**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and facility policy review, the facility failed to ensure three of five residents (Resident (R) 8, R18, and R91) and/or their resident representatives (RR) out of a sample of 23 residents reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the residents and their RRs by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's undated policy titled, Transfer and Discharge (including [against medical advice] AMA) revealed the following (12) e. provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form or manner that the resident can understand .(h) the Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. 1. Review of R8's admission Record from the electronic medical record (EMR) Profile tab, showed a facility admission date of 01/04/25 with a diagnosis of gastrointestinal hemorrhage. Review of R8's annual Minimum Data Set (MDS) assessment from 01/08/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of R8's Health Status Note, dated 12/27/24 and located under the Progress Notes tab of the EMR, revealed resident sent to [emergency department] ED via [emergency medical services] EMS due to dyspnea and blood in stool. Further review of the EMR Documents tab did not show any documentation of a written notice of transfer provided to R8 or R8's RR. During an interview on 01/28/25 at 12:33 PM, R8 stated she thought she was in the hospital one month ago for pneumonia. 2. Review of R18's admission Record from the EMR Profile tab showed a facility admission date of 12/03/24 with diagnoses of metabolic encephalopathy, Guillain-Barre Syndrome, /hemiplegia and Hemiparesis following cerebral infarction affecting non-dominant side, polyneuropathy, muscle weakness (generalized, and other abnormalities of gait and mobility. Review of R18's quarterly Minimum Data Set (MDS) assessment from 01/03/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little or no cognitive deficit. Review of R18's Health Status Note, dated 12/01/24 and located under the Progress Notes tab of the EMR, revealed Resident was complaining of fecal impaction last night. After speaking with her and the on-call [nurse practitioner] NP, resident wanted to go to the ER. Resident's abdomen was distended and hard. The [emergency room] ER is currently waiting on a room at [Hospital Name] to transfer her. According to her nurse at [hospital ER], a scan was done and showed a large amount of impaction. Further review of the EMR Documents tab did not show any documentation of a written notice of transfer provided to R18 or RR. 3. Review of R91's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 09/21/24 with a diagnoses of nonrheumatic aortic valve stenosis, idiopathic pulmonary fibrosis, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified dementia, urinary tract infection, type two diabetes, chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, and hypertensive heart disease with heart failure. Review of R91's 5-Day Minimum Data Set (MDS) assessment from 01/16/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little or no cognitive deficit. Review of R91's Health Status Note, dated 09/21/24 and located under the Progress Notes tab of the EMR, revealed The Resident's daughter said she wanted to speak with a doctor, this nurse states the Resident needs to go to the ER, but the Resident's daughter says No, I want to speak with the doctor on call to tell me where we need to go. This nurse called the on-call service number and chose [the] option for them to give a call back. Upon entering the room again, the Resident's daughter said she went ahead and called 911. EMS arrived at 19:00 (7:00 PM). [R91] left with EMS via stretcher at 19:05 (7:05 PM). [The] daughter left and took [the] resident's belongings. EMS states they are taking [the] resident to [Name] ER. DON (Director of Nursing) and admin (Administrator) notified. Resident alert and talking upon discharge. Further review of the EMR Documents tab did not show any documentation of a written notice of transfer provided to R91 or RR. During an interview on 01/31/25 at 10:13 AM, the Administrator stated discharge summaries were not provided to residents or family members in a language they could understand regarding the reason for discharge to the hospital. During an interview on 01/31/25 at 10:08 AM, Unit Manager (UM) 1 stated an [situation, background, assessment, recommendation] (SBAR) form, face sheet, and medication list were sent to the hospital with residents. She stated a separate discharge summary indicating the reason for discharge in a language the resident could understand was not sent with the residents or provided to family members. During an interview on 01/31/25 at 10:29 AM, the DON stated the facility did not have a separate discharge sheet to provide the resident and/or representative indicating why the resident was sent to the hospital in a language they could understand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to complete the comprehensive care plan to include the use of oxygen for one of 23 sample residents (Resident (R) 20) reviewed for care planning. The failure had the potential for R20's medical, nursing, mental, and psychosocial needs not being met. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, indicated .develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/24 and located in the electronic medical record (EMR) under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. The MDS revealed the resident was admitted on [DATE] with diagnoses to include hypoxemia, and shortness of breath or trouble breathing when lying flat and had oxygen therapy with intermittent use. Review of R20's EMR located under the Care Plan Tab a comprehensive care plan with an initiated date of 12/16/24 did not display the use of oxygen for R20. During an interview on 01/31/25 at 11:00 AM, Licensed Practical Nurse (LPN) 8 stated yes oxygen (O2) should be on the care plan to help communicate the care needed for that resident. During an interview on 01/31/25 at 12:40 PM, the MDS Coordinator (MDSC) stated that O2 should be on the care plan so that staff knew the needs of the resident. We just missed it. We will get it corrected immediately. During an interview on 01/31/25 at 1:15 PM, the Director of Nursing (DON) stated that O2 should have been on R20's care plan to let the staff know that O2 was being used and how it's being used such as continuous or as needed (PRN). DON stated the care plan let's all nursing staff know how to properly take care of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure medications were received in a manner that allowed administration for one of one resident (Resident (R) 91) reviewed for medication administration of 23 sample residents. This failure has the potential to cause R91 not to receive the therapeutic benefits of their prescribed medications. Findings include: Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated 10/01/19, revealed (1) medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Review of the facility's policy titled, Pharmacy Services, dated 2024, under the Compliance Guidelines section revealed the following (1). the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of R91's admission Record located in Profile tab of the electronic medical record (EMR) revealed R91 admitted on [DATE] with diagnoses of nonrheumatic aortic valve stenosis, idiopathic pulmonary fibrosis, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified dementia, urinary tract infection, type two diabetes, chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, and hypertensive heart disease with heart failure. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/24 and located in the MDS tab of the EMR revealed R91 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating little or no cognitive deficit. Review of the Medication Administration Record (MAR), dated September 2024, located in the EMR under the Order tab, revealed the resident did not receive most of her prescription medication that was ordered on 09/21/24 due to pending pharmacy delivery. She received over the counter (OTC) medications and a nitroglycerin (medication used to treat acute chest pain) that was pulled from the emergency kit and was administered. Review of the Packing Slip Proof of Delivery form, provided by the facility, revealed the following medications were delivered for R91 on 09/20/24 at 9:21 PM but was not provided to the resident: albuterol HFA 90 [micrograms] mcg (for respiratory illness), famotidine 10 mg [milligrams] (for acid reduction), fluoxetine 20 mg (to treat depression), furosemide 20 mg (diuretic), ipratropium/albuterol (for shortness of breath) nebulizer (device for breathing treatments), isosorbide Mono ER (extended release) 30 mg (treat chest pain and heart failure), levothyroxine 100 mcg (for thyroid disorders), and memantine 5 mg (for Alzheimer's), metoprolol SUCC ER 25 mg (for high blood pressure), montelukast 10 mg (for allergies and asthma), pantoprazole 40 mg (for gastroesophageal disease) and potassium CL [chloride] ER 20 MEQ [milliequivalents]. During an interview on 01/29/25 at 4:27 PM, the Director of Nursing (DON) stated new orders were entered into the system and faxed to pharmacy prior to a resident arriving in the facility. She reviewed the MAR and confirmed the MAR indicated medications were not administered pending pharmacy delivery. She stated R91was admitted in the middle of the night and the orders were not entered prior to R91 being admitted . The DON stated R91's orders came with her discharge packet from the hospital and were entered after she arrived at the facility. She stated the pharmacy would need the orders by 4:00 PM on Saturday to deliver them on Sunday. Per the DON, the pharmacy did not deliver medications on Sunday. She stated they kept some Lasix in the e-kit (emergency medication supply). She stated if it was the correct dose for the resident, the nurse could have pulled the Lasix to administer it. She stated R91 had an order for Lasix 20 mg start date 09/21/24. The DON stated the e-kit had 20 mg doses of Lasix in it. She verified and confirmed the charge nurse could have administered the Lasix on 09/21/24. During an interview on 01/30/25 at 9:18 AM, the DON stated the nursing staff could call the pharmacy and ask for medication to be delivered stat [immediate] and/or they could use a local pharmacy. During an interview on 01/30/25 at 1:34 PM, Registered Nurse (RN) 4 stated the charge nurse never informed her she was waiting for R91's medications to be delivered from the pharmacy. RN4 stated if the charge nurse had mentioned this, they could have looked in the e-kit to see what was available to give the resident based on her current orders. RN4 was notified of the medications being delivered to the long-term care side of the facility and not delivered to the rehabilitation side. During an interview on 01/30/25 at 4:34 PM, Licensed Practical Nurse (LPN) 6 stated the pharmacy did not deliver medications on Sundays. She stated they could have called for a stat delivery and could also check the orders and e-kit to see what medications were available to administer. During an interview on 01/31/25 at 1:03 PM, the Medical Director stated his expectations were for nurses to access the e-kit for medications if they were available or to contact the pharmacy for a stat delivery. During an interview on 01/31/25 at 1:19 PM, LPN5 stated medications received on the long-term side of the facility that were for rehab residents should be taken to the rehab unit by a staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and facility policy review, the facility failed to identify target behaviors for monitoring effectiveness of antipsychotic medication for one of five residents (Resident (R) 48) reviewed for unnecessary medications of 23 sample residents. This failure had the potential to contribute to unnecessary antipsychotic medication use in R48 who used the medication to treat behavioral symptoms of anxiety. Findings include: Review of the facility's undated policy titled, Use of Psychotropic Medication, revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documented of the resident response to the medication. 4. The indication for use of any psychotropic drug will be documented in the medical record. Review of R48's undated admission Record located in the Profile tab of the electronic medical record (EMR), revealed R48 was admitted to the facility on [DATE] with diagnoses including, history of falls, multiple fractures of the left arm and pelvis, panic attacks, anxiety and major depression disorder. Review of R48's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 and located in the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little or no cognitive deficit. Review of R48's Physician's Orders, dated 01/25 and located in the Orders tab of the EMR, revealed an order for lorazepam (an antipsychotic medication), 0.5 milligrams (mg) every eight hours as needed for anxiety, which originated on 01/27/25, with a stop date 02/08/25. Review of R48's EMR Progress Notes under the Notes tab and Medication Administration Records (MAR) under the Orders tab revealed no documentation of monitoring moods and behavioral symptoms to evaluate the nature and circumstances of anxiety and to monitor for continued need of the medication related to behavioral symptoms. During an interview on 01/31/25 at 1:45 PM, Registered Nurse (RN) 3 was asked how the behaviors of R48 were tracked to know when R48 would need the lorazepam, RN3 replied we chart in the MAR. When asked to show the documentation of the behaviors that indicated need for lorazepam, RN3 was unable to show the documentation. During an interview on 01/31/25 at 2:00 PM, the Director of Nursing (DON) stated the behaviors were monitored in the MAR and her expectation would be for behaviors to be documented with each administration. During an observation and interview on 01/31/25 at 2:23 PM, R48 was sitting in her wheelchair in her room. R48 stated she had taken the Ativan (brand name for lorazepam) for approximately 15 years and it's the only medication that has consistently helped me and it just makes my life better.

