming to this facility to work. She stated that the recipes were probably somewhere, but she did not have the recipes for rice, squash, or ham. She stated that she should measure liquids. [NAME] #14 stated that puréed food should be a milkshake consistency. She stated that she did not put any seasoning on the puréed squash and that she usually tried to season it. During an interview on 3/6/2024 at 1:15 pm, the Administrator stated that they identified that there was a problem in the kitchen about a month ago and took disciplinary action against the previous Dietary Manager (DM) and gave her a chance to make things better, but they did not see any improvement. He stated that on Friday, 3/1/2024, they suspended the previous DM and brought in staff from a sister facility to begin working to make improvements. During an interview on 3/7/2024 at 9:36 am, the Registered Dietician (RD) stated that the previous DM told her there were complaints from the Resident Council that residents did not like the food and asked if she could change the menu, so she did change it to an older one. She stated that dietary staff should follow the recipes, use the correct chicken, make sure the food looked more pleasing, talk to the residents, ask what they thought, and sample test trays to see if the meal was something they would want to eat. She stated that she found a lot of cooks did not use the recipes. She stated that there were multiple missing recipes. During an interview on 3/7/2024 at 10:51 am, the Director of Health Services (DHS) stated that she had not eaten the food from the facility's kitchen in a while. She stated that the food quality started to go down while the previous DM was there. The DHS agreed that the food should be to the residents' liking, appealing, and flavorful. She stated that the food should not be bland and should not cause someone to cough when eating. She stated that she felt sad that the residents were excited to eat food on Wednesday, 3/6/2024, which could be considered subpar. During an interview on 3/7/2024 at 11:36 am, the Administrator stated he had been at the facility for about a month. He stated that he had taste-tested the food. He stated that their goal was to make sure staff followed recipes and the food was presentable and tasty. The Administrator stated that he leaned on the dietary staff to follow the recipes. He stated that some of the older cooks thought they had memorized the recipes but that they should still have them available for reference.

Based on observations, staff interviews, record review and review of the facility's policy titled Cleaning Schedule Policy, Dietary Partner Hygiene and Dress Code, and Handwashing: Dietary Services, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This deficiency had the potential to affect 64 of 67 residents who ate meals from the facility's kitchen. Findings include: A review of the facility's policy titled Cleaning Schedule Policy, dated 9/29/2022, under the section titled Policy Statement revealed, It is the policy of [the facility] that the Dietary Manager [DM] prepares a list of all cleaning tasks and posts them in the Dietary Department. It is the Dietary Manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. Under the section titled Procedure revealed, 1. The cleaning schedule: daily, weekly, and monthly lists all cleaning tasks, specifies frequency of the task, and the position (job title) responsible for completion of the task. The dietary partner will initial the form once the cleaning tasks is completed. 2. The cleaning schedules are posted in the Dietary Department. 3. Completed daily, weekly, and monthly cleaning schedules should be kept on file for six months. 4. The Dietary Manager or designee will complete the Kitchen Observation in [an electronic log]. A review of a facility document titled Cleaning Assignments Form - Daily, dated 4/27/2016, included the following: - Work tables: top/shelves/legs clean. - Freezer/Refrigerator Reach-In: Clean inside and outside. - Hand sink Area: Clean sink. Replace soap and hand towels as needed. Clean inside and outside the trash can. - Floors: All areas (behind & [and] under equipment) swept/mopped. - Dish Room: Worktables/shelves-clean. - Range: Clean Surface Areas. - Can Opener: Clean and sanitize blade and base. A review of a facility document titled Cleaning Schedule Form - Weekly, dated 4/27/2016, revealed the following: - Floors: Scrub and deck brush all floor areas - including under shelves, along baseboards, and in corners. - Walk-in Freezer & Refrigerator: Sweep and mop floors and under shelves. - Food Carts: Detail clean and sanitize inside and out. - Dish Dollies / Cart /Rack: Clean and sanitize. - Utility Carts & Bun Racks: Clean and Sanitize. - Trash Can: Clean and scrub trash cans. A review of a facility document titled Cleaning Schedule Form - Monthly, dated 4/27/2016, revealed the following: - Floors: Clean floor drains. - Store room(s): Clean shelving units. - Walk-in Freezer: Clean shelving units. - Walk-in Refrigerator: Clean shelving units. - Food Storage Containers: Clean inside & out all food storage bins (sugar, flour corn mill, etc. [et cetera]). - Can Opener: Clean base inside. Remove base from table and clean under base and table area. A review of the facility's policy titled Dietary Partner Hygiene and Dress Code, dated 6/14/2016, under the section titled Policy Statement revealed, It is the policy of [the facility] for partners working in the Dietary Department to dress in a manner appropriate for preparing, handling, and serving food that prevents contamination and spread of bacteria. Under the section titled Scope revealed, This applies to all dietary partners, and any person(s) who handles and serves food employed by [the facility]. Under the section titled Hygiene revealed, 2. Hair is covered with hair net and/or cap. 5. Eating or drinking is not permitted while in the kitchen. 