Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to implement the care plan related to oxygen (O2) therapy for one of 17 residents (R) (R21) receiving oxygen. The deficient practice had the potential for R21 not to receive treatment and/or care according to their needs. Findings include: Review of the facility's policy titled Care Plans revised 7/27/2023 revealed under admission Comprehensive Plan of Care: . 4. The goal is an expected outcome the patients/residents should achieve by implementing specific interventions. Review of the 12/27/2024 quarterly Minimum Data Set (MDS) for R21 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition and is on oxygen therapy. Review of the care plan dated 5/24/2024 revealed R21 has oxygen use related to failure to maintain oxygen saturation above 90 percent and has shortness of breath when lying flat. Interventions include but is not limited to oxygen as ordered. Review of physician orders for R21 revealed an order on 12/11/2024 for Oxygen at 2 Liters Per Minute (LPM) via nasal cannula (NC) to keep O2 Saturations (Sats) greater than 90 percent. Observation on 3/14/2025 at 8:23 am revealed R21 resting in bed. She was clean with no odors present. O2 was in place via NC. O2 was set at a flow rate of 1.5 LPM. Interview during this time with R21 revealed she received 2 liters of O2. Observation on 3/15/2025 at 7:31 am revealed R21 resting in bed. She was clean with no odors present. O2 in place via NC. O2 remained at 1.5 LPM. A joint interview on 3/15/2025 at 9:05 am with MDS Coordinator AA and MDS Coordinator BB revealed it was the responsibility of the nurse to ensure new care plans were put into place or that new interventions were put into place on current care plans. They revealed they were made aware of any changes or newly added interventions to care plans during the morning meeting and by reviewing resident charts. MDS Coordinators AA and BB revealed that the staff were very good about letting them know when changes had been made to the care plans and stated that it was the responsibility of the Unit Managers (UM) to ensure staff were educated on what was on the care plan and that they understood the care plan was how they would know the care needs of a particular resident as each care plan was person centered. Interview on 3/15/2025 at 9:17 am with UM CC with UM DD present revealed that during the orientation process and periodic in-services she taught how staff should look at the resident profile and the care plan to understand care needs for an individual resident. She stated for O2 therapy she taught the staff to bend down at eye level with the O2 gauge to ensure the resident was on the ordered LPM and it was her expectation that staff were looking at the care plan, and following those directions to ensure the care plan was being followed based on the physician ordered LPM.

Based on observations, record review, staff and resident interviews, and review of the facility's policy titled, Oxygen (O2) Administration, the facility failed to ensure that (O2) concentrators were clean, and O2 orders were followed for two of 17 residents (R) (R21 and R6) receiving O2. The deficient practice had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Oxygen Administration revised 8/20/2023 revealed a Policy Statement: It is the policy of this facility to provide oxygen safely and accurately to appropriate patients/residents. Under Safety revealed: . 10. Clean exterior of concentrators weekly and between each patient/resident use with bactericidal surface cleaner. 1. Review of the 12/27/2024 quarterly Minimum Data Set (MDS) for R21 revealed a Brief Interview for Mental Status score (BIMS) of 13, indicating intact cognition and is on oxygen therapy. Review of the care plan dated 5/24/2024 revealed R21 has oxygen use related to failure to maintain oxygen saturation above 90 percent and has shortness of breath when lying flat. Interventions include but is not limited to oxygen as ordered. Review of physician orders for R21 revealed an order on 12/11/2024 of Oxygen at 2 Liters Per Minute (LPM) via nasal cannula (NC) to keep oxygen (O2) Saturations (Sats) greater than 90 percent. Observation on 3/14/2025 at 8:23 am revealed R21 resting in bed. She was clean with no odors present. O2 was in place via NC. The vent on the back of the O2 concentrator had gray, dusty debris noted. O2 was set at 1.5 LPM. Interview during this time with R21 revealed she received 2 liters of O2. Observation on 3/15/2025 at 7:31 am revealed R21 resting in bed. She was clean with no odors present. O2 in place via NC. The vent on the back of the O2 concentrator continued to have gray, dusty debris noted. O2 remained at 1.5 LPM. 2. Review of the 1/9/2025 quarterly MDS for R6 revealed a BIMS score of 15, indicating intact cognition and is on oxygen therapy. Review of the care plan dated 5/30/2024 revealed R6 has oxygen and is short of breath lying flat with an intervention of Oxygen to maintain O2 at 92 percent. Review of physician orders for R6 revealed an order on 2/7/2025 for Oxygen at 2 Liters Per Minute (LPM) continuously. Observation on 3/14/2025 at 8:30 am revealed R6 resting in bed. She was clean with no odors present. O2 was in place via NC. The vent on the back of th eO2 concentrator had gray, dusty debris noted. O2 was at 1.5 LPM. Interview during this time with R6 revealed she was on 2 LPM of O2. Observation on 3/15/2025 at 7:40 am revealed R6 resting in bed. She was clean with no odors present. O2 was in place via NC. The vent on the back of the O2 concentrator continued to have gray, dusty debris noted. O2 remained at 1.5 LPM. Observation and interview on 3/15/2025 at 7:50 am with Registered Nurse (RN) EE revealed it was the responsibility of housekeeping to clean the O2 concentrators. He stated he ensured the humidifiers were filled and would change out tubing when needed. During this time the weekend supervisor verified that the side vent on the O2 concentrator for R21 and R6 had gray, dusty debris and that the Physician order for R21 and R6 was for O2 at 2 LPM and that R21 and R6's concentrators were set on 1.5 LPM.