Based on observations, staff interviews, and record review, the facility failed to hire qualified dietary staff certified to serve food in a clean, safe and sanitary manner. The potential for foodborne illnesses could affect 84 of 85 residents. Findings include: Interview on 3/06/2024 at 10:36 am with the Food Service Director revealed he did not know about two essential areas needed to keep residents safe from foodborne illnesses, the appropriate dish machine temperatures to ensure clean, sanitized dishes and utensils, or the safe holding temperature for meals served to residents on their trays. Review of the Food Service Director's employee file revealed no certification for Certified Dietary Manager (CDM) or safe food handling card. His title was Food Service Director and did not claim to be a CDM. He corrected the surveyor twice when called CDM. Interview on 3/7/2024 at 10:54 am with the Human Resource Director revealed the Food Service Director does not have a CDM certificate or safe food handling card.

Based on observations, resident and staff interviews, and record review, the facility failed to serve the appropriate quantities of food according to the prescribed dietary recipe. The deficient practice had the potential for malnutrition and could affect 84 of 85 residents receiving an oral diet from the kitchen. Findings Include: Observation on 3/5/2024 from 11:46 pm to 12:02 pm, the Dietary [NAME] placed chicken and dumplings, and peas on two resident's plates using a 3-ounce (oz) sized ladle for the chicken and dumplings. When asked about the size of the serving ladle, the Dietary [NAME] immediately grabbed a 4 oz ladle. She stated that the 4 oz ladle will be used to serve the meal/meat, then the 3 oz ladle will be used to fill the bowl with just the liquid. The Dietary [NAME] added This is how the chicken and dumplings are served. Review of the chicken and dumplings recipe dated 10/24/2023 revealed the serving utensil sizes as Spoon & 6 oz ladle. Interview on 3/6/2024 at 12:24 pm with the facility's Registered Dietician (RD) revealed that food service staff are required to follow the recipes to the detail. While looking at the recipe, the RD said that chicken and dumplings should be served using the 6 oz ladle and not the 4 oz and 3 oz method. The RD explained that both liquids and solids should have been served together and not separately. Subsequent interview on 3/6/2024 at 2:30 pm with both the Dietary [NAME] and Food Service, the Dietary [NAME] stated that she used the additional 3 oz ladle to fill the bowl with liquid. Both the Food Service Director and the [NAME] were confused about the details of the recipe concerning the serving size of the chicken and dumplings, and correct utensil sizes and usage. Interview 3/4/2024 at 9:20 am with Resident (R) (R8), he stated that they had a serious belief the facility was not serving the required quantities of food.

Based on observations, resident and staff and complainant interviews, and record reviews, and review of the facility policy titled, Temperature for Food Safety, the facility failed to serve food that is palatable, attractive and at required temperatures. The deficient practice had the potential to affect 84 of 85 residents utilizing dining services. Findings Include: Review of the facility policy titled Temperature for Food Safety dated 3/6/2024 indicated 135 [degrees] F [Fahrenheit] minimum temperature for holding hot food. Danger Zone 41 [degrees] -135 [degrees] F Rapid Bacteria Growth Zone. On 3/4/2024 at 5:15 pm, a test tray of Monday's menu Week 4 Dinner was served to this Surveyor, which included stuffed cabbage soup, roast beef sandwich, carrot raisin salad, and mixed melon salad. The stuffed cabbage was flavorless and not edible. The roast beef sandwich was served with just meat and cheese, no lettuce, tomato, onions, etc. The mixed melon salad only contained cantaloupe that appeared to have been frozen and thawed or was fresh and was going bad. The cantaloupe was unappealing and did not appear fresh. Interview on 3/4/2024 at 9:20 am with anonymous residents (A) (A1 and A2) complained of receiving cold food. A1 reported that grits are sometimes delivered in a bowl shape. A2 reported that their eggs were cold, rubbery and resembled mangoes. Interview on 3/5/2024 at 9:03 am, the Food Service Director stated that liquid scrambled eggs take on the appearance of mangoes because they shrivel up and become solid and smooth when cold. Multiple residents described the disk-shaped eggs with a yellow circle in the middle as undesirable and that they wanted real eggs. The Food Service Director stated that he was aware of the egg complaints. Review of Resident Council Minutes showed that residents complained of cold food in the following meetings: 1/17/2024, 11/22/2023, and 7/26/2023. Review of a grievance filed by a resident on 6/21/2023 reads Resident reports food is cold when arriving to the rooms. Residents reporting grievances are anonymous. Interview on 3/4/2024 at 3:25 pm with CNA DD and CNA AA2 revealed that some residents are not willing to eat the food based solely on the food's appearance. When they see the food, they want something else. Some are pickier than others. I sit the tray in front of the residents. Some may not like what is on the tray. In that case, I take the tray and ask if there is something else they would like to eat from the alternative menu. The popular alternatives are peanut butter and jelly, ham and cheese sandwiches, and soups. Interview on 3/4/2024 at 2:59 pm with CNA AA3 revealed they were sometimes embarrassed to serve some meals to the residents, although they serve the meals and tried to convince the residents to eat it. Residents are complaining about the food. It does not look as appetizing as they like. Meals look kind of monochromatic, lacking colors. They complain two or three times daily about how bad the food is. The complaints are constant and are not new. I first try to convince the residents to eat the food. Then, if that is not possible, I offer alternative meals. They like the salads, and they usually request it as an alternative. Interview with anonymous resident (A) (A2), they stated Often they serve 3 chunks pieces or three 1 oz portions of sausage, mystery meat, small potatoes, snack sandwich with just meat, no lettuce, tomatoes, onions, etc. Every once in a while, we get a banana. Grits are served solid. The food is not always warm. Interview 3/5/2024 at 10:25 am with A3 revealed that the quality of the food here is terrible. A3 stated that it has gotten so bad that they are weighing me daily. The meat is overcooked and tasteless. Last night, I received a roast beef sandwich with no tomatoes, lettuce, onion, etc. with really, really, thin slices of roast beef and mozzarella cheese. It was not palatable, though, this time they included a pack of mayo. The turkey sandwich from the night before had no condiments. Corned beef hash is horrible. Veggies are hard like corn and black beans. Interview via telephone on 3/5/2024 at 2:32 pm with a Complainant for A2 revealed the food photos on the menu do not match the actual menu. Sometimes they claim it is gourmet. No may, no mustard, thin slices of luncheon meat. Almost all the food is non-edible [sic]. It has never gotten better. On 3/5/2024 at 1:16 pm, the Food Service Director placed two test trays in the food cart to be delivered to the training room. The Food Services Director was requested to bring the entire cart with the two test trays. However, he stated that if he took the entire cart then the CNAs could not return the dirty dishes/trays to the cart. The Food Service Director was observed as he carried one of the test trays to the conference room. The other test tray remained in the Middle Hall on the cart. The initial temperatures while on the steam table (approximately at 12:00 pm) was 160 degrees Fahrenheit for the chicken & dumplings and 165 degrees Fahrenheit for the peas. The Food Service Director delivered the test tray and returned with the Dietary [NAME] who then took the temperatures of the food items using a digital thermometer. The chicken and dumplings temperature were 132.9 degrees Fahrenheit and the peas measured at 123.5 degrees Fahrenheit. The Food Service Director stated that the appropriate serving temperature for meals was 110 degrees Fahrenheit. Interview on 3/6/2024 at 9:58 am with the Administrator, he stated that food service was supposed to add at least two garnishments such as an orange slice, apple slice or parsley to lunch/dinner to make it more appealing and appetizing. The Administrator apologized that these items were not included on the test trays or residents' meals.