7. Handwashing must take place prior to the start of each shift, during their shift, upon returning to the kitchen area, after using the restroom, and returning from breaks. A review of the facility's policy titled Handwashing: Dietary Services, dated 4/14/2016, , under the section titled Policy Statement revealed, It is the policy of [the facility] to prevent the spread of bacteria which may lead to foodborne illnesses by using proper hand washing techniques. Under the section titled Scope revealed, This applies to all partners employed by [the facility]. A review of a document titled January RD [Registered Dietician] Inspection, dated 1/31/2024, completed by the RD, indicated that food preparation equipment was not clean and that the floor of a walk-in needed to be cleaned. A review of a Kitchen Observation document, dated 2/12/2024, completed by DM #21, the previous DM, indicated that the food preparation equipment was not clean and that a refrigerator needed to be swept. The document revealed that DM #21 documented Floor a mess. Observation on 3/4/2024 at 8:35 am, during the initial tour of the kitchen, revealed that the floors were covered with dirt and crumbs and felt sticky to walk on. The handwashing sinks by the bathroom had a film covering the entire sink, which was removed when wiped. The top of the trashcan under the sink was discolored, and the lid appeared to be a red/rust color. There were boxes on the floor, making it impossible to walk around the area, and only the floor directly inside the door was visible. In the cooler, dirt, paper, and food crumbs covered the floor and underneath the shelves. The floor of the freezer was dirty, covered with paper and crumbs. Individualized cartons of ice cream were observed under one of the shelving units. Boxes covered the middle of the floor, making it impossible to walk around the freezer, and only the floors directly around the door were visible. A layer of dirt and fuzz covered the metal shelving units that sat between the freezer and walk-in cooler. The fuzz could be scraped off with a finger. Boxes covered the floor of a dry food storage room. Under the shelving units were large amounts of trash, single-serving size cereal boxes, and crumbs. The front of the convection oven was covered with a large amount of grease build-up. Floors under all the cooking equipment were covered with dirt, crumbs, and trash; the floors were sticky to walk on. During an interview at the time of the observation, Dietary Aide (DA) #20 stated that he had only been working at the facility for about two weeks and did not know anything about the cleaning schedules. During an interview on 3/5/2024 at 10:50 am, the RD stated that the previous Dietary Manager (DM) was suspended on Friday, 3/1/2024, for poor performance. The RD stated that she was at the facility the previous Friday and saw that the kitchen was in poor condition. During an interview on 3/5/2024 at 11:54 am, the RD stated she used the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Pathway as her checklist for her kitchen inspections. The RD stated she thought the DM only used the daily checklist and not the weekly or monthly checklists to track cleaning. During an observation on 3/6/2024 starting at 9:40 am, [NAME] #14 was cooking. A cart next to the food preparation table with condiments had a thick layer of dirt along the edge that could be scraped off with a finger. At 9:43 am, [NAME] #14 was not wearing gloves as she cut up fresh squash, put them in a pan, and then added salt and pepper. She cut up more squash and put it in a smaller pan. [NAME] #14 wore a hat with no hair net on, and her hair hung down past her shoulders. She added the smaller pan of squash to a steamer. A larger pan of squash was in the steamer already. She pulled the larger pan out and set it on the counter. She placed the smaller pan of squash in the steamer and then placed the larger pan in with the heaping pan of squash, touching the bottom of the larger pan above it, and closed the door. She donned gloves without washing her hands, cleaned up some of her mess where she cut up the squash, then removed the gloves and did not wash her hands. She grabbed two smaller pans and sat them by a food processor. She put ham from the steamer into the food processor, ground the meat, and then removed her gloves. Without washing her hands, she pulled the cornbread out of the oven, put foil over the ground ham, and then put it in the oven. She removed the gloves and did not wash her hands. [NAME] #14 pulled the cornbread out of the oven and put the small pan of ham in. During an observation on 3/6/2024 at 9:50 am, Certified Dietary Manager (CDM) #16 was in the kitchen and not wearing a hairnet. [NAME] #14 wore gloves to prepare the pureed foods and then removed her gloves, touched the inside of a trashcan, and grabbed foil to put over the pureed ham. At 10:30 am, [NAME] #14 began cleaning up the food preparation table and carried all the dishes into the dish room. She rinsed the dishes, put them through the dishwasher, and then immediately went back to rinsing dishes again. She washed 11 loads of dishes and did not wash her hands at all during the 30-minute observation. [NAME] #14 put away the dishes, then loaded more dishes onto a cart to put them away. She continued to move back and forth between the dirty and clean sides and did not wash her hands. After the last load of dishes, she took two paper towels, dried her hands, threw the paper towels in the trashcan, and pushed the cart out to put the dishes away without washing her hands. During an observation on 3/6/2024 at 11:00 am, [NAME] #14 wet a hand towel with water from a sink and then wiped off the food preparation table. She did not have a sanitizer bucket out with water to use to clean off the counter. [NAME] #14, then put the rest of the dishes away, including the food processor, without washing her hands. She then pushed the cart back into the dish room. [NAME] #14 placed a piece of parchment paper on a baking sheet. During this time, Certified Nurse Aide (CNA) #17 entered the kitchen and walked into the food preparation area to get three cups of coffee. CNA #17 did not put on a hairnet before entering the kitchen. [NAME] #14 left the baking sheet on the counter in the food prep area, went into the office, and obtained a bottle of water to drink. She took the water into the food preparation area and sat it on the counter by the three-compartment sink. At 11:10 am, [NAME] #14, without washing her hands or putting on gloves, pulled rice out of the steamer to check the temperature. She put her fingers down into the pan, pulled some rice out, and ate it while she rolled a piece around her fingers. She then pulled a piece