Based on observations, staff interviews, and review of facility policy titled, Food Ordering, Receiving, and Storage, the facility failed to store food off the floor and failed to remove dented canned food item from the storage rack. The deficient practice had the potential to affect 70 of 73 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Ordering, Receiving, and Storage revealed under Procedure: . 9. Dented cans should be kept in a separate designated area with a dented can sign, and away from regular stock. The policy also stated under Storage and Rotation Guidelines: . Food should be stored six inches from the floor. 1. Observation on 3/14/2025 at 8:00 am of the nursing staff break room revealed 29 cases of emergency water stored directly on the floor. Observation on 3/14/2025 at 8:22 am of the walk-in freezer revealed a case of sliced yellow squash and a case of split top white bread directly on the floor. During an interview on 3/14/2025 at 8:22 am the Dietary Manager (DM) revealed that they could use more food storage shelves for the freezer, but it had not been requested. Observation on 3/15/2025 at 7:45 am of the nursing staff break room revealed that the 29 cases of emergency water remained stored directly on the floor. Observation on 3/15/2025 at 8:25 am of the walk-in freezer revealed that the case of sliced yellow squash and case of spit top white bread remained directly on the floor. During an interview on 3/15/2025 at 8:25 am, the DM confirmed that the two cases of food were stored on the floor. The DM stated that the cases had been stacked, and the stack tipped over causing the two cases to be directly on the floor. The DM revealed that all food items should be stored off the floor. During an interview on 3/15/2025 at 2:30 pm, the Administrator confirmed that the cases of emergency water were stored directly on the floor in the nursing staff break room. The Administrator revealed he approved for staff to store the emergency water in the break room to prevent them from freezing in the outside storage shed. When asked why the cases were not stored off the floor and stored on empty crates or pallets, he stated that he could have but did not. During an interview on 3/16/2025 at 9:05 am, the Administrator revealed that he expected all food items not to be stored on the floor. 2. Observation on 3/14/2025 at 8:25 am of the dry storage area revealed a large can of sliced beets in the can rack that had a large dent to the side. During an interview on 3/14/2025 at 8:25 am, the DM confirmed that the can of sliced beets were stored in the can rack and that the can had a large dent on the side. The DM revealed that all dietary staff were responsible for assisting with putting groceries away when they were delivered and if any can(s) had a dent, dietary staff were to place them by the back door. The DM stated that dietary staff should not have put the can in the storage rack.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the resident's right to be free from mental/emotional abuse by a staff member for one of three residents (R) (R56) reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) NN engaged in a personal relationship with R56 which he understood to be intimate. He suffered emotional distress when he alleged CNA NN told him she was not in love with him. Findings include: Review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 12/7/2022, revealed the following: Policy Statement: It is the policy of Pruitthealth and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Review of the electronic medical record (EMR) for R56 revealed he was admitted to the facility with diagnoses to include unspecified paraplegia, generalized muscle weakness, neuromuscular dysfunction of bladder, generalized anxiety disorder, recurrent major depressive disorder, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment for R56 dated 10/19/2023, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment; a Mood score of zero, indicating no depression; and no behaviors exhibited during the seven-day assessment period. Section GG documented functional status/ activities of daily living (ADL) as needing setup assistance for eating and oral hygiene, but substantial to dependent assistance for all other ADLs. In addition, Section N documented R56 received antianxiety and antidepressant medications. Review of the Facility Reported Incident (FRI) dated 11/11/2023 revealed R56 reported to staff and filed a formal grievance related to a personal relationship with CNA NN, which he understood to be intimate, and gave her money for her rent. The FRI investigation could not substantiate exploitation as there was no proof of money exchange, however, R56 gave permission to nursing management to review the text messages on his phone which exchanged messages with CNA NN and were documented to be of an intimate, sexual nature. Review of the local police report documented an interview with CNA NN on 11/16/2023 in which she admitted to being in a relationship with R56, asking for money but not taking it, sending intimate text messages, nude photographs and videos to his phone, and allowing R56 to touch her body over her clothing while she was on duty. Local police arrested CNA NN on 11/27/2023 for sexual assault against a person in custody. Interview on 12/13/2023 3:04 pm with R56 in his room, he stated he thought CNA NN was his girlfriend; she said they were a couple, boyfriend and girlfriend. He stated he later found out she was doing the same with other men in the facility. He stated money changed hands, approximately $780 which he neither expected to get back nor did he ask for it back from CNA NN or the facility. He stated he gave her cash which she didn't push for, but stated she needed it, so he gave it to her. He stated he wound up in the same room with the other [NAME]. He stated he did not expect her to get arrested but thought she would only be fired because she was playing people for money. R56 said you should not play with people for money. He stated CNA NN did not perform any sexual favors, but they kissed almost daily when she worked. He finally stated there was no proof that he gave her money because it was in cash. Interview on 12/13/2023 at 3:45 pm with the Medical Director revealed he did not know of any exploitation efforts against R56 until the facility notified him. He stated, as a result, he needed to increase the frequency of R56's antianxiety medications, which he hoped to wean back to baseline within six months. He stated, other than that, he hadn't made any other changes to R56's plan of care and found him to be stable so far. Review of the Physician's Orders documented an order dated 9/20/2023 for alprazolam one (1) milligram (mg) orally BID (twice daily) related to anxiety. The order was discontinued on 11/15/2023 and a new order was placed for an increase in frequency of the same medication every eight hours. Interview on 12/13/2023 4:40 pm with the Area [NAME] President (AVP), she stated the company terminated CNA NN on 11/17/2023 for violating the company's code of conduct policy and resident rights. She stated there was enough information in the resident's phone to confirm inappropriate interactions between staff and resident. She stated R56's mother informed the facility that her son had a history of attaching to female staff at another facility. She stated the staff followed up with residents for psychosocial support. Interview on 12/14/2023 at 1:54 pm with the Administrator, he stated the facility and corporate office launched an immediate investigation when notified of the allegations. He stated R56's mother called to tell of R56's history of connecting with staff. He stated he had not seen any changes in