Based on observations, resident and staff interviews, and record review, the facility failed to serve residents their preferences and alternative meals. The deficient practice had the potential to affect 84 of 85 residents receiving meals from the kitchen. Findings include: During the initial tour on 3/4/2024, multiple residents complained that their food choices were not honored. Interview on 3/4/2024 at 9:14 am with anonymous resident (A) (A5) revealed that the food is okay, but she prefers raw fruit and vegetables like avocados. Interview on 3/4/2024 at 9:28 am with A6 revealed they do not serve fresh fruit or veggies. Interview on 3/4/2024 with A7 revealed that the meat is too tough like the pork shops, steak, and hamburgers, and would like more veggies. Sliced apples in a packet are the only fresh fruit we receive. Interview on 3/4/2024 with A2 revealed that the only fruit usually served is canned fruit, but they do serve fresh sliced oranges or apples. Interview on 3/5/2024 at 8:33 am with A4 revealed he requested that Dietary not to serve him boiled eggs (on at least fifteen occasions), but he keeps receiving them. On 3/4/2024, the Food Service Director provided a copy of the residents' meal preferences and on it stated, no boiled eggs. The Food Service Director stated that he would consult with the resident. On 3/5/2024 at 8:33 am, the same resident A4 stated that he received boiled eggs again. The following morning on 3/6/24 the same resident declined to give an answer. Review of Resident Council Minutes dated 11/23/2024 revealed that residents Received items from dietary that have been requested not to receive and that they Would like little cartons of milk. Resident Council Minutes dated 1/17/2024 references concerns regarding Food preferences/allergies. Resident Council Minutes dated 9/30/2023 read Not able or asked to choose alternate meals and Receiving food they have requested not to. Resident Council Minutes from 6/21/2023 revealed that residents are Not getting alternate meals. A test tray was ordered and sampled on 3/4/2024 at 5:20 pm by a surveyor. They revealed that the stuffed cabbage was flavorless and not edible. They could not swallow the contents of one spoonful of the stuffed cabbage. Observation on 3/5/2024 from 12:02 pm to 1:00 pm revealed alternate meals of meatloaf, mashed potatoes and brown gravy were not on the serving hot steaming tray unit nor were they requested, plated or served to residents during the observation timeframe. There were only two meals from the menu on the steam table ready to be served to the residents: chicken and dumplings and peas. They were served in two forms, regular and pureed. When asked, Is this it? The [NAME] responded, This is it, and serving began. Only three residents received little cartons of milk during serving observations. There was no milk served on the beverage carts on each of the five units. Each beverage cart contained a hot water dispenser, fresh brewed iced tea, and cups. Interview on 3/6/2024 at 12:24 pm with the Registered Dietician revealed they plan to serve fresh fruit in the Spring, confirming resident's complaints. Interview on 3/6/2024 at 2:30 pm with the Food Service Director, he stated that the alternative meals were not on the serving table along with the main menu because of the lack of space in the steam table/serving area. He also stated that the meals were in a separate compartment that was not visible and that the alternate meals would have been served upon request. Interview on 3/6/2024 at 5:20 pm with the Administrator, he revealed that if the residents do not like what is posted on the menu, they will ask the CNA or someone to place an order from the alternative menu. Their meals are based on their likes and preferences. We brought out the main menu concept to eliminate the need for residents to see what others have ordered. Their eyes make the meal. Food service is supposed to add two garnishments such as orange slice or parsley during lunch/dinner to make meals more appealing and appetizing. They take pictures of each tray line to review for complaints.

Based on observations, staff interviews and record reviews, the facility failed to recognize the dish machine was malfunctioning and producing temperatures too low to kill bacteria and germs for the last 10 months. The potential for foodborne illnesses could affect 84 of 85 residents. Findings include: The facility had no policy for the required temperatures for the dishwashing machine. Review of the Resident Council Minute/Grievance dated 6/21/2023 showed various complaints as follows Residents continue to voice that coffee cups are dirty and Numerous residents report hair being found in their food. Observation and interview on 3/6/2024 at 10:24 am with the Food Services Director, the Food Service Director found dirty utensils in a pile of clean, ready to use silverware. The silverware contained caked on debris that the Food Service Manager was able to flick off or remove with his fingernails. This led to the discovery that the dish machine was not working properly. The Food Service Director revealed that he looked at the temperature logs once a week or maybe once every two weeks. He expected his dishwashers to let him know if the temperature was out of range. He has not trained or in-serviced the dishwashers on the proper temperatures. The Food Service Director was not aware of the proper dishwashing temperatures for the machine. The metal plaque affixed to the machine on the right side of the machine reads NSF Machine Operational Requirements as Manufactured by 'name of manufacturer' Dish Machines. Wash temperatures minimum 155 degrees Fahrenheit. Wash cycle time is 49 seconds. Rinse temperature minimum is 180 degrees F. Rinse cycle time 12 seconds. Steam evacuation 41 seconds. Review of the Dish Machine Ware Washing Log (Low Temp) and Dish Machine Ware Washing Log (High Temp) indicated that proper wash and final rinse temperatures were not met for the last 10 months. The facility called the maintenance contractor company to fix the dish machine temperatures after it was brought to their attention for the second time on 3/6/2024 at 2:46 pm. The company repaired the shut off valve for the cold water and fixed the final rinse temperature for the leased dishwasher and found that the water was turned off the condenser and booster heater for the CMA 180VL (dish machine model). The repairman stated, After turning the water back on, water and the booster heater were lit up and it was reaching the final proper rinse temperature. I had to turn up the water pressure for the final rinse. Interview on 3/6/2024 at 4:30 pm with the Administrator, the Administrator confirmed that he was aware of the dish machine problems and the food temperatures were too low. He has some in-services to do with the kitchen staff and other people as well. Observation on 3/7/2024 at 9:29 am revealed the dish machine was not working again. The machine was shut off and no dietary aides were present in the dishwashing area. According to the Food Service Director, the machine stopped working 10 minutes before the surveyor's arrival to the kitchen. Wash temperatures reportedly read 145 degrees Fahrenheit four consecutive times and final rinse was only 90 degrees Fahrenheit. The Food Service Director did not expect a repair date until the following workday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the policy titled Hemodialysis, the facility failed to ensure that one of two residents (R) (R#20) receiving dialysis treatment received care and services consistent with professional standards of practice related to assessing the arteriovenous fistula (AVF) access site and documenting findings daily and after dialysis treatments and providing documented communication between the facility and the dialysis center before and after dialysis appointments. Findings included: A review of the policy titled Hemodialysis dated 1/1/21 and revised 3/24/23 revealed the purpose was to assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The Compliance Guidelines section revealed: The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications. The facility will ensure that the physician's orders for dialysis include: The type of access for dialysis (for example graft, arteriovenous shunt, external dialysis catheter). The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill (a procedure used to assess for patency of the fistula used for dialysis treatment). A review of the clinical record revealed that R#20 was an [AGE] year-old female admitted on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed R#20 had a BIMS of 15, indicating the resident is cognitively intact; required extensive assistance for activities of daily living (ADLS); and that R#20 received dialysis. A review of the care plan revealed R#20 needed dialysis hemodialysis related to end stage renal disease (ESRD). The goal was that R#20 will have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date. Interventions included: Do not draw blood or take blood pressure in the arm with a graft; encourage resident to go for the scheduled dialysis appointments three times weekly; monitor vital signs as warranted; notify physician of significant abnormalities. A review of the care plan revealed there were no interventions to monitor the AVF site or assess for thrill and bruit. A review of the physician's orders reviews revealed orders included (not all inclusive): 3/22/23: Full set of vitals prior to dialysis on Monday, Wednesday, Friday one time a day related to ESRD. 3/20/23: Resident is to receive dialysis at DaVita on Monday, Wednesday, Friday. A review of the physician's orders revealed there was not a physician's order to monitor the AVF site or to assess for thrill and bruit. A review of the medication administration record (MARS) revealed there was not a section to monitor the AVF site or assess for thrill and bruit. A review of the electronic medical record (EMR) and the paper chart revealed there were no dialysis communication forms in the charts. A review of the nursing progress notes revealed documentation of pre-dialysis information was documented on 3/20/23, 3/24/23, 4/7/23; for three of twenty-one dialysis appointments opportunities and post dialysis documentation was not present on any days. On 4/29/23 at 8:45 a.m. and at 1:40 p.m. observations and interviews of R#20 revealed her to have light blue discoloration around her AVF site on her left upper arm. She revealed she was unaware of staff assessing the site on any day. On 4/30/23 at 12:50 p.m. observation and interview with R#20 revealed staff had observed her AVF site on this date and she did not remember the facility staff observing her AVF site prior to this date. On 4/29/23 at 9:00 a.m. an interview with Licensed Practical Nurse (LPN) II revealed she had worked at the facility for two months. She revealed the dialysis access site was assessed for thrill and bruit one time daily and was not documented. She revealed on the days R#20 went to dialysis a printed copy of the MARS containing vital signs and weight was sent with the resident to dialysis appointments. She revealed she normally called the dialysis office for a verbal report after the resident returned. She revealed a communication form was available, but she normally did not use it. She revealed if the communication form was completed and returned, it was filed in the resident paper chart. A review of R#20s paper chart with LPN II revealed there were no dialysis communication forms in R#20's chart. On 4/30/23 at 1:10 p.m. an interview with the Director of Nursing (DON) revealed her expectations were for physician orders to include monitoring and assessing for thrill and bruit of dialysis access sites and for monitoring and assessment of dialysis access sites to be performed by the nurse daily and upon return from a dialysis appointment. She further revealed the care plan should include interventions to monitor the dialysis access site and perform thrill and bruit assessment daily and after return from dialysis appointments and to document the assessment. She revealed her expectation was for the nurse to complete a Dialysis Communication Transfer Form and send to the dialysis center with the resident at each dialysis appointment and if the form is not returned when the resident returns, the nurse should call the dialysis center for a report and should document the report findings on the nursing progress notes. She further revealed she planned to provide education to the nurses on assessment of the dialysis access site, completion of the Dialysis Communication Transfer Form, and documentation of the assessment and any telephone or verbal reports received from the dialysis center. The DON verified there was no documentation of the assessment of the AVF access site on the MARS or the nursing progress notes and verified there were only three of twenty-one dialysis appointments opportunities documented in the nursing progress notes. She verified there was not any interventions on the care plan to assess the AVF site for thrill and bruit daily and upon return from a dialysis appointment.