of rice off the thermometer and ate it. During an interview on 3/6/2024 at 12:55 pm, CNA #17 stated that she usually wore a hairnet in the kitchen. She stated that she did not wear one that day because she was in a hurry. During an interview on 3/6/2024 at 1:15 pm, the Administrator stated that they identified there was a problem in the kitchen about a month ago, and disciplinary action was taken against the previous DM. He stated that they gave the previous DM a chance to make things better, but they did not see any improvement. He stated that on Friday, 3/1/2024, they suspended the previous DM and brought in staff from a sister facility to begin working to make improvements. During an interview on 3/6/2024 at 1:25 pm, [NAME] #14 stated that staff should wash their hands every chance they get, after coming from the bathroom, between changing gloves, when their hands were dirty, and every five to ten minutes. She stated that staff were supposed to wash their hands between dirty and clean dishes and acknowledged that she did not do that. She stated that staff should wash their hands after touching trash cans or taking out the trash. [NAME] #14 stated that she probably did not wash her hands enough that day. She stated that staff should have a hairnet on as soon as they entered the kitchen. She stated that she forgot to put on a hairnet until someone told her. [NAME] #14 stated that she could wear a hat, but she had to have a hairnet under the hat. During an interview on 3/6/2024 at 2:45 pm, [NAME] #15 stated she did not have a lot of training in the kitchen. She stated that she did not know they needed to have sanitizer in buckets. She stated that she started doing that a couple of days ago and that no one had ever trained her on that. She stated that the kitchen staff did not have assigned tasks to clean every day, every month, or every week; she just kept her work area clean, swept, and washed the dishes. She stated that everyone did what they could, but there were only two of them in the kitchen a lot of the time. During an interview on 3/6/2024 at 3:00 pm, CDM #16 stated that she should wear a hairnet anytime she was in the kitchen. During an interview on 3/7/2024 at 9:35 am, [NAME] #14 stated dietary staff should use the sanitizer to wipe things down. She stated that they did not do that the day prior because the sanitizer dispenser was messed up and did not work; they were supposed to be working on it. During an interview on 3/7/2024 at 9:36 am, the RD stated that staff should use sanitizer buckets that had been tested. She stated that staff should not put water on a rag and wipe a counter down. She was unaware of an issue with the sanitizer dispenser but stated that CDM #16 thought there was an issue with how the dispensers were connected. She stated that they should have someone who swept the floor, and each person should have assignments, and stated that had not been done. The RD stated that all staff were assigned to do the deep cleaning. She stated that staff should wash their hands every time they touched themselves, after using the bathroom, and when they prepared food. The RD stated that staff should also wash their hands between changing their gloves or when changing tasks between dirty and clean dishes. She stated that staff should wear gloves when touching the food on the serving line, rolling silverware, or when touching dirty trays in the dish room. The RD stated that dietary staff should not taste test food with their bare hands. She stated that staff should wear hairnets in the kitchen any time they were around food being prepared. She stated that she did not think hats were a good alternative to hairnets but stated they could wear them if there was not more than one inch of hair hanging out. The RD stated that CNAs should wear hairnets in the kitchen or wait at the door to get whatever they need. Per the RD, staff should not have drinks in the kitchen; they could keep them in the office or the breakroom. During an interview on 3/7/2024 at 10:51 am, the Director of Health Services (DHS) stated that she expected the kitchen staff to follow all infection control standards and the Department of Public Health standards. She stated that the kitchen should be clean and a place where someone would want to eat. She stated that staff should always wear hairnets in the kitchen. The DHS stated that staff should always adhere to hand hygiene and infection control policies. She stated that staff should wash their hands a lot, including any time they were soiled or after handling dirty dishes, before they touched clean dishes. During an interview on 3/7/2024 at 11:36 am, the Administrator stated he had been at the facility for about a month. He stated that the kitchen needed to be cleaned. He stated that the facility had a daily cleaning schedule that needed to be followed, as well as a monthly and weekly schedule that was more deep cleaning. He stated that the DM should be taking the lead on that. He stated that they were not following the weekly or monthly schedules, but he thought, as of recently, they were working to be better at it. He stated that he depended on the RD and the DM for cleaning schedules. The Administrator stated that part of the daily cleaning schedule should address the use of sanitizers to clean the food preparation areas. He stated that staff should wear a hairnet but thought hats were acceptable. He stated that the RD talked to him about hairnets and agreed that all hair should be covered. He stated that CNAs should stay at the kitchen entrance door, and if they go into the kitchen, they should have a hairnet on. The Administrator stated that he expected staff to wash their hands during meal preparation, before meal preparation, before cleaning dishes, or after touching a trash can. He stated that he expected staff to wash their hands whenever they touched something that would be considered dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to ensure staff provided privacy for two of two residents (R) (R#22 and R#47) during medication administration. The sample size was 32. The findings include: 1.Review of the clinical record revealed R#22 was admitted to the facility on [DATE] with diagnoses that include but not limited to congestive heart failure (CHF), hypertension HTN), diabetes, and dementia. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as zero, which indicated severe cognitive impairment. Observation on 2/8/2023 at 8:22 a.m., Registered Nurse (RN) GG was observed administering medications to Resident #22. The RN entered the resident's room without knocking on the door nor closing the door to the room or pulling the curtain to provide privacy, the RN administered medications to resident followed by a cup of water. 2. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses that include but not limited to stroke, depression, brain cancer, and prostate cancer. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Observation on 2/8/2023 at 9:04 a.m., RN GG was observed preparing medications for administration for R#47. RN GG entered the resident's room without knocking on the door, did not close the door, or pull the curtain to provide privacy, while resident took his medications. Interview on 2/8/2023 at 10:55 a.m., R#47 revealed They never close the door. Interview on 2/8/23 at 11:53 a.m. the Director of Health Services (DHS), stated she expects the staff to knock on the resident's door and announce themselves before entering the room. During further interview, she stated residents should be provided privacy during the medication pass. The facility did not have a policy that addressed providing privacy during medication pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled Advance Directives: Georgia, the facility failed to ensure that the health record including physician orders, accurately reflected the code status for one resident (R) (R#47) of 31 sampled residents. Findings: Review of the policy titled Advance Directives: Georgia revised [DATE], revealed the healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Advance Directives relate to the provision of care when the patient/resident lacks the capacity to make healthcare decisions. Advance Directives executed in accordance with state law will be honored by the healthcare center. Number 5. Revocation of Advance Directive: The healthcare center shall enter in the patient's/resident's medical record any change in or termination of the advance directive for health care that becomes known to the healthcare center. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses that include but not limited to stroke, depression, brain cancer, and prostate cancer. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Review of the current Physician Order's (PO) in the electronic medical record, revealed an order for Code Status: Full Code, with order date of [DATE]. Further review of the medical record revealed a Physician's DNR (do not resuscitate) Order Form dated [DATE] and signed by R#47's son or daughter, and two physicians. The banner in the electronic medical record indicated that resident is a DNR. Review of care plan created [DATE] revealed Advance Directive-Allow Natural Death-do not attempt resuscitate. The longterm goal revealed if the resident's heart stops, or if they stop breathing, Cardiopulmonary Resuscitation (CPR) will not be initiated in honor of the DNR wishes. Approaches to care include all staff to be made aware of the patient/resident's wishes. Interview on [DATE] at 2:23 p.m. with the Director of Health Services (DHS), revealed it is the responsibility of the unit manager or charge nurse to enter Physician Orders for Code Status when they are received. She stated the facility does an audit to make sure that documents, orders, and care plans match, and does not know how it this one got missed. Interview on [DATE] at 2:35 p.m. with the Social Services Director (SSD), stated he does a code status audit quarterly, and revealed the last audit was conducted in 11/2022. He stated the audit is to ensure that the EMR banner, care plan, physician's orders, and documents match.

Based on observations and staff interviews, the facility failed to ensure the confidentiality of resident electronic medical records during medication administration for two residents (R) (R#14 and R#53) on one of four nursing units. The sample size was 31. Findings include: Observation on 2/8/23 at 9:26 a.m., Licensed Practical Nurse (LPN) KK was observed administering medication to R#14 on C hall. LPN KK left the medication cart to administer R#14 medications in her room, without providing privacy of the Electronic Medication Administration Record (EMAR). Observation on 2/8/23 at 9:16 a.m., Licensed Practical Nurse (LPN) KK was observed administering medication to R#53 on C hall. LPN KK left the medication cart to administer R#53 medications in her room, without providing privacy of the residents' EMAR. Interview on 2/8/23 at 10:15 a.m., LPN KK revealed she was aware she should have concealed residents EMAR while giving the resident their medications. Interview on 2/8/23 at 11:53 a.m., the Director of Health Services (DHS) revealed it is her expectation for the nursing staff to provide privacy for all medication records while administering medications to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to coordinate with the appropriate State designated authority, one resident (R) (R#8) who was admitted to the facility with a diagnosis of bipolar disorder and depression, for a Level II Preadmission Screening and Resident Review (PASRR) evaluation, to ensure resident received care and services in the most integrated setting appropriate to his needs. The sample size was 31residents. Findings Include: Review of the clinical record revealed R#8 was admitted to the facility on [DATE] with diagnosis of but not limited to bipolar disorder and unspecified depressive disorder. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was coded as 15, indicating no cognitive impairment. Section A. indicated the resident had not been evaluated for a Pre-admission Screening and Resident Review (PASARR) Level II assessment. Section I- Active Diagnoses include depression and bipolar. Section N revealed antipsychotics and antidepressants were received 7 out of 7 days. Antipsychotics were received on a regular basis. Review of Pre-admission Screening/Resident Review (PASRR) Level I Assessment (Form: DMA-613) dated 4/13/2022 revealed the resident did not have a severe mental illness, developmental disability or related condition and no evidence of a Level II PASRR. Further review revealed if the nursing facility admits the applicant and discovers information that was not disclosed to the PASRR screeners, the nursing facility is required to contact the [screening authority] immediately. Interview on 2/8/2023 at 3:00 p.m., the admission Director, stated he wasn't sure who was responsible for requesting PASARR II evaluations. During further interview, he stated if he identifies a PASARR II is needed, he passes the information to the Director of Health Services (DHS) or the Social Services Director (SSD). He revealed there is no system in place to assure Level II PASSAR evaluations are captured. Interview on 2/8/2023 at 3:10 p.m. with the MDS Director, stated the admission Director is responsible for making sure residents with appropriate diagnoses have a PASARR Level II completed. She confirmed R#8 did not have a PASARR Level II. Interview on 2/8/2023 at 4:45 p.m. with Registered Nurse (RN) CC stated the facility does not have a policy regarding PASARR Level II. She stated the facility follows federal requirements for PASARR II. Interview on 2/9/2023 8:45 a.m. with the Administrator revealed the admission Director is responsible for obtaining a PASARR II if needed. During further interview, the Administrator revealed if a PASARR II is needed, the admission Director or Social Worker (SW) would input the information into Georgia Medicaid Management Information System (GAMMIS) to obtain a PASARR II so that Psych services could be initiated. He stated both the admission Director and Social WW received training on how to obtain a PASARR II but revealed there is no documentation of the training. Interview on 2/9/23 at 10:45 a.m. with the SW revealed PASARR 's are presented at the time of admission or the DMA-6 is requested in GAMMIS, from the transferring facility. He stated he does not know how to request a Level II. He revealed he has had no training on how to request a Level II PASARR. The Social Worker stated if a resident is exhibiting behaviors or needs psychiatric services they are discussed in the weekly Patient At Risk (PAR) meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based onobservation, record review, interviews, and review of the policy titled Care Plans, the facility failed to develop a comprehensive person-centered care plan with measurable goals and interventions for one resident (R) (R#16) who required assistance with eating. The sample size was 32. Findings include: Review of the policy titled Care Plans dated12/31/1996, revealed the comprehensive person-centered care plan is developed by the interdisciplinary team for each resident within seven days after completion of the comprehensive assessment. The care plan should be reviewed quarterly, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so the care plan will reflect the residents needs at any given moment. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/residents medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral vascular accident (CVA), atrial fibrillation, respiratory failure with hypoxia, hemiplegia/hemiparesis, and chronic kidney disease stage 3. The residents quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicates no cognitive impairment. Section G indicated resident required limited assistance of one person for eating. Review of the Care Area Assessment (CAA) on the Significant Change MDS dated [DATE] indicated resident functional status was extensive assistance with one person for eating. Review of the care plan, dated 11/23/2022, indicated a problem of left hemiplegia and requires training and skill practice in grooming and passive range of motion (PROM). Approaches to care include restorative nursing program: assist patient daily with grooming tasks of brushing teeth, washing face, washing hands, and combing hair, PROM of left shoulder, elbow, wrist, and fingers. There were no interventions to address residents need for assistance with eating. Observation on 2/7/2023 at 2:49 p.m. resident noted in her room and was wearing a splint to left hand. Interview on 2/7/2023 at 2:49 p.m. R#16 stated she was left-handed and has a hard time feeding herself because of the splint on her left hand. She stated her husband comes to feed her every day, because the staff do not feed her when he is not there. Interview o 2/8/2023 at 8:45 a.m., resident stated her husband didn't come to feed her breakfast this morning and she tried to feed herself cereal, and stated the cereal kept falling off the spoon. She stated no-one offered to assist her with her breakfast. Interview on 2/9/2023 at 9:00 a.m. with Licensed Practical Nurse (LPN) LL confirmed resident's Activities of Daily Living (ADL) care plan does not address the need for assistance with eating. Interview on 2/9/2023 at 9:28 a.m. with Registered Nurse (RN) NN, confirmed residents care plan for restorative care did not address residents need for assistance with meals. She stated based on the Care Area Assessment (CAA) on the 7/22/2022 Significant Change MDS, an update to her care plan should have been done. Interview on 2/9/2023 at 11:42 a.m., the Director of Health Services (DHS) confirmed R#16 did not have a care plan that addressed the need for assistance with meals. She stated her expectation was that residents be care planned for identified areas of concern, including assistance with feeding. Interview on 2/9/2023 at 2:00 p.m., Certified Nursing Assistant (CNA) PP stated residents care plan directs the care that is needed for each resident. He stated he was unaware of R#16 being left-hand dominant or her need for assistance during meals. He stated her husband usually is visiting and feeds her during meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of policy titled Restorative Nursing Program, the facility failed to identify the need and assist one resident (R) (R#16) with meals. The sample size was 32. Findings include: Review of policy titled Restorative Nursing Program revised 11/4/2021, revealed the policy is to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and wellbeing. Restorative nursing services are provided by Restorative Nursing Assistants (RNAs) and Certified Nursing Assistants (CNAs), and other qualified nursing staff. Screening and care planning: 1. Nurse will complete a restorative nursing screening tool 2. Determine appropriate restorative services based on the screening 