R56's behavior or condition so far. He stated during staff interviews he was told that R56 and his roommate were known to instigate inappropriate conversations with staff. He stated he advised staff to team up to care for those residents and not care for either of them alone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to apply for Level two (2) preadmission screening and resident review (PASARR) for evaluation and determination of specialized services for one of one resident (R) (R11) reviewed for positive Level I PASARR for mental illness and diagnoses of post traumatic stress disorder (PTSD), generalized anxiety disorder, and major depressive disorder prior to and on admission to the facility. This deficient practice had the potential for R11 to be denied specialized services for psychological, psychiatric, and functional needs. Findings Include: The facility's Nurse Consultant informed the surveyor it does not have a PASARR policy in place and follows state guidelines. Review of the Resident Face Sheet for R11 located in the electronic medical record (EMR) revealed the following diagnoses but not limited to PTSD, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R11 revealed in section C- Cognitive Patterns-Brief Interview for Mental Status (BIMS) score of 15, indicating R11 was cognitively intact, section E-Behaviors-no behaviors exhibited, I-Active Diagnoses-anxiety, PTSD, and major depressive disorder, section N-Medication-on an antidepressant medication 7 days, section O-Special Treatments, Procedures, and Programs-no therapies noted. Review of the care plan dated 8/14/2023 for R11 located in the EMR revealed: address emotional and psychosocial needs of resident. Assess and monitor mood and behavior. Identify any triggers that prompt behaviors or re-experiencing of stressful event. Encourage social support. Review of the Physician's Orders for R11 located in the EMR revealed an order: Trazadone 50mg (milligram) give half tablet at bedtime. Interview on 12/14/2023 at 3:25 pm with the RN Nurse consultant revealed Social Services did not do a PASARR level II because nothing triggered in the system to indicate it was necessary and the PASARR committee stated, Because he had not had a triggered behavior or new onset issues associated with PTSD, a PASARR level II was not needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility policy titled, Care Plans, the facility failed to ensure that the care plans included interventions for a diagnosis of post-traumatic stress disorder (PTSD) for one of two residents (R) (R2). This failure had the potential to prevent R2 from receiving the comprehensive care he required. Findings include: Review of the facility policy titled Care Plans last revised on 7/27/2023 revealed on page 6, Comprehensive care plans updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition and as needed following each hospital stay. Review of the electronic medical record (EMR) revealed R2's last quarterly Minimum Data Set (MDS) assessment completed on 9/22/2023 revealed a Brief Interview for Mental Status (BIMS) score of nine, which indicates moderate cognitive impairment. Pertinent diagnoses included unspecified dementia, senile degeneration of brain, schizophrenia, and PTSD. The diagnosis of PTSD was first noted on the annual MDS assessment dated [DATE]. An active diagnosis of PTSD was first notated in R2's medical record on 6/30/2022. Record review revealed R2 has been receiving psychiatric services since 4/19/2023 with a diagnosis of PTSD indicated in the psychiatric notes dated 4/24/2023. Review of the EMR revealed R2's care plan did not include any mention of or interventions for his diagnosis of PTSD. Interview on 12/14/2023 at 9:03 am with Registered Nurse (RN) MDS Director BB confirmed R2 had a diagnosis of PTSD, but care for this diagnosis had not been addressed in his current care plan. She stated that he may be the only resident at the facility at the time with PTSD, but he needed to have PTSD addressed on his care plan.

Based on observations, staff interviews, and review of the facility policy titled, Infection Control: Glucometer Cleaning and Disinfecting, the facility failed to ensure disinfecting the glucometer per facility policy between residents requiring fingerstick blood sugars checks for two of 18 sampled residents (R) (R4, R36). The deficient practice had the potential to cause an unclean environment for R4 and R36 and increase the potential for infections caused by cross contamination between residents. Findings include: Review of the facility policy titled Infection Control: Glucometer Cleaning and Disinfecting last revised on 6/29/2023, page 2, section E. Cleaning and Disinfection revealed, NOTE: The Glucose Meter must be cleaned and disinfected after each patient/resident use to minimize the risk of transmission of blood-borne pathogens between patient/residents and healthcare professionals. To ensure proper disinfection, it is important to clean the meter prior to disinfecting the meter (Step 4). 4. Clean and disinfect the meter by using the EPA approved wipes [sic] Germicidal and Disinfectant Wipes. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. 5. Ensure that the surface of the meter remains wet at room temperature for the contact time listed on the wipe's directions for use. Allow to air dry. Page 3, section E. revealed: 7. Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Observation on 12/13/2023 at 7:58 am revealed Licensed Practical Nurse (LPN) DD checked a fingerstick glucose level on R4. LPN DD stated that the glucose machine had just been cleaned, so did not reclean prior to performing the fingerstick blood glucose check. After obtaining the blood sugar result, LPN DD placed the used glucometer on a paper towel on top of the medication cart and cleaned it with an alcohol swab. An interview after the fingerstick with LPN DD revealed that she always sanitized the glucometer with an alcohol wipe unless they have beach wipes. She stated that last time she asked, she was told it was ok to use alcohol wipes to clean it. Observation on 12/13/2023 at 11:28 am revealed LPN EE performed a fingerstick blood glucose check on R36. Following obtaining the fingerstick blood glucose result, LPN EE was observed cleaning the glucometer with an alcohol wipe. An interview after the fingerstick with LPN EE revealed that she always uses alcohol wipes to sanitize the glucometer. She revealed she was taught to use an alcohol swab to clean the glucometer. Interview on 12/14/2023 at 8:33 am with the Director of Nursing revealed that her expectation was that staff sanitize the glucose machine after each resident with the purple wipes (germicidal/disinfectant wipes) and not alcohol swabs. She confirmed the facility policy and that disinfection of the glucometer using just an alcohol swab was not adequate for proper disinfection. She revealed she was not aware nurses were using alcohol wipes to clean the glucometers. Interview on 12/14/2023 at 4:59 pm with LPN HH, LPN FF and LPN GG revealed they had had education on the proper process for cleaning the glucometer a couple of times this year, including during the mandatory skills lab held in October 2023. These LPNs confirmed that disinfecting the glucometer included using the purple top disinfectant wipes to clean and to make sure the dwell time is several minutes between uses. LPN HH, LPN FF and LPN GG revealed they had received education on how to clean the glucometer during the required nursing staff skills lab in October 2023. An interview on 12/14/2023 at 5:19 pm with the LPN Nurse Manager revealed the skills lab held October 2023 was mandatory and had personally seen LPN DD and LPN EE attend and complete the skills lab.