Based on staff interview, record review, and review of the facility policy titled Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days, for as-needed (PRN) psychotropic medications for one of five residents (R) (R#41) reviewed for unnecessary medications. Findings included: A review of the facility policy, Use of Psychotropic Medication, revealed if an attending physician or prescribing practitioner believed it was appropriate for an as-needed (PRN) psychotropic medication order to be extended beyond 14 days, they would document their rationale in the resident's medical record and indicate the duration for the PRN order. A review of the physician orders for R#41, dated 2/17/23, revealed the physician ordered Klonopin 0.5 mg, one tablet by mouth twice a day, as needed for agitation. The order had no stop date. A review of the Monthly Administration Record (MAR) revealed R#41 received Klonopin, 0.5 mg by mouth, on the following dates and times: A review of the MAR revealed R#41 was administered klonopin 0.5 mg by mouth on the following date and times: 2/23/23 at 9:24 a.m., 3/3/23 at 9:28 a.m., 3/11/23 at 9:41 a.m., 3/12/23 at 7:46 a.m., 3/19/23 at 8:07 a.m. and 9:43 p.m., 3/24/23 at 8:07 a.m., 3/25/23 at 8:04 a.m., 3/26/23 at 7:38 a.m., 3/28/23 at 6:40 p.m., 3/29/23 at 4:20 p.m., 3/30/34 at 6:47 p.m., 4/1/23 at 6:36 p.m., 4/2/23 at 9:47 a.m. and 7:15 p.m., 4/4/23 at 6:50 p.m., 4/5/23 at 7:10 p.m., 4/6/23 at 6:23 p.m., 4/7/23 at 6:37 p.m., 4/10/23 at 6:59 p.m., 4/11/23 at 6:37 p.m., 4/12/23 at 7:43 p.m., 4/13/23 at 7:02 p.m., 4/14/23 at 10:08 p.m., 4/18/23 at 8:32 p.m., 4/19/23 at 7:34 p.m., 4/20/23 at 4:13 p.m., 4/21/23 at 7:15 p.m. and 3:07 p.m., 4/22/23 at 7:55 p.m., 4/24/23 at 6:59 p.m., 4/25/23 at 7:06 p.m., 4/26/23 at 7:07 p.m., 4/27/23 at 7:09 p.m. An interview on 4/29/23 at 11:52 a.m. with the Director of Nursing (DON) revealed that all psychotropic medications should have an automatic 14-day stop unless the MD had a clinical rationale to continue administering the medication. The DON acknowledged R#41's PRN order for Klonopin did not have a clinical rationale to continue the medication or a 14-day stop date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and a review of facility's policy titled, Baseline Care Plan, the facility failed to develop a 48-hour base line care plan for 16 of 45 sampled residents (R) (R#48, R#241, R#242, R#192, R#49, R#246, R#87, R#240, R#68, R#195, R#340, R#342, R#245, R#341, R#244, and R#247). Finding included: A review of the facility's document titled Basic Care Plan revised 12/2/22 and implemented 9/19/22 states the facility's policy interpretation and implementation include the following: The baseline care plan will be developed within 48 hours of the resident's admission. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed 1. A review of the admission Record for R#48, located in the electronic medical record (EMR), revealed the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy, acute vulvitis, atherosclerosis of native arteries, venous thrombosis and embolism, peripheral vascular disease and muscle wasting, dementia, respiratory failure, anxiety disorder, glaucoma, and hypertension. A review of the Assessments in the EMR for R#48 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 2. A review of the admission Record for R#241 revealed the resident was admitted on [DATE] with diagnoses that burns involving 20-29% of body surface with 0-9% third degree burns, urine retention, Diabetes Mellitus type 2, acute kidney failure, and chronic respiratory failure. A review of the Assessments in the EMR for R#241revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 3. A review of the admission Record for R#242 revealed the resident was admitted on [DATE] with diagnoses that included muscle wasting and atrophy, abdominal aortic aneurysm, syncope and collapse, and thyrotoxicosis. A review of the Assessments in the EMR for R#242 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 4. A review of the admission Record for R#192 revealed the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy, anemia, thrombocytopenia, hypothyroidism, Diabetes Mellitus type 2, atrial fibrillation, and hypomagnesemia. A review of the Assessments in the EMR for R#192 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 5. A review of the admission Record for R#49 revealed the resident was admitted on [DATE] with diagnoses that include fracture of neck of right femur, aphasia, dysphagia, chronic obstructive pulmonary disease, major depressive disorder hypertension, and history of falling. A review of the Assessments in the EMR for R#49 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 6. A review of the admission Record for R#246 revealed the resident was admitted on [DATE] with diagnoses that include fusion of the spine cervical region, spinal stenosis, pulmonary embolism, pneumonia, arthritis, and muscle wasting and atrophy. A review of the Assessments in the EMR for R#246 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 7. A review of the admission Record for R#87 revealed the resident was admitted on [DATE] with diagnoses that include cerebral infarction due to embolism of left middle cerebral artery, aphasia, sprain of right ankle, Diabetes Mellitus type 2, muscle wasting and atrophy. A review of the Assessments in the EMR for R#87 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 8. A review of the admission Record for R#240 revealed the resident was admitted on [DATE] with diagnoses that include acute respiratory failure, anemia, atrial fibrillation, congestive heart failure, and muscle wasting and atrophy. A review of the Assessments in the EMR for R#240 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 9. A review of the admission Record for R#68 revealed the resident was admitted on [DATE] with diagnoses that include rheumatoid arthritis, sepsis, asthma, Parkinson's disease, dysuria, and respiratory failure. A review of the Assessments in the EMR for R#68 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 10. A review of the admission Record for R#195 revealed the resident was admitted on [DATE] with diagnoses that include sepsis, candida stomatitis, hypothyroidism, depression, anxiety disorder, glaucoma, and paroxysmal atrial fibrillation. A review of the Assessments in the EMR for R#195 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 11. A review of the admission Record for R#340 revealed the resident was admitted on [DATE] with diagnoses that include cerebral infarction, Diabetes Mellitus type 2, aneurysm, major depressive disorder, cellulitis of right lower limb, wedge compassion fracture of first lumbar vertebra, vascular dementia, congestive heart failure, and shortness of breath. A review of the Assessments in the EMR for R#340 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 12. A review of the admission Record for R#342 revealed the resident was admitted on [DATE] with diagnoses that include viral hepatitis C, displaced transverse fracture of left patella, thrombocytopenia, obstructive sleep apnea, asthma, spondylosis, acute frontal sinusitis, muscle wasting atrophy. A review of the Assessments in the EMR for R#342 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 13. A review of the admission Record for R#245 revealed the resident was admitted on [DATE] with diagnoses that include acute osteomyelitis right ankle and foot, phlebitis and thrombophlebitis, anemia, bandemia, elevated blood cell count, asthma atelectasis, disc degeneration, lumbar region, myositis, immunodeficiency, and Diabetes Mellitus type 2. A review of the Assessments in the EMR for R#245 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 14. A review of the admission Record for R#341 revealed the resident was admitted on [DATE] with diagnoses that include acute and chronic respiratory failure, sepsis, pneumonia due to Methicillin Resistant staphylococcus aureus, chronic obstructive pulmonary disease, cellulitis of left lower limb, congestive heart failure, hyperkalemia, deviated nasal septum, acute kidney failure, benign prostatic hyperplasia, and dysphagia. A review of the Assessments in the EMR for R#341 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 15. A review of the admission Record for R#244 revealed the resident was admitted on [DATE] with diagnoses that include candidiasis of skin and nail, disorder of thyroid, hypokalemia, nicotine dependence, scoliosis, hyponatremia, spondylosis, and muscle wasting and atrophy. A review of the Assessments in the EMR for R#244 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. 16. A review of the admission Record for R# 247 revealed the resident was admitted to the facility on [DATE] with diagnoses that include sepsis, candida stomatitis, anemia, hypokalemia, acute atopic conjunctivitis bilateral, supraventricular tachycardia, generalized anxiety disorder, pneumonia, gastro-esophageal reflux disease, chronic obstructive pulmonary disorder, and chronic respiratory disease A review of the Assessments in the EMR for R#247 revealed there was not an assessment completed, and there was no evidence of a signed baseline care plan anywhere in the resident's medical record. During an interview with the Director of Nursing (DON) on 4/29/23 at 12:36 p.m. she stated R#195, who was admitted on [DATE], had a baseline care plan that had not been completed yet. She further stated the base line care plan was due to be completed on 5/1/23. During an interview on 4/30/23 at 8:45 a.m. with MDS Coordinator HH, she confirmed that the baseline care plan should be completed on admission. She stated that the admission nurse had completed this task in the past, but she recently resigned. She further stated that it should be up to the unit managers on the unit to initiate and complete the baseline care plan and that the baseline care plan was expected to be completed and in the EMR within 48 hours. During an interview with the DON on 4/30/23 at 11:25 a.m. she confirmed she was not aware that the baseline care plans were not being completed in the timeframe allotted of 48 hours. She further revealed that there have been instances where people are initiating the care plan but stated that the basic care plan documentation is not being followed through to completion. The DON stated that her expectation is that all new admissions have a basic care plan within 48 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy titled, Nutritional Management, the facility failed to complete a Comprehensive Nutritional Assessment for nine of 45 sampled residents (R) (R#86, R#20, R#10, R#70, R#77, R#25, R#192, R#38, and R#16). Findings included: A review of the facility policy, Nutritional Management, revised 4/1/23, revealed a comprehensive nutritional assessment would be completed by a dietician within 72 hours of admission, annually, quarterly, and upon a significant change in condition. Follow-up assessments would be completed as needed. 1. A review of the clinical record revealed that R#86 was an [AGE] year-old male admitted on [DATE] with diagnoses including acute kidney failure, pressure ulcer of left heel, muscle weakness and age-related physical debility. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#86 presented with Brief Interview for Mental Status (BIMS) score of 15; indicating that the resident was cognitively intact; required limited assistance of one person for eating; and that the resident presented with no swallowing disorders and no weight loss. A review of the care plan for R#86 revealed a focus area of nutritional problems or potential nutritional problems related to impaired mobility and impaired cognition. The goal was that R#86 would maintain adequate nutritional status as evidenced by maintaining weight within 5% of prior month's weight without signs of malnutrition. Interventions included monitoring, documenting, and reporting signs of dysphagia or refusing to eat; monitoring, recording, and reporting to the physician signs of malnutrition; RD to evaluate and make diet change recommendations as needed. A review of physician's orders included (not all inclusive): cardiac with sodium restriction diet with regular texture and regular/thin consistency 2gm (gram) sodium restriction; Juven (a therapeutic nutrition powder to help support wound healing) two times a day for supplement; Boost (a nutritional drink to provide extra nutrition) three times a day for recent weight loss; multivitamin men oral tablet one time a day for weight loss. A review of the Electronic Medical Record (EMR) revealed in the weights section, R#86 had a 11.46% one-month weight loss from admission date of 3/16/23 to 4/19/23. Additional review of the EMR revealed no documentation to suggest that a Comprehensive Nutritional Assessment was completed upon admission. On 4/30/23 at 8:40 a.m. an interview with the Director of Nursing (DON) revealed she was unaware that an initial dietary assessment had not been completed for R#86. She revealed she was unsure who was responsible for ensuring the Registered Dietician (RD) completed timely assessments. On 4/30/23 at 9:10 a.m. a telephone interview with the RD verified there was not an initial dietary assessment for R#86, and she had no explanation for the missing assessment. She revealed she was made aware of newly admitted residents by reviewing the MDS information, during the weekly Patients at Risk (PAR) meetings, and by notification by the DON. 2. A review of the clinical record revealed that R#20 was an [AGE] year-old female admitted on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, unspecified diastolic (congestive) heart failure, type 2 diabetes mellitus. A review of the admission MDS assessment dated [DATE] revealed R#20 presented with a BIMS of 15, indicating R#20 was cognitively intact; required set-up and supervision for eating; and that R#20 presented with the behavior of holding food in mouth or cheeks or residual in mouth after meals was marked yes. A review of the care plan revealed R#20 was at risk for nutritional problems related to diagnosis of dysphagia, diabetes mellitus, and end stage renal disease requiring hemodialysis. The goal included R#20 will have no signs of malnutrition. Interventions included monitoring, documenting, and reporting signs of dysphagia; monitoring, recording, and reporting to the physician signs of malnutrition; RD to evaluate and make diet change recommendations as needed. A review of physician's order included (not all inclusive): daily weight one time a day for congestive heart failure; diabetic diet, regular texture, regular thin consistency; Juven two times a day for supplement. A review of the comprehensive dietary assessment revealed that it was completed by the RD on 4/11/23. On 4/30/23 at 8:40 a.m. an interview with the DON revealed she was unaware that an initial dietary assessment had not been completed for R#20. She revealed she was unsure who was responsible for ensuring the RD completed timely assessments. On 4/30/23 at 9:10 a.m. a telephone interview with the RD verified R#20 was admitted on [DATE] and the initial comprehensive dietary assessment was completed on 4/11/23. She revealed the initial comprehensive dietary assessment should have been completed within 72 hours of admission. She further revealed she had no explanation why the initial comprehensive assessment was not completed within 72 hours of admission. She revealed she received notification of new residents by reviewing the MDS information or during the PAR meetings. 3. A review of the clinical record revealed that R#10 was a [AGE] year-old male admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, dysphagia dementia chronic kidney disease, depression, Alzheimer's disease. A review of R#10's annual MDS assessment dated [DATE] revealed a BIMS of 3, indicating sever cognitive impairment; R#10 required set-up and supervision for eating; R#10 had a weight loss; and was edentulous. A review of the care plan revealed R#10 had a potential nutritional problem related to diagnosis of congestive heart failure, muscle wasting, chronic kidney disease. Goals were R#10 will maintain adequate nutritional status with no unaddressed significant weight loss through review date. Interventions included observed, document, and report signs of dysphagia or malnutrition to the physician; RD to evaluate and make diet change recommendations as needed. A review of the physician's order review revealed (not all inclusive): NAS (No Added Salt) diet, pureed texture, regular thin consistency, double portions. Ensure (a nutritional supplement) two times a day for nutrition support and increase appetite. A review of the dietary progress notes and clinical record for R#10 revealed there was not a dietary assessment to address the significant weight gain of 12.99% determined on 4/19/23. On 4/29/23 at 9:10 a.m. a telephone interview with the RD revealed she must have missed R#10 significant weight gain during review of the weights. She revealed she should have been aware and asked for the resident to be reweighed. She further revealed if the weight change was accurate, she should have performed a dietary assessment to address the weight change. 4. A review of the clinical record revealed that R#70 was an [AGE] year-old long term care resident that was admitted to the facility on [DATE]. A review of the physician orders revealed that R#70 was ordered a regular diet with minced and moist texture. A review of the medical record revealed that the RD had not completed an initial comprehensive nutrition assessment. Further review revealed that the RD had no progress notes regarding R#70 nutrition status. 5. A review of the clinical record revealed that R#77 was a [AGE] year-old long term care resident that was admitted to the facility on [DATE]. His diagnosis included, but not limited to, protein-calorie malnutrition and dysphagia. A review of the physician ordered revealed R#25 was ordered a regular diet, mechanical soft texture. A review of the medical record revealed that the RD had not completed an initial comprehensive nutrition assessment for R#25. A review of the medical record revealed that the RD documented a progress note on 3/8/23, 3/15/23/ and 3/29/23. The notes indicated that R#77 had weight loss but did not indicate what weights were used for calculations. 6. A review of the clinical record revealed that R#25 was a [AGE] year-old long term care resident that was admitted to the facility on [DATE]. Her diagnosis included, but not limited to, type 2 diabetes, congestive heart failure, and chronic obstructive pulmonary disease. A review of the physician orders revealed R#25 was ordered a no added salt diet, 1500mL fluid restriction, and one Ensure per day. A review of the medical record revealed that the RD had not completed an initial comprehensive nutrition assessment. A review of the medical record revealed the RD wrote a progress note on 2/1/23 and 9/21/22. The progress notes did not address the resident's 1500mL fluid restriction and resident's non-compliance with following the restriction. An interview on 4/30/23 at 2:20 p.m. with the East Wing Nursing Unit Manager revealed that R#25 is non-complaint with her fluid restriction. R#25 self-propels in wheelchair and will go and get her own coffee and other beverages when nursing staff is not looking. The Unit Manager revealed that R#25 has been educated on following fluid restriction. 7. A review of the clinical record revealed that R#192 was admitted to the facility on [DATE]. There was no documentation in the clinical record to suggest that the resident received a Comprehensive Nutritional Assessment within 72 hours of admission. 8. A review of the clinical record revealed that R#38 was admitted to the facility on [DATE]. There was no documentation in the clinical record to suggest that the resident received a Comprehensive Nutritional Assessment within 72 hours of admission. 9. A review of the clinical record revealed that R#16 was admitted to the facility on [DATE]. There was no documentation in the clinical record to suggest that the resident received an annual Comprehensive Nutritional Assessment. The last documented Comprehensive Nutritional Assessment for R#16 was dated 1/25/22. An interview on 4/30/23 at 8:05 a.m. with the Director of Nursing (DON) revealed that once the staff determined a weight loss or gain, the resident was discussed during the weekly Patient at Risk (PAR) meetings. The Registered Dietician (RD) was present during the meetings. If required, based on diagnosis, the resident is reweighed for accuracy. During the meetings, the staff discussed labs, supplements, medications, and any new diagnoses, to determine the cause of the weight loss or gain. The staff notified the Physician and Physician Assistant of any nutritional and weight changes, and new orders may be required to help establish a nutritional plan for the residents. The DON explained that the staff texted the RD if a resident had a nutritional problem or if the facility had a new admission. The RD stated that if a patient were on Hospice and had a weight loss or gain, the RD continued to assess the resident, and the RD followed all residents that required tube feedings despite diagnosis or admission to Hospice. The DON said the staff did not typically document when the RD was notified. The DON stated she expected the RD to calculate the nutritional and fluid needs of all the residents in the facility. If the MD changed any resident's diet, she would expect the RD to re-calculate and document the nutritional changes and goals for the residents. The DON stated it was her expectation for the RD to complete and document a Comprehensive Nutritional Assessment for all new admissions or significant changes within 72 hours. She added the RD should also be conducting and documenting a Comprehensive Nutritional Assessment for each resident quarterly and annually. The RD said she was unsure who was responsible for ensuring the RD completed the required assessments. An interview on 4/30/23 at 9:46 a.m. with the Corporate [NAME] President of Nursing Services and the Corporate Clinical Nurse revealed an electronic system for nutritional assessments was available in the electronic system, but the RD had not used it. They knew the RD was free writing her assessments, but they were unfamiliar with the term free writing, which was not a typical format for nutritional evaluations. They explained that the RD had historically gotten behind on her assessments at one point and had caught up; however, they were made aware during the survey that the RD was behind on the assessments again. They explained the RD was expected to follow up when a nutritional change was made for a resident. For example, if an MD changed a resident's diet or a patient had weight loss or gain, the RD had access to the electronic record, and the expectation would be for the RD to follow up and make any necessary changes in the resident's dietary plan. They added it was their expectation for the RD to calculate the caloric needs and review the resident's labs, diagnoses, and any other pertinent information to determine a nutritional plan. The nurses stated the facility had not audited any of the RD's assessments since May 2022. They were unaware of the current process for auditing the RD's assessments. A telephone interview on 4/30/23 at 9:04 a.m. with the RD revealed that when she completed a Comprehensive Nutritional Assessment, she calculated the resident's kilocalories based on weight, age, BMI, and diagnoses. She added that she assessed the resident's labs, the presence of wounds, medications, diet orders, and any nutritional risks. The RD stated she documented all her evaluations and assessments through free writing instead of any electronic form because that was how she was trained. The RD reported that Comprehensive Nutritional Assessments were conducted for each resident on admission, quarterly, annually, and upon significant change. The RD stated she was made aware of new admission or a need for an assessment or follow-up through MDS reports in the electronic system. She also attended the weekly Patient at Risk (PAR) meetings. The RD acknowledged she had not provided the necessary Comprehensive Nutritional Assessments for R#86, R#20, R#10, R#70, R#77, R#25, R#192, R#38, and R#16.