3. Develop a care plan for each restorative service with measurable goals and individualized interventions Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral vascular accident (CVA), atrial fibrillation, respiratory failure with hypoxia, hemiplegia/hemiparesis, and chronic kidney disease stage 3. The residents quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicates no cognitive impairment. Section G indicated resident required limited assistance of one person for eating. Review of updated care plan for R#16, dated 11/23/2022, indicated Left hemiplegia and requires training and skill practice in grooming and skill practice in grooming. Approaches to care include restorative nursing program: assist patient daily with grooming tasks of brushing teeth, washing face, washing hands, and combing hair. There were no interventions to address residents need for assistance with eating. Observation on 2/7/2023 at 2:49 p.m. resident noted in her room and was wearing a splint to left hand. Interview on 2/7/2023 at 2:49 p.m. with R#16's spouse stated resident is not receiving assistance from staff with meals. Her spouse stated she is left-handed and has a splint on her left hand. He spouse stated he comes to visit every day and spends the whole day with her and feeds her every meal because the facility doesn't feed her when he is not there. R #16 confirmed that staff do not feed her. Interview on 2/8/2023 at 8:45 a.m., R #16 stated her spouse had not arrived at the facility before breakfast. She stated she had [NAME] Krispie's cereal for breakfast and was unable to feed herself properly because the cereal kept falling off the spoon. She stated no one offered to assist her with her breakfast. Review of the documented meal consumption on 2/8/2023 revealed an intake of 25-50%. Interview on 2/9/2022 at 9:00 a.m. with Licensed Practical Nurse (LPN) LL, confirmed R#16 was on restorative nursing care for left hand splint, passive range of motion (PROM) to left upper extremity, and train and skill practice with grooming tasks. During further interview, she stated she was unaware of R#16's left hand dominance and her need for assistance with meals. Interview on 2/9/2023 at 9:28 a.m. with Registered Nurse (RN) NN, revealed she was unaware that R#16 was left hand dominate. She confirmed the care plan for restorative care did not address residents need for assistance with meals. Interview on 2/9/23 at 11:42 a.m., the Director of Health Services (DHS) revealed she was unaware that R#16 was left hand dominate and needed assistance with feeding. She confirmed the resident did not have a care plan that addressed the need of assistance with meals. She stated her expectation was that residents are assessed and care planned for activity of daily living (ADL) decline, when needed. During further interview, she stated staff should notice when a resident doesn't eat much, is frequently fed by family, or those residents who spill most of their food. Interview on 2/9/2023 at 2:00 p.m., CNA PP stated residents care plan directs the care that is needed for each resident. He stated R#16 is usually fed by her husband and only requires meals to be set up. He stated he was unaware of her left-hand dominance and her need to be fed if her husband was not present during meals. Interview on 2/9/2023 at 2:09 p.m. with CNA II, stated they refer to the resident's care plan to see what kind of assistance each resident requires. She stated that she has noticed residents that need assistance with eating, but it would not be on their care plan, so she would report to the charge nurse the resident needed assistance with eating, and then a care plan is developed for assistance with eating. Interview on 2/9/2023 at 3:00 p.m., R #16 stated she does not refuse assistance with meals, but she stated assistance has not been offered to her before today. She stated someone offered and assisted her with every meal today and stated today was the first time this had occurred. Cross Refer F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and review of the policy titled Restorative Nursing Program, the facility failed to provide palm protectors to prevent further contractures for one resident (R) (R#17). The sample size was 32 residents. Findings include: Review of the policy titled Restorative Nursing Program revised 11/4/2021, revealed the policy is to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and wellbeing. Review of the clinical record revealed that R#17 was admitted to the facility on [DATE] with diagnoses of intercranial hemorrhage, hemiplegia, dysphagia, seizures, vascular dementia with behavioral disturbance and major depressive disorder. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as three, indicating severe cognitive impairment. Section G revealed resident required extensive assistance of two people for activities of daily living (ADL) and had limitations in range of motion (ROM) of both upper and lower extremities. Review of the care plan dated 1/23/2023 revealed resident has contractures of hands and fingers. Interventions to care include observe extremities daily and requires palm protectors. Observation on 2/7/2023 at 10:58 a.m. and 3:37 p.m., R#17 was lying in the bed. The resident had right hand contracture. There was no evidence of a palm protector device in place to prevent further contractures. Observation on 2/8/2023 at 12:05 p.m. resident was observed without palm protectors in either hand. Observation on 2/8/2023 at 2:02 p.m., Director of Health Services (DHS) assessed the resident's right hand and confirmed resident was not wearing a palm protector. Interview at this time revealed R#17 should be wearing palm protectors but could not find one in her room. Interview on 2/8/2023 at 1:56 pm with Restorative Nurse LL, revealed that R#17 was on the restorative program for passive range of motion and bed mobility. She stated that palm protectors do not fall under restorative services because they are not considered a splint. During further interview, she stated they are made aware of the need for palm protectors as a preventative measure. Interview on 2/8/23 at 12:45 p.m., the Director of Nursing (DON) revealed she was not aware that R#17 was not wearing her right-hand palm protector. She stated her expectation is that the palm protectors be applied with ADL care.