Based on observations, staff interviews, and review of the facility policy titled, Cleaning Schedules and Labeling, Dating and Storage, the facility failed to ensure that kitchen equipment was kept clean and sanitary and the dating and labeling of food items. Specifically, the facility failed to ensure routine cleaning of the oven, ice machine, fish basket and food items in the freezer were not dated and labeled. Also, pureed food was not prepared using a recipe. These deficient practices had the potential to affect 81 of 82 residents receiving an oral diet. Findings include: Review of the facility policy titled, Cleaning Schedules dated September 2022, under Policy revealed . It is the Dietary manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment . Under Guidelines number 4. The Dietary Manger will conduct routine sanitation checks and maintains a file of completed checks. Review of the facility policy titled, Labeling, Dating, and Storage dated November 2022, revealed all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Under Guidelines number 1. Food and beverage items will have an identifying label as well as a received date and open date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. Initial walk thru 12/12/2023 at 8:50 am with the Dietary Manager (DM) revealed the ice machine lid was dirty, three bins that contained various cereal were not dated or labeled, and three other bins next to the compartment sink containing corn meal, flour and sugar were not dated or labeled. Continued observation also revealed cold foods in the freezer were not labeled or dated including a box of sausage patties in a plastic bag that was opened, but was not dated, and the plastic bag was left open, which could cause freezer burn. Further observation revealed the shelves where the dishwasher baskets were stored were rusted, the fish fry basket sitting on the fryer was covered with food debris, and the oven was covered with food stains and burned debris. A follow up walk through on 12/13/2023 at 8:30 am of the main kitchen revealed all previous observations including the dishwasher basket stored on a rusty shelf by the dish washer machine. All observations were confirmed with the DM during the walk through. During the observation of puree preparation on 12/13/2023 at 2:20 pm, [NAME] II pureed ham and melted butter for six residents and mixed vegetables with melted butter for six residents. [NAME] II did not follow the proper procedure to use the recipe book for pureed foods. [NAME] II revealed she did not use the recipe book and could not explain the amount, or the quantity used by measurement. Interview on 12/13/2023 at 9:00 am with the DM revealed her expectation of the dietary staff was to conduct daily cleaning of the kitchen equipment after their shift. Further interview revealed that there was currently no cleaning schedule in place for the kitchen. Interview on 12/13/2023 at 9:10 a.m. with the Administrator revealed his expectation of the dietary staff was to keep the kitchen equipment clean daily and for foods to be labeled and dated when opened and including the discard date. He revealed that there should be a schedule of tasks to be completed. Interview on 12/13/2023 at 2:44 pm with the DM revealed her expectation from dietary staff during puree preparation was to ask questions if they weren't sure of what to do.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to develop/implement the care plan for two residents (R) (R#45 and R#62) related to providing baths and/or showers. The sample size was 34. Findings include: 1. R #62 was admitted to the facility on [DATE] with diagnoses that include but is not limited to unspecified dementia without behavioral disturbance, type II diabetes mellitus, and major depressive disorder. Review of the 7/1/22 Quarterly Minimum Data Set (MDS) for R #62 revealed in section (C) Cognitive Patterns a Brief Interview for Mental Status Score of 7 indicating severe cognitive impairment. Section (G) Functional Status (G0120) Bathing - A. Self Performance - 8. Activity itself did not occur during the entire period. B. Support Provided: One person physical assist. Review of the Care Plan for R#62 revealed a problem start date: 2/17/21. Category: ADL Functional / Rehabilitation Potential: (R#62) requires assistance with ADLs related to Dementia. Interventions include but is not limited to: Approach Start Date: Assist with showers 3x/week and as needed. Review of the Point of Care History, Certified Nursing Assistant (CNA) documentation, related to bathing for R #62 revealed from 5/1/22 through 7/18/22 the resident received a documented total of 10 baths/showers, 67 times it is documented that the activity did not occur, and one documented refusal. The last documented shower/bath for R#62 is 6/22/22, 3 weeks and 5 days ago. During an interview and observation with R#62 on 7/17/22 at 2:17 p.m. revealed a strong smell of urine. The pads were bunched up under him and partially out from under the resident and was observed to have yellow stains. During this time the resident began to cry, and he stated that he had not had a bath in weeks and added that he stunk so bad that it was no wonder no one wanted to be around him. During an interview on 7/19/22 at 10:47 a.m. with CNA GG she revealed she has worked in the facility for 3 years. She revealed she is the only full time CNA on day shift working in the facility. She revealed there is no bath team and added that the residents do not get their baths as they should and that the residents do have body odor. She revealed there is not enough staff to get all the baths done and revealed on Tuesdays, sometimes, the extra part time CNA will do as many baths as she can, but she cannot get to everyone. CNA GG revealed she has spoken to the Director of Nursing (DON) related to the facility being short staffed of CNAs and how this affects resident Quality of Care in a negative way and revealed the DON told her they are working on it. 2. R #49 was re-admitted to the facility on [DATE] with diagnoses that include but is not limited to dementia and Parkinson's disease. Review of the 6/17/22 quarterly MDS Assessment for R#49 revealed in Section (C) Cognitive Patterns a BIMS score of 00 indicating severe cognitive impairment. Section (G) Functional Status revealed R #49 is a 2+ person physical, extensive assist, for bed mobility. (G0120 - Bathing) revealed the resident is totally dependent for bathing. Review of the current care plan for R#49 revealed there was no care plan developed related to ADLs. Review of the shower sheets beginning 4/20/22 through 7/22/22 revealed R#49 received a total of seven baths/showers. During an observation on 7/17/22 at 1:15 p.m. of R#49 revealed he was resting in bed with his eyes closed. A strong odor of urine was noted, and the resident appeared unkept.