Based on observation, staff interviews, and recipe review, the facility failed to ensure puree recipes were followed to conserve nutrient value of puree vegetable and puree chicken strips for six of six resident receiving puree consistency. Findings included: A review of the recipe for Puree Vegetable Medley revealed that the recipe yielded 20 servings. Ingredients included vegetable medley, water, butter, salt, vegetable seasoning. A review of the recipe for Puree Chicken Fingers revealed that the recipe yielded 5 servings. Chicken fingers 10 pieces, hot water 3/4 cup, and chicken base 1 tablespoon. Observation on 4/29/23 at 11:10 a.m. of Dietary [NAME] AA complete puree food items for lunch meal revealed no recipes were used, reviewed, or available for reference. Dietary [NAME] AA placed an unmeasured amount of cooked vegetable medley in the food processor and pureed. Dietary [NAME] AA then added an unmeasured amount of vegetable broth two different times to achieve proper puree consistency. An interview on 4/29/23 at 11:10 a.m. with Dietary [NAME] AA during observation, he confirmed that he did not measure the amount of cooked vegetable or vegetable broth for puree vegetable medley. He stated that there are recipes, but he knows by experience the correct consistency for puree. An observation on 4/29/23 at 11:30 a.m. of Dietary [NAME] AA complete puree chicken strips revealed he placed 15, three-ounce scoops of chopped chicken strips in the food processor along with an unmeasured amount of chicken broth and pureed. Continued observation revealed Dietary [NAME] AA added an unmeasured amount of chicken broth four additional times to achieve puree consistency. During an interview on 4/29/23 at 11:30 a.m., Dietary [NAME] AA confirmed that he added the chicken broth without measuring. During an interview on 4/29/23 at 11:35 a.m., the Interim Dietary Manager (IDM) confirmed that the dietary cook did not follow recipes for puree vegetable medley and puree chicken strips. The IDM revealed that he expects the cooks to follow recipes. During an interview on 4/29/23 at 11:45 a.m. with another dietary cook, Dietary [NAME] BB, they revealed that they do have recipes but go by eye for proper puree consistency.

Based on observations, staff interviews, and policy review the facility failed to ensure the pipes to the fire suppression system under exhaust hood were clean and free from grease build-up; failed to ensure pans were stored dry to prevent wet nesting; failed to proper store foods in dry storage area; failed to ensure label, date, and securely wrap opened food items in the kitchen and resident nourishment room; failed to ensure kitchen equipment was properly cleaned to prevent cross contamination; failed to ensure food spills were cleaned from walls; and failed to ensure dietary staff wore hair restraint while in the kitchen. This had the potential to affect 90 residents receiving an oral diet. Findings included: 1. An observation on 4/28/23 at 8:50 a.m. of the pipes to the fire suppression system under the exhaust hood revealed they were coated with a heavy layer of grease. Suspended collection of grease was noted attached to the pipe directly under the fryer. An observation on 4/30/23 at 11:10 a.m. of the pipes under the exhaust hood continued to be coated with a heavy layer of grease. Further observation revealed a sticker to the left side on the exhaust hood which revealed the date the exhaust hood was professionally cleaned which was 3/18/23. During an interview on 4/30/23 at 11:10 a.m., the Interim Dietary Manager (IDM) confirmed that there was a heavy grease build-up on the pipes to the fire suppression system to the exhaust hood. The IDM confirmed that the grease build up was hanging from the pipe directly under the fryer and could potentially contaminate the fryer. An interview on 4/30/23 at 11:10 a.m. with the lead dietary aide revealed that she notified the maintenance department about three weeks ago about the grease build-up to the pipes under the exhaust hood. The lead aide stated that dietary staff did not attempt to remove the grease in fear they may set off the fire suppression system. An interview on 4/30/23 at 11:40 a.m. with the Maintenance Director revealed that he had been made aware of the heavy grease build-up on pipes to the fire suppression system under the exhaust hood. He stated that he had not attempted to clean the pipes and has not contacted the professional cleaners to assist with removing the grease. 2. A review of the policy titled Dish Washing Policy revealed that after washing dishes, place on rack evenly spaced out to allow air drying. An observation on 4/28/23 at 8:57 a.m. of the pan rack where food carts were stored revealed a stack of 18-sheet trays and the top tray was turned over and the inside was completely wet and water drops were running off. Continued observation of a stack of five large rectangle steam table pans revealed when the top pan was turned over moisture was found inside. Further observation of the pan rack near the entry door to the kitchen revealed a stack of three medium rectangle steam table pans revealed the top pan was turned over and the inside had a light brown/tan colored food type substance that covered part of the inside. During an interview on 4/28/23 at 9:25 a.m., the lead dietary aide confirmed that the large sheet tray and large rectangle steam table pan were stored on the storage rack wet. The dietary aide stated that the pans should have been air dried before stacking. The lead dietary aide confirmed that the medium rectangle steam table pan had some type of food substance inside and was dirty. The lead aide stated that staff should have looked at the pan before placing it on storage rack to make sure it was clean. 3. A review of the policy titled Food Safety Requirements revealed proper food storage by keeping foods covered or in tight containers. An observation on 4/28/23 at 9:05 a.m. of the dry storage area revealed a 50-pound bag of dried beans wide open exposing the inside contents. Continued observation of the dry storage area revealed a large white storage bin labeled self-rising flour. Inside the bin was a 12-ounce Styrofoam cup that was covered with flour. During an interview on 4/28/23 at 9:30 a.m., the lead dietary aide confirmed that the 50-pound bag of dried beans was open and not securely closed. The lead aide stated that the cook should have closed the bag after use. The lead dietary aide confirmed that there was a white Styrofoam cup in the self-rising flour bin. She stated that the cup was likely used as a scoop and should not have been used and left inside the bin. 4. A review of the policy titled Food Safety Requirements revealed all equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. An observation on 4/28/23 at 9:12 a.m. of the stand mixer revealed a light brown food substance on the front part of the mixing arm. During an interview on 4/28/23 at 9:37 a.m., the lead dietary aide confirmed that the stand mixer had light brown colored food debris. The lead aide revealed that dietary staff are to clean the mixer after each use. An observation on 4/30/23 at 10:50 a.m. of the stand mixer revealed the light brown colored food substance remained. When touched the food substance flaked off into hand. During an interview on 4/30/23 at 10:50 a.m., the IDM confirmed that the stand mixer had not been cleaned properly and the light brown food substance remained. The IDM confirmed that the food substance could flake off when touched. The IDM revealed that dietary staff should have cleaned the mixer after use. 5. A review of the policy titled Food Safety Requirements revealed labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers so it is used by its use-by date, or frozen/discarded. An observation on 4/28/23 at 9:13 a.m. of the stand-up refrigerator labeled Veg revealed a 16-ounce container of Cool-Whip topping with a facility label date of 1/31. An observation on 4/28/23 at 9:19 a.m. of the stand-up freezer across from walk-in refrigerator revealed a block of frozen hot dogs wrapped in plastic wrap with no label or date. Continued observation revealed a clear plastic bag containing chicken breasts that had been opened with no date. During an interview on 4/28/23 at 9:38 a.m., the lead dietary aide confirmed that the Cool-Whip container was labeled with a date of 1/31/23 and should have been discarded. The lead aide confirmed that the block of hot dogs and bag of chicken breast were not labeled or dated. The lead aide stated that staff have been educated to label and date food items before storing. An observation on 4/29/23 at 8:45 a.m. of the East Wing resident nourishment room refrigerator revealed a one-gallon container of Tropicana orange juice with no label or date. This refrigerator also had gray and black plastic-colored bags containing food items and no label or date noted. During an interview on 4/28/23 at 8:45 a.m., the IDM confirmed that the gallon container of orange juice and the gray plastic bag and black plastic bag with food items had no resident name or date. The IDM stated that all food items in the resident refrigerator should be labeled and dated. An interview on 4/28/23 at 8:50 a.m. with the Director of Nursing (DON) revealed that resident food items should be labeled and dated before storing in nourishment room refrigerator. The DON stated that if food items are not labeled or dated nursing staff should discard. 6. A review of a dietary in-service sheet dated 1/12/23 revealed staff were educated on the dish room, chemicals, floor/wall cleaning, moping, and food carts. A review of the cleaning sheet for week of 4/11/23 - 4/17/23 revealed that dietary staff initialed that the task of wiping down doors/walls daily was completed. No cleaning sheet could be found for the current work week. An observation on 4/29/23 at 11:00 a.m. of the ceramic tile wall behind the food processor revealed a splashed yellow colored food substance. Continued observation of the kitchen walls revealed a red colored food substance splashed above the exhaust hood. An observation on 4/30/23 at 11:05 a.m. of the walls in the kitchen revealed the area behind the food processor and area above the exhaust continued to exhibit splashed food substance. When touched the yellow food substance was able to flake off wall title. During an interview on 4/30/23 at 11:05 a.m. with the IDM, he confirmed that the yellow food substance and the red food substance were on the walls. The IDM revealed that staff should wipe/clean as they go. The IDM revealed that dietary staff have daily, weekly, and monthly cleaning tasks. The IDM revealed that the food substance on the walls should have been cleaned. 7. Review of the policy titled Food Safety Requirements (not dated) revealed: Dietary staff must wear hair restraints (hair net, hat, and/or beard restraint) to prevent hair from contacting food. An observation on 4/30/23 at 11:25 a.m. of Dietary Aide CC revealed that he was in the kitchen and not wearing a hair net. Continued observation revealed a box of hair nets located on the wall next to the door to enter the kitchen. An interview on 4/30/23 at 11:25 a.m. with Dietary Aide CC revealed that he knows he needs to be wearing a hair net when in the kitchen and just forgot to put it on. During an interview on 4/30/23 at 11:25 a.m., the IDM confirmed that Dietary Aide CC was in the kitchen and was not wearing a hair restraint. The IDM revealed that he expects all dietary staff to wear a hair restraint when in the kitchen.