Based on observations, interview, and review of facility policy titled Medication Administration Guidelines, the facility failed to ensure two of three licensed nursing staff performed hand hygiene during observation of medication administration. The census was 59. Findings include: Review of the policy titled Medication Administration Guidelines revised 4/10/2019, revealed Procedure 23. If breaking tablets is necessary to administer the proper dose, hands are washed with soap and water or alcohol gel prior to handling tablets (preferably gloves should be worn). Observations on 2/8/2023 from 8:22 a.m. through 9:00 a.m. during medication administration, Registered Nurse (RN) GG was training RN HH. While preparing and administering medications for multiple residents, RN GG did not sanitize or wash hands before, during, or after administering the medications. During the preparation of one resident's medication, RN GG dropped a single pill on the medication cart, and RN HH picked up the dropped pill with her bare hands and without donning gloves or sanitizing her hands. RN HH placed the dropped pill in a medicine cup and proceeded to administer to resident. During the preparation of other residents' medications, RN GG placed two pills in her bare hand without using hand sanitizer, before putting them into the medication cup and administering to resident. Interview on 2/8/2023 at 11:53 a.m. with the Director of Nursing (DON), stated that all staff are expected to follow infection control guidelines for hand washing and policy and procedures during medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of policies titled, Foodborne Illness, Labeling, Dating, and Storage, Patients/Residents' Personal Food, Nourishments, and Dishwashing, the facility failed to ensure opened food items in the walk-in cooler and dry storage area were labeled and dated; failed to discard food items by expiration date; failed to ensure staff and resident food items were not stored together in same refrigerators; failed to maintain temperature logs on nursing unit refrigerators. In addition, the facility failed to ensure high temperature dish machine was maintained in working order. This deficient practice had the potential to affect 59 residents who received an oral diet. Findings include: 1. Review of the policy titled Foodborne Illness revised 10/18/2017, revealed foods will be used before the expiration date, use by date, and the sell by date indicated on the food item. Foods not used by these dates must be discarded. The Dietary Manager (DM) is responsible for maintain safe food preparation to prevent spread of bacteria and proper storage of food to reduce chance of foodborne illness. 2. Review of the policy titled Labeling, Dating and Storage revised 11/11/2022, revealed food and beverage items will have identifying labels with received date/opened date as appropriate and for foods prepared onsite a use by date will be indicated. Foods will be stored in their original container. Observation on 2/7/2023 at 9:30 a.m., with cook SS, revealed the following: Walk-in cooler: Mild cheddar cheese package opened and not dated. Pitcher of brown colored liquid - no label or date. Low fat cottage cheese five-pound container opened and not dated. one French Vanilla 32-ounce (oz) coffee creamer with employee's name on it, no date. Dry Storage: Imperial thickened Apple Juice, 46 oz, expired on 1/25/2023 x 7 boxes. Tomato Juice, 46 oz, expired on 1/30/2023 x 5 boxes. Apple Juice Blend, 33.8 oz, box opened on 12/26/2022 no expiration date on container [NAME] Corn Starch, 16 oz, expired on 2/2/2023, x 9 boxes. Interview on 2/7/2023 at 9:35 a.m. with [NAME] SS, confirmed expired items in the walk-in cooler and dry storage and stated expired items should be discarded on expiration date. Interview on 2/7/2023 at 9:45 a.m., the Registered Dietitian (RD) revealed her expectation is that all expired foods are to be discarded. 3. Review of the policy titled Patients/Residents' Personal Food revised 11/11/2022, revealed the facility allows family to provide food items for resident consumptions following specific guidelines. The guidelines include but are not limited to food must be in a covered container and must be consumed during the visit and leftovers will not be refrigerated or reheated at the facility. 4. Review of the policy titled Nourishments revised date 10/18/2017, revealed the staff are to offer nourishments routinely to residents. The Dietary department is responsible for stocking the nourishment kitchens by delivering nutritional supplements to the nursing stations at designated times. Dietary is to label and date all items sent from their department to the nourishment refrigerator, discard all items according to their use by date. Refrigerator temperatures must be recorded daily on the refrigeration temperature log. Staff are not permitted to store their food or drinks in the nourishment refrigerators. Observation on 2/7/2023 at 3:25 p.m., two breakroom refrigerators revealed staff and resident food items were being stored together in the same refrigerators. There was no temperature log located on or near either refrigerator. The following items were discovered it the A/B hall breakroom refrigerator to be expired: one 46 oz box of thickened lemon-flavored water opened on 2/7/2023 expired 1/25/23 two 46 oz boxes of thickened apple juice expired on 1/20/23 Observation on 2/8/2023 at 10:15 a.m., revealed in C/D hall breakroom refrigerator a pizza box with a resident's name on it and no date. The Director of Health Services (DHS) confirmed this was a left-over pizza that should not be in this refrigerator, and stated all leftovers brought in from outside must be discarded and cannot be kept for later consumption. Interview on 2/7/2023 at 3:25 p.m. with [NAME] TT, stated resident drinks and food items are stored in both breakroom refrigerators. She confirmed staff foods and resident foods both were in the A/B hall breakroom refrigerator. During further interview, she confirmed there was no temperature log located on or around this refrigerator. She stated Nursing department was responsible for keeping temperature logs for this refrigerator. She confirmed all items that were found to be expired in this refrigerator. She immediately removed all expired items and disposed of them. Interview on 2/7/2023 at 3:40 p.m. with Licensed Practical Nurse (LPN) LL, revealed the dietary staff stock the breakroom refrigerator with resident foods. She stated the dietary staff are responsible for maintaining the temperature logs for the breakroom refrigerators. She verified there was staff food and