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure heals were floated and/or heel boots were used to prevent further decline in one resident's (R#49) wound of four residents reviewed for pressure ulcers. Findings include: R#49 was re-admitted to the facility on [DATE] with diagnoses that include but is not limited to dementia and Parkinson's disease. Review of the 6/17/22 Quarterly MDS Assessment for R#49 revealed in Section (C) Cognitive Patterns a BIMS score of 00 indicating severe cognitive impairment. Section (G) Functional Status revealed R#49 is a 2 or more-person physical, extensive assist for bed mobility. Section (M) Skin Conditions revealed R #49 (M0150 - Risk for Pressure Ulcers) is at risk for pressure ulcer and (M0210 - Unhealed Pressure Ulcers) has one or more unhealed pressure ulcers stage 1 or higher. Review of the Care Plan dated 1/15/22 for R#49 revealed he has pressure ulcer on his left lateral ankle with an estimated long term goal target date of 9/12/22 that R#49's ulcer will heal without complications. Interventions included try to keep heels floated/ heel boots on resident due to his confusion and combative behavior. Review of the Wound Management Detail Report dated 6/24/22 for R#49 revealed the left ankle measured 1.5 cm x 1 cm x 0.1 cm has light, serosanguineous exudate that is pale red to pink, thin and watery, is a stage III, has no odors and is stable. The 7/15/22 Wound Management Detail Report revealed the left ankle wound measures 2 cm x 3 cm x 0.1 cm, has light, serosanguineous exudate that is pale red to pink, thin and watery, is a stage III, has no odors and is declining. During observations on 7/17/22 at 1:15 p.m., 7/18/22 at 11:00 a.m., 7/19/22 at 1:28 p.m., R#49 was resting in bed with his eyes closed. He was covered with a thin sheet and his feet were observed resting on the bed and did not appear to have on heel boots. During an interview on 7/20/22 at 9:05 a.m. with Wound Care Nurse (WCN) EE she revealed she has worked in the facility since March 2022 and since that time there has been a serious staffing issue related specifically to CNAs. She revealed the residents are not provided the care they need. Review of the Physician Order Report dated 6/22/22 through 7/22/22 reveal an order on 7/1/22 that reads: Treatments Non-RX: Clean left lateral ankle with normal saline, pat dry, cover with dry foam dressing. Change two times weekly on Tuesday and Friday and as needed for dislodgement. Treatment Administration Record (TAR) for R#49 was reviewed for the last three months and revealed all treatments were provided to the residents left ankle wound as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R#276 was admitted to the facility on [DATE] with diagnoses including Other Neurological Conditions, Seizure Disorder or Epilepsy, Unsteadiness on feet, and Legal blindness. The resident has a BIMs of 15 meaning cognition intact. R#276 has a functional status that requires one person supervision with ADL's. During an interview on 7/17/22 at 4:38 p.m. R#276 stated that he did not get a shower last week and none today. He revealed that he asked for a shower 3 times a week but is only getting once a week. Review of the Point of Care History related to bathing for R#276 revealed from 5/1/22 through 7/18/22 the resident received a documented total of six baths/showers, 67 times it is documented that the activity did not occur, and no documented refusal. The last documented shower/bath for R#276 is 7/10/22, eight days ago. Review of the Progress Notes for the above time period revealed that there was no documentation indicating resident's refusing shower. During an interview on 7/18/22 at 12:17 p.m. with the DON regarding facility policy for showers, she revealed that the facility does not have a policy for showers. When asked her expectations from CNAs regarding providing showers for the residents, she revealed that showers are provided per resident preference. She revealed that CNAs are encouraged to provide showers to the residents according to their preference and if they refuse to notify the charge nurse who will document the refusal. 3. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#4 was admitted to the facility on [DATE] with a diagnosis to include but not limited to Multiple Sclerosis, Paraplegia, Pressure ulcer of sacral region, stage 4, Pressure ulcer of right buttock, stage 4, Pressure ulcer of left buttock, stage 4, osteoarthritis, Primary lateral sclerosis. The assessment indicated R#4 had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident was assessed in Activities of Daily Living (ADL) functional status to require the total dependence of two staff with toileting and personal hygiene requires the extensive assistance of one staff. R#4 was assessed have an indwelling catheter of bladder. The resident was assessed to always be always incontinent of bowel. The resident was assessed to have one stage three pressure ulcer present on admission. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#4 received six baths/showers during this period. During an observation on 7/17/22 at 10:30 a.m. and 2:00 p.m., R#4 was observed lying in bed and was not dressed for the day. During an interview on 7/17/22 at 10:35 with R#4, she revealed being lucky if she gets a bath once in two weeks. She stated the facility has no staff and she lays in her brief for at least an hour waiting for someone to change the soiled brief for bowel movements. During an interview on 7/17/22 at 1:45 p.m. with Licensed Practical Nurse (LPN) AA, she revealed being at the facility is sometimes a challenge with the lack of staffing to take care of the residents every day needs. She stated trying to help the CNA's with changing briefs, turning, and refilling water cups but there are more residents than the CNA staff can handle at one time. 4. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#48 was admitted to the facility on [DATE] with a diagnosis to include but not limited to Lower extremity sepsis, Muscle weakness, Morbid obesity, Pressure ulcer of sacral region, unspecified stage, congestive heart failure, Neuropathy, Non-pressure chronic ulcer of foot, Generalized anxiety disorder. The assessment indicated R#4 had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require the extensive assistance of one staff with toileting and personal hygiene. R#4 was assessed to be frequently incontinent of bladder. The resident was assessed to always be frequently incontinent of bowel. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#48 received five baths/showers during this period. An observation and interview on 7/17/22 at 4:06 p.m., R#48 stated she has not received a bath in several weeks and is placed in her electric wheelchair only once a week. The resident appears with dirty gown, greasy hair and unkept facial hair. The smell of urine is present in the room. An observation on 7/18/22 at 10:00 a.m., R#48 is lying in bed with dirty gown, no bath as of this morning, and continued to appear with greasy hair and unkept facial hair. The smell of urine is present at bedside. During an interview on 7/18/22 at 9:45 a.m. with a Certified Nursing Assistant (CNA) EE, she revealed the facility is short staffed with CNA's and typically the facility does not bring in other CNA's from sister facilities. She stated normally she works on the A hall and these residents need the most care, but it is impossible to get everyone turned every two hours and changed appropriately. The CNA EE further revealed working alone on the A hall multiple days and she does her best to get each residents need met but they do have to wait until she can get to each person. Bathing residents is difficult and right now they are mostly getting bed baths. She stated the nurse does help any way she can and tries to give out water during medication pass. The CNA EE stated management continues to say they are bringing over help from sister facilities, but it is very inconsistent with the needs we have here in this facility. The CNA EE further stating taking care of both R#4 and R#48 every day she works since she only works the A hall, and the two residents are located on this hall. The residents are not known to refuse showers or baths when she is working and do want to have their clothes and linens changed several times a week. An interview on 7/22/22 at 11:00 a.m. with Certified Nursing Assistant (CNA) DD revealed having shower sheets in the shower room along with a Master shower list with the names of residents due for showers. The CNA DD stated she documents the resident's name, room, and whether a bath or shower was given to the resident on the shower sheet. She would include on the shower sheet if hair, nails, or shaving was completed. The CNA DD further revealed the charge nurse signs off on the shower sheet, and the sheet is picked up at the end of the week. Based on observation, resident/staff interview, and record review the facility failed to provide baths/showers for five residents (R) (R#62, R#49, R#4, R#48, and R#276) of 10 residents reviewed for Activities of Daily Living (ADL). Findings include: 1. R#62 was admitted to the facility on [DATE] with diagnoses that include but is not limited to unspecified dementia without behavioral disturbance, type II diabetes mellitus, and major depressive disorder. Review of the 7/1/22 Quarterly Minimum Data Set (MDS) for R#62 revealed in section (C) Cognitive Patterns a Brief Interview for Mental Status Score of 7 indicating severe cognitive impairment. Section (E) Behaviors, none identified. Section (G) Functional Status (G0120) Bathing - A. Self Performance - 8. Activity itself did not occur during the entire period. B. Support Provided: One person physical assist. Section (H) Bowel and Bladder, R#62 is frequently incontinent of bladder and occasionally incontinent of bowel. Section (N) Medication revealed R#63 receives a diuretic 7 out of 7 days a week. Review of the Point of Care History, Certified Nursing Assistant (CNA) documentation, related to bathing for R#62 revealed from 5/1/22 through 7/18/22 the resident received a documented total of 10 baths/showers, 67 times it is documented that the activity did not occur, and one documented refusal. The last documented shower/bath for R#62 is 6/22/22, 3 weeks and 5 days ago. During an interview and observation, with R#62 on 7/17/22 at 2:17 p.m. revealed a strong smell of urine. The pads were bunched up under him and partially out from under the resident and was observed to have yellow stains. During this time the resident began to cry, and he stated that he had not had a bath in weeks and added that he stunk so bad that it was no wonder no one wanted to be around him. During an interview on 7/18/22 at 1:31 p.m. with the DON she revealed the facility does not have a shower/bathing policy/procedure. She stated showers/baths are given by resident preference and stated CNAs have a list they go by. Review of the Master Shower List updated 6/1/22 revealed R#62 is scheduled to receive baths/showers on Mondays, Wednesdays, and Fridays. During an interview and observation on 7/18/22 at 1:45 p.m. of R#63 he was in clean clothes, and his bed was observed to be clean. During this time R#63 revealed he got a shower this afternoon and stated he is so grateful to be clean. There were no unpleasant odors noted. During an interview on 7/19/22 at 10:47 a.m. with CNA GG she revealed she has worked in the facility for 3 years. She revealed she is the only full time CNA on day shift working in the facility. She revealed there is no bath team and added that the residents do not get their baths as they should and that the residents do have body odor. She revealed there is not enough staff to get all the baths done and revealed on Tuesdays, sometimes, the extra part time CNA will do as many baths as she can, but she cannot get to everyone. CNA GG revealed she has spoken to the Director of Nursing (DON) related to the facility being short staffed of CNAs and how this affects resident Quality of Care in a negative way and revealed the DON told her they are working on it. During an interview on 7/19/22 at 11:18 a.m. with Wound Care Nurse (WCN) EE she revealed the residents are not getting their baths. She revealed there is not enough staff to give baths as they should be given. During an interview on 7/19/22 at 11:56 a.m. with the Staffing Coordinator she confirmed residents are not receiving their