Based on observations and staff interviews the facility failed to ensure that the dumpsters doors/lids were closed at all times and failed to ensure the area surrounding the dumpsters was free from trash debris. This had the potential to affect all 91 residents in the facility. Findings included: An observation on 4/29/23 at 8:40 a.m. of the dumpster area revealed that the facility had three large dumpsters located at the back of the building. The dumpsters were sitting on concrete and a concrete retaining wall was to one side. Continued observation revealed the dumpster closest to the retaining wall, both side doors were wide open exposing trash contents inside. Further observation revealed a white 50-gallon round trash can next to a dumpster with no lid, exposing the inside which consisted of several trash bags as well as an empty eight-ounce carton of milk and an empty individual cereal bowl of mini-wheats. The ground around the dumpsters had several pieces of trash such as plastic spoons, paper masks, blue latex gloves, and pieces of paper. During an interview on 4/29/23 at 8:40 a.m. the Interim Dietary Manager (IDM) confirmed that the side doors to one of three dumpsters were open. The IDM stated that dumpster doors should be closed. The IDM confirmed that the 50-gallon trash can did not have a lid and the inside contents were exposed. The IDM revealed that maintenance or housekeeping was responsible for the cleanliness of the dumpster area. An observation on 4/30/23 at 11:45 a.m. of the dumpster area revealed the dumpster closest to the building, one of the side doors was partially open exposing trash bags and contents inside. Continued observation of the dumpster closest to the back door of the dietary department revealed the right-side top lid was not closed, exposing multiple trash bags. Further observation revealed the trash on the ground noted from the previous day continued to be on the ground. Additional trash items included items such clear plastic gloves and two round shaped paper products (lids from individual ice cream tops). An interview on 4/30/23 at 11:45 a.m. with the Maintenance Director revealed that he is responsible for the dumpster area which includes ensuring the lids and doors are closed, area surrounding the dumpsters is clean, ensuring that the dumpsters are clean and free from food debris. The Maintenance Director confirmed that one dumpster side door was partially open, and another dumpster top lid was not closed. The Maintenance Director confirmed that there was trash on the ground surrounding the dumpsters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility (1) failed to ensure proper infection control practices during wound care for two of three residents (R) (R#39 and R#86); (2) failed to ensure staff wore Personal Protective Equipment (PPE) into Transmission Based Precaution (TBP) rooms and that appropriate signage was on the door for two of three residents (R#5 and R#9) on TBP; and (3) failed to develop an updated water management program plan for the prevention of Legionella for 91 of 91 residents in the building. Findings included: 1. A review of the facility policy titled Clean Dressing Change, undated, revealed it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. if the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape). 7. Wash hands and put on gloves. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. (Policy is noted that staff should wash hands between each glove change.) A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition; requires extensive 2+ person assist with all Activities of Daily Living (ADLs); is always incontinent of bowel and bladder; is at risk for pressure ulcers; has one stage IV Pressure Ulcer; and is on an antipsychotic and antidepressant seven out of seven days per week and an opioid four out of seven days per week. A review of the care plan dated 12/31/20 revealed R#39 has a pressure ulcer, Stage IV to coccyx (last revised 4/12/23). R#39 will reposition self or ask for assistance to reposition back into desired positions. She will not allow side to side schedule. R#39 will at times refuse to allow staff to perform wound care. Wound care Nurse Practitioner (NP) provides amnion grafts weekly as treatment to chronic stage IV sacral wound with a goal that R#39's pressure ulcer will show signs of healing through the next review date. Interventions include to administer treatments as ordered and monitor for effectiveness, apply amnion graft, followed by wound care, heel cushion to elevate bilateral lower extremities (BLE) as allowed, monitor nutritional status, serve diet as ordered, position side to side per round as allowed, obtain and monitor lab/diagnostic work as ordered and report results to Medical Doctor (MD) and follow-up as indicated, specialty air mattress, vitamins and supplements as ordered for wound healing, and weekly treatment documentation. A review of the physician order with a start date of 2/16/23 and end date of 4/29/23 revealed stage IV ulcer coccyx: Cleanse with wound cleaner, pat dry with 4x4 gauze, apply Triad peri wound, Silver Collagen, apply super absorbent foam bordered dressing QD (per day) and PRN (as needed) every dayshift. A review of the physician order dated 4/30/23 revealed stage IV ulcer coccyx: Cleanse with wound cleaner, pat dry with 4x4 gauze, apply zinc oxide peri wound, Silver Collagen, apply super absorbent foam bordered dressing QD and PRN every dayshift. An interview on 4/28/23 at 9:13 a.m. with R#39 revealed she has a sore on her bottom that she has had a long time. She said they come and clean it every day. She stated they do not get her up in a chair but added that she really does not want to be gotten up in a chair. During an observation on 4/29/23 at 10:30 a.m. of Wound Care Nurse (WCN) providing wound care for R#39, WCN read the Physician order and gathered her supplies. She pulled a spray bottle of wound cleanser out of the cart. An interview was conducted at this time with the WCN, and she revealed she uses the same wound cleanser bottle for all residents receiving wound care, but she cleans the bottle with sani-wipes after each use before returning it to the cart. WCN did not clean the wound cleanser bottle after pulling it from the cart and before taking it into the resident room. She gathered 2 brown paper sheets and brought them into the resident room and laid the paper sheets, then other supplies on top of paper sheets, onto a chair sitting in the room without cleaning the seat of the chair. WCN picked up gloves and began to put one on then laid them back down on the chair with the other supplies and went into the resident bathroom to wash her hands. Certified Nursing Assistant (CNA) MM picked up the gloves the WCN laid back down on the other supplies and put them on. WCN returned from the bathroom, donned gloves, and took the supplies from the chair laying down one of the brown papers onto the resident bed then placing wound care supplies and cleanser onto the paper. She took the other piece of brown paper and slid it under the resident then opened a clear plastic bag laying it at the foot of the bed. CNA MM rolled the resident toward her onto the residents left side and opened the brief. It was noted the resident had a bowel movement (BM). WCN and CNA MM did not provide incontinent care, but WCN continued with wound care treatment by removing the current dressing that was observed to be dated the previous day and initialed. She placed the old dressing in the clear bag at the foot of the resident bed, doffed gloves, washed her hands, donned new gloves and continued on with the wound care treatment touching the soiled brief then touching the resident skin with the gloved hand she had touched the soiled brief with. WCN doffed gloves, did not wash or sanitize her hands before donning new gloves. She took clean gauze and dabbed the area to dry. She doffed gloves, did not wash, or sanitize her hands, donned new gloves and applied zinc oxide (Triad) to the reddened area that was just under the dressing to the lower back. WCN removed gloves, washed her hands, donned new gloves, and sprayed gauze with wound cleaner and cleaned around the wound bed from the inside out then, without washing or sanitizing her hands, took clean gauze and dabbed the area dry. WCN doffed gloves, washed her hands, donned new gloves, and applied Silver Collagen to the wound bed. She doffed her gloves, washed her hands, donned new gloves, and put a clean dressing over the wound. The dressing did not have a date or initial. WCN doffed gloves, went out to the cart and retrieved a new dressing with date and initial. She laid the dressing on brown paper and went to the bathroom and washed her hands and donned new gloves, removed the current dressing, and discarded it in the clear bag on the resident bed. WCN doffed gloves, washed her hands, donned new gloves, and put the new dressing with date and initial over the wound. After wound care