resident foods in the A/B hall breakroom refrigerator. During further interview, she confirmed there was no temperature log on or around the refrigerator, and stated dietary staff were responsible for maintaining the temperature log for the breakroom refrigerators. Interview on 2/8/2023 at 9:00 a.m. with the Dietary Manager (DM), stated the dietary staff were responsible for stocking the breakroom refrigerators with resident food/drinks. She stated she was not sure who was responsible for monitoring the temperature of the break-room refrigerators. During further interview, she stated no left-over foods brought into the facility should be kept in the resident's refrigerator. She stated that resident and staff foods should not be in the same refrigerator. Interview on 2/8/2023 at 10:15 a.m., the Director of Health Services (DHS) revealed the resident refrigerators are located in the medication rooms behind each nursing station. She stated the refrigerators in the breakrooms are staff refrigerators. She verified resident food was stored in both breakroom refrigerators, and stated her expectation is that no resident food or drinks should be in either of the staff refrigerators. She stated the breakroom refrigerators are monitored by housekeeping, and she was unsure of where the temperature logs were. Interview on 2/9/2023 at 10:15 a.m. with housekeeping supervisor RR stated the dietary department was responsible for maintaining the temperature log for the refrigerator in each break room. 5. Review of the policy titled Dishwashing revised 3/23/2016, revealed dietary staff are to record temperatures of wash and rinse cycle on the dish machine temperature log. It is policy to adhere to the manufacturer's guideline for appropriate temperature ranges. The dish machine temperature log must be completed by staff directly involved in the dishwashing process. All temperatures out of range are to be reported immediately to the DM. Observation on 2/8/2023 at 9:00 a.m. the dish washing area revealed a high temperature dishwasher. Two consecutive wash and rinse cycles revealed the wash temperature reached 145 degrees Fahrenheit (F) and the rinse cycle temperature reached 168 degrees Fahrenheit. Interview on 2/8/2023 at 9:00 a.m., the Dietary Manager (DM), verified the dishwasher wash and rinse temperatures were below the requirement for proper sanitization of dishes. She stated the dishwasher had preventative maintenance a few weeks ago. Interview on 2/7/2023 at 9:35 a.m., the Registered Dietitian (RD), stated if the dishwasher is not reaching the minimal temperatures recommended by the manufacturer, then the machine should be taken out of service, call maintenance for repairs, and use disposable tableware until the dishwasher is repaired. She stated the manufacturers recommended high temperature dishwasher was 150 degrees F. for wash cycle and 180 degrees F. for rinse. Interview on 2/9/2023 at 12:00 p.m., the Administrator stated the dietary staff are responsible for the temperature log for the refrigerators in the breakrooms. He stated his expectation was that all foods that are expired are to be discarded. He stated the nurses are responsibility for discarding expired items from resident refrigerators, as well as documenting the temperatures. He stated he expected the dietary staff who is washing dishes to notify the DM if the temperatures are not reaching the minimum temperature recommended by the manufacturer for proper sanitization of the dishes remove the machine from use, and then the DM is to notify maintenance of issues, in the meantime they are to use disposable table ware while the dishwasher is not in service.

Based on observation, interviews, and review of the policy titled Infection Control-Linen and Laundry, the facility failed to ensure that essential equipment in the laundry was in working order to properly sanitize facility linens, as evidenced by a non-functioning boiler. The facility was currently in COVID-19 outbreak status and had no hot water for laundry. The census was 69 residents. Findings: Review of facility policy titled Infection Control-Linen and Laundry, revised on 4/2/2020, revealed it is the policy to mitigate or decrease infections caused by sources of microbial contamination through collection, handling, sorting, transportation, processing, and storage of laundry. Procedure F. number 5 v. revealed that soiled laundry is washed with an organization approved detergent and hypochlorite product at a temperature of >120 degrees to 160 degrees. If hypochlorite product is not utilized in the laundry process, soiled laundry is washed at >160 degrees. Review of documents provided by the facility revealed that a replacement boiler request was submitted on 11/10/2022. Two quotes were sent with the request. The document revealed it received final approval by the Chief Executive Officer (CEO) on 2/3/2023. Observation on 2/9/2023 at 9:35 a.m. during a tour of the laundry room with Laundry Aide SS, stated that there were three washers. She was asked about checking the temperature of the water and she stated, I guess it is this right here and pointed to a digital gauge on the washer. She stated she checks the washer to make sure that the chemical level is what it should be though. She revealed that she does not clean the washer out after soiled laundry is completed. Interview on 2/9/2023 at 12:45 p.m. with the Maintenance Director, revealed the boiler has been non-functioning for about three years. He stated that he requested the boiler be replaced and completed the appropriate requestions with quotes for replacement. He stated it was approved, but then the approval was cancelled due to pricing. Interview on 2/9/2023 at 1:05 p.m. with Housekeeping Manager revealed that she has been the manager for 15 years. She stated the Maintenance Director has been trying to get the boiler replaced since 2021. She stated that she has been using extra bleach in the soiled, contaminated laundry to make up for no hot water. Interview on 2/9/2023 at 3:00 p.m. with Certified Nursing Assistant (CNA) II and JJ stated they have seen some linens that were dirty, and stated it was mostly sheets. Interview on 2/9/2023 at 3:33 p.m. with the Administrator, revealed the process of replacing the boiler had been started when he came to the facility in 12/2021. He stated he received an updated quote and submitted it for approval. During further interview, he stated the requisition was approved in January 2023. When asked what his expectations were for sanitizing the laundry without hot water, he stated it's the chemicals that are the cleaning agents, not the hot water.