treatment the WCN and CNA MM provided incontinent care to the resident and a clean brief. Resident was repositioned in bed and made comfortable. WCN discarded soiled supplies appropriately. She doffed gloves, washed her hands, donned new gloves, and cleaned the wound care cleanser bottle with a sani-wipe, allowed it to dry and placed it back in the cart. WCN doffed gloves and washed her hands. Each observation to the bathroom to wash her hands revealed she used a paper towel to turn the water off and discarded the paper towel into the trash can before donning new gloves. During an interview on 4/29/23 at 10:55 a.m. with WCN, she stated she did wash her hands during treatment and when going over notes with her from the observation she only replied OK when it was brought to her attention the observations that she did not wash or sanitize her hands between glove changes or touching the brief then touching the resident skin near the wound. During an interview on 4/29/23 at 11:40 a.m. with the Director of Nursing (DON) she revealed it is her expectation that the WCN wash or sanitize her hands between glove changes, anytime soiled, or when accidentally touched to prevent contamination. She stated the WCN should have ensured R#39 received incontinent care prior to performing wound care to prevent cross contamination. During an interview on 4/30/23 at 12:40 p.m. with the WCN she stated she has been doing wound care for 2 years and learned how to do wound care via a preceptor. She stated R#39 does not like anyone to touch her bedside table or her things on it so she could not use her table for wound care supplies and uses the bed. WCN stated she was not aware there were unused bedside tables available to her. She stated she knows wound care inside and out and can talk someone through it but stated she was just very nervous yesterday being observed and that is why she made some slip ups. A review of the clinical record revealed that R#86 was an [AGE] year-old male admitted on [DATE] with diagnosis including pressure ulcer, acute kidney failure, muscle wasting and atrophy. A review of the admission MDS dated [DATE] revealed a BIMS of 12; revealed R#86 required extensive assistance of two plus persons for bed mobility and transfers; revealed there were no ulcers documented; and there were pressure reducing devices for bed and chair. A review of the care plan revealed a focus area of documented pressure ulcer for R#86. The goals were prevention of future pressure ulcers, management of pressure ulcer, wound will show signs of improvement. Interventions included to evaluate ulcer characteristics, provide wound care per treatment order, refer to specialized practitioner for wound management. A review of the physician's orders revealed an order dated 4/28/23: Stage three to coccyx: cleanse with in-house wound cleanser, pat dry with 4x4 gauze, apply honey to wound bed, apply zinc to peri-wound, cover with bordered foam dressing every day and as needed. On 4/29/23 at 1:40 p.m. observation of wound care for R#86's sacral ulcer performed by Licensed Practical Nurse (LPN) JJ revealed her to fail to cleanse the container of wound cleaner prior to entering the resident room; failed to clean the over bed table prior to placing the barrier and supplies on the table; failed to change gloves and perform hand hygiene after cleaning the wound and prior to applying the treatments of honey and zinc and the dressing to the wound. On 4/29/23 at 1:55 p.m. interview with LPN JJ revealed the container of wound cleaner was a floor stock product and was used for all residents. She revealed she cleaned it after each use and did not clean it prior to taking it into the resident's rooms. She revealed she thought she performed wound care and hand hygiene appropriately during wound care and was unaware she should clean the table prior to use if she placed a barrier on it. She further revealed she was nervous and must have forgotten to change gloves and perform hand hygiene after cleaning the wound and prior to applying the treatment and clean dressing. On 4/30/23 at 1:45 p.m. interview with the DON revealed her expectations for wound cares were for surfaces used to be cleaned prior to use, reusable items such as the container of wound cleanser to be cleaned prior to entering the resident room and after exiting the room, hand hygiene to be performed appropriately during wound cares, pain to be assessed frequently during wound cares, the physician orders to be followed, and for the nurse to report any changes to the physician. 2. A review of the facility's policy titled, Infection Prevention and Control Program undated revealed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 4. Standard Precautions: All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. 16. Water Management a. A water management program has been established as part of the overall infection prevention and control program. B. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. C. The Maintenance Director serves as the leader of the water management program. A review of the clinical record revealed R#5 was diagnosed on [DATE] with Methicillin-resistant Staphylococcus aureus (MRSA) to the left foot from a deteriorating diabetic ulcer. A review of the most recent quarterly MDS for R#5 dated 4/25/23 revealed Medication-Antibiotics and Antidepressants; Skin Problems - Infection to the foot; Diabetic Ulcer; Skin treatments - pressure reducing device for bed; and application of dressing to the feet. A review of the physician orders revealed an order on 3/21/23 for contact isolation and on 4/24/23 Clindamycin HCL oral 150 (mg) milligrams, one capsule by mouth four times a day for 14 days. An observation on 4/28/23 at 10:32 a.m. on the door of R#5 revealed signage of how to don and doff. There was no signage to indicate why the resident was in isolation, and for staff to know which PPE (personal protective equipment) was appropriate for entering the room. The PPE cart has N95 masks and gowns, but no shields, goggles, or gloves. An observation on 4/29/23 from 10:00 a.m. to 10:30 a.m. a CNA entered the room of R#5 without wearing any PPE and left the room after approximately 20 minutes without wearing any PPE. An interview on 4/29/23 at 10:30 a.m. with CNA GG revealed that she did not normally work on the rehabilitation hall, and this was her first time working in the rehabilitation unit. CNA GG stated she did not see the PPE cart and did not know why the resident was in isolation. She confirmed that she walked in the room and delivered care without using PPE. An interview on 4/29/23 at 10:50 a.m. with Rehabilitation Unit Manager (UM) revealed her expectation was for staff to wear the appropriate PPE and use N95 mask on new admissions. The UM was unaware as to why the door did not have signage related to what isolation the resident needed TBP. A review of the clinical record revealed that R#9 was diagnosed with klebsiella pneumonia in the urine on 4/24/23 after a final urinalysis report to the facility. A review of the most recent quarterly MDS for R#9 dated 3/27/23 revealed ADL's for toileting- total dependence with two persons assist, always incontinent bowel and bladder. A review of the physician orders revealed an order on 4/24/23 for Levofloxacin 750 mg one tablet by mouth once daily for ESBL (klebsiella pneumonia) times seven days. An observation and interview on 4/28/23 at 9:40 a.m. with LPN EE revealed the resident is on TBP due to having ESBL in her urine. LPN EE revealed the resident does not have a catheter. The room is observed to have its own bathroom but neither resident is continent and unable to use the restroom. An observation of the Physical Therapist PT (II) entered R#9's room without PPE. PT II worked with the resident in bed one, who is not on TBP. The PT II left the room at 9:35 a.m. and came back with supplies in her hands at 9:43 a.m. CNA HH was putting on PPE to enter the room. The Therapist sat her supplies down outside the door on the PPE cart and walked away. Therapist returned at 9:47 p.m. wearing an N-95 mask but did not put on other PPE upon entering the room. The CNA was working with bed two and was dressed in gown, mask, gloves, and face shield. Signage is noted on the door for how to don and doff, but no signage as to what type of TBP (contact, air born, etc.). An interview on 4/29/23 at 11:30 a.m. with LPN EE revealed she did not know what type of TBP R#9 was receiving. She stated R#9 was taking antibiotics for a urinary tract infection (UTI). An interview on 4/30/23 at 1:00 p.m. with DON revealed she was unaware that the resident's on TBP did not have what precautions they were under on the door. The DON stated that the expectation was for each resident under TBP to have the appropriate signage on the door for the safety of the resident's and staff. 3. The facility does not have updated measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency, or EPA). A review of the current water management plan revealed daily water temperature logs through December 2022. The facility does not have a log for flushing lines. In addition, the facility was unable to provide an assessment to identify where Legionella could grow and spread or measures to prevent the growth of opportunistic waterborne pathogens, and how to monitor. An interview on 4/30/23 at 11:45 a.m. with the Maintenance Director revealed he was not aware of any changes to the water management plan. The facility was checking water temperatures daily but does not have an assessment of the buildings water system. The Maintenance Director stated the facility is not currently flushing monthly to clear the lines. He further revealed the temperature logs are updated through the end of 2022. The employee who was maintaining the logs left the facility a few weeks ago and the logs cannot be found. An interview on 4/30/23 at 1:00 p.m. with the Administrator revealed he was made aware of the updates regarding waste management as of today. The Administrator stated that going forward a plan and active practice will be in place. An interview on 4/30/23 at 1:15 p.m. with DON stated that the Infection Control Preventionist (ICP) and Maintenance Director would collaborate to devise a plan for the water management plan.