baths as they should and stated staffing is an issue. During an interview on 7/21/22 at 11:00 a.m. with the Administrator he revealed his role in the facility is overseeing the facility, ensuring the best resident care, and listening to staff, family, and residents' concerns. The Administrator stated he provides feedback to the corporate team concerning staffing, hospitalizations, ADLs, and therapy. He further revealed that his goal for this facility is to continue improving and providing optimum care to the residents. He revealed his only concerns have been call light response time, customer service, and the need for more therapy and stated there were occasions staff brought concerns about showers, but usually, that issue is taken up with the charge nurse. He stated the staff does not typically run down the hall chasing him about showers and changing people. The Administrator further revealed the facility has a morning meeting where they discuss tasks for the day and any major daily concerns. Administrator revealed he ensures concerns are assigned to the appropriate person if significant issues are brought up during the morning meeting. 2. R#49 was re-admitted to the facility on [DATE] with diagnoses that include but is not limited to dementia and Parkinson's disease. Review of the 6/17/22 Quarterly MDS Assessment for R#49 revealed in Section (C) Cognitive Patterns a BIMS score of 00 indicating severe cognitive impairment. Section (E) Behaviors revealed R #49 exhibited no behaviors. Section (G) Functional Status revealed R#49 is a 2 or more-person physical, extensive assist, for bed mobility. (G0120 - Bathing) revealed the resident is totally dependent for bathing. Section (H) Bowel and Bladder revealed R#49 is always incontinent. Review of the Master Shower List updated 6/1/22 revealed R#49 is listed on the Saturday/Sunday column only. Review of the shower sheets for R#49 revealed beginning 4/20/22 through 7/22/22 he received a total of 7 baths/showers. During an observation on 7/17/22 at 1:15 p.m. of R#49 revealed he was resting in bed with his eyes closed. A strong odor of urine was noted, and the resident appeared unkept with greasy hair noted. During an observation on 7/18/22 at 11:00 a.m. of R #49 revealed he was resting in bed with eyes open. He was covered with a sheet. During this time R#49 revealed he has not had a bath or been cleaned up in a long while. A strong odor of urine continued to be present and appeared unkept with greasy hair noted. During an observation on 7/19/22 at 1:28 p.m. of R#49 revealed he was resting in bed with eyes closed. Again, he was covered with a sheet. An odor of urine remained and the resident appeared unkept with greasy hair noted. During an interview on 7/20/22 at 9:05 a.m. with WCN EE she revealed she has worked in the facility since March 2022 and since that time there has been a serious staffing issue related specifically to CNAs. She revealed the residents do not receive their baths and are not provided the care they need. During an interview on 7/22/22 at 12:30 p.m. with CNA DD, she revealed R#49 can make his needs known and stated he has not gotten showers as he has asked due to the facility being so short staffed. She stated when she works at this facility the skin of R#49 is dry from not having lotion applied. CNA EE revealed R#49 has been asking for a full bath, and she believes he finally had a bed bath today.

Based on observation, staff interview, and record review the facility failed to provide adequate staff to ensure baths/showers were provided as scheduled for five residents (R) (R#62, R#49, R#4, R#48, and R#276) of 10 residents reviewed for Activities of Daily Living (ADL). Findings include: The following residents were affected due to lack of staffing: 1. Review of the Master Shower List updated 6/1/22 revealed R#62 is scheduled to receive baths/showers on Mondays, Wednesdays, and Fridays. During an interview and observation, with R#62 on 7/17/22 at 2:17 p.m. revealed a strong smell of urine. The pads were bunched up under him and partially out from under the resident and was observed to have yellow stains. During this time the resident began to cry, and he stated that he had not had a bath in weeks and added that he stunk so bad that it was no wonder no one wanted to be around him. During an interview on 7/19/22 at 10:47 a.m. with CNA GG she revealed she has worked in the facility for 3 years. She revealed she is the only full time CNA on day shift working in the facility. She revealed there is no bath team and added that the residents do not get their baths as they should and that the residents do have body odor. She revealed there is not enough staff to get all the baths done and revealed on Tuesdays, sometimes, the extra part time CNA will do as many baths as she can, but she cannot get to everyone. CNA GG revealed she has spoken to the Director of Nursing (DON) related to the facility being short staffed of CNAs and how this affects resident Quality of Care in a negative way and revealed the DON told her they are working on it. 2. Review of the Master Shower List updated 6/1/22 revealed R#49 is listed on the Saturday/Sunday column only. Review of the shower sheets for R#49 revealed beginning 4/20/22 through 7/22/22 he received a total of seven baths/showers. During an observation on 7/17/22 at 1:15 p.m., 7/18/22 at 11:00 a.m., 7/19/22 at 1:28 p.m., R#49 appeared unkept with greasy hair noted and there was a strong odor of urine. During an interview on 7/20/22 at 9:05 a.m. with WCN EE she revealed she has worked in the facility since March 2022 and since that time there has been a serious staffing issue related specifically to CNAs. She revealed the residents do not receive their baths and are not provided the care they need. During an interview on 7/22/22 at 12:30 p.m. with CNA DD, she revealed R#49 can make his needs known and stated he has not gotten showers as he has asked due to the facility being so short staffed. 3. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#4 received six baths/showers during this period. During an observation on 7/17/22 at 10:30 a.m. and 2:00 p.m., R#4 was observed lying in bed and was not dressed for the day. During an interview on 7/17/22 at 10:35 with R#4, she revealed being lucky if she gets a bath once in two weeks. She stated the facility has no staff and she lays in her brief for at least an hour waiting for someone to change the soiled brief for bowel movements. During an interview on 7/17/22 at 1:45 p.m. with Licensed Practical Nurse (LPN) AA, she revealed being at the facility is sometimes a challenge with the lack of staffing to take care of the residents every day needs. She stated trying to help the CNA's with changing briefs, turning, and refilling water cups but there are more residents than the CNA staff can handle at one time. 4. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#48 received five baths/showers during this period. An observation and interview on 7/17/22 at 4:06 p.m., R#48 stated she has not received a bath in several weeks and is placed in her electric wheelchair only once a week. The resident appears with dirty gown, greasy hair and unkept facial hair. The smell of urine is present in the room. An observation on 7/18/22 at 10:00 a.m., R#48 is lying in bed with dirty gown, no bath as of this morning, and continued to appear with greasy hair and unkept facial hair. The smell of urine is present at bedside. During an interview on 7/18/22 at 9:45 a.m. with a Certified Nursing Assistant (CNA) EE, she revealed the facility is short staffed with CNA's and typically the facility does not bring in other CNA's from sister facilities. She stated normally she works on the A hall and these residents need the most care, but it is impossible to get everyone turned every two hours and changed appropriately. The CNA EE further revealed working alone on the A hall multiple days and she does her best to get each residents need met but they do have to wait until she can get to each person. She stated the nurse does help any way she can and tries to give out water during medication pass. The CNA EE stated management continues to say they are bringing over help from sister facilities, but it is very inconsistent with the needs we have here in this facility. 5. During an interview on 7/17/22 at 4:38 p.m. R#276 stated that he did not get a shower last week and none today. He revealed that he asked for a shower 3 times a week but is only getting once a week. Review of the Point of Care History related to bathing for R#276 revealed from 5/1/22 through 7/18/22 the resident received a documented total of six baths/showers, 67 times it is documented that the activity did not occur, and no documented refusal. The last documented shower/bath for R#276 is 7/10/22, eight days ago. During an interview on 7/19/22 at 10:47 a.m., Certified Nursing Assistant (CNA) FF revealed she has worked in the facility for three years and she currently works Monday through Thursday, and on Thursday she revealed she leaves at 3:00 p.m. She revealed there is no bath team and that there is one CNA who has been giving some baths on Tuesday and the weekend staff are doing some as well, but most are not getting done. She revealed she is the only CNA that is fulltime on dayshift and added that sometimes they will send over staff from their sister facility but that does not always happen. She revealed resident care has declined but with the staff they currently have, they are doing the very best they can. During an interview on 7/19/22 at 11:56 a.m., the Staffing Coordinator revealed with the current census, staffing should include 3 Licensed Practical Nurses (LPN)s and 8 to 9 CNAs on day shift, and 5 CNAs on evenings. She revealed the facility currently has only 1, full time, CNA currently employed for day shift, 1 part time CNA for day shift, and no CNA's employed for evening. Staffing Coordinator revealed with the current census on 7:00 p.m. to 7:00 a.m. the facility should have 2 LPNs and 2 CNAs and those are staffed at this time. She revealed it is the responsibility of the Area [NAME] President of Operations to ensure recruiting of new employees. Staffing Coordinator revealed weekends are fully staffed and there are no issues, and that Monday through Friday is where the facility has a staffing issue. She stated on Mondays she has 2 CNAs staffed for the facility on day shift, one that works 7:00 a.m. to 7:00 p.m., and that there are 2 part time CNAs that work either 2:00 p.m. to 9:00 p.m., or 3:00 p.m. to 7:00 p.m., on Monday through Wednesday evenings, then 2 CNAs and 2 LPNs 7:00 p.m. to 7:00 a.m. Staffing Coordinator revealed on Thursday their 1 full time CNA does not work, nor does either part time CNA, so there is no CNA coverage for 4 hours from 3:00 p.m. to 7:00 p.m. but added nursing management, to include the unit manager, Director of Nursing (DON), and others, will come out to the floor and do the CNA work during that time. She revealed she had a meeting with the facility Administrator 2 weeks ago and he informed her that management should get on the halls to help and in the meantime, he is looking into ways to get staff into the building. During an interview on 7/19/22 at 12:56 p.m. with the Area [NAME] President of Operations for the facility, she revealed there is a recruiter for the facility, and she has a weekly meeting with the recruiter. She stated they have applied with Nursing Agency Services to be able to utilize their services but because the area the facility is in is small, and there is not a hotel within approximately 30 miles, none of the agencies will take them on which makes it very difficult to staff. She revealed because their sister facility in Rome is staffed the best, she calls on them to send over help from their facility to this facility and offers incentives and bonuses to get those employees to come and help on their off days. During a telephone interview on 7/22/22 at 10:38 a.m. with the Senior Talent Acquisition Recruiter she revealed she has different sources to recruit staff, but the major source is Indeed. She revealed she has left messages for 413 LPNs, 416 for Registered Nurses (RN)'s, and 659 for CNAs. She revealed those people she contacted are active sources that are already on Indeed and she sends a message out to them about positions available. Recruiter revealed she does not handle Agency recruitment for the facility and revealed she believes the facility does this. She stated she reached out to local colleges and was involved in different job fairs and revealed that the DON has spoken to graduating LPN classes as well as CNA classes. Recruiter revealed that she has done hiring events which have not been very successful due to the poor attendance but with information given for return response upon invite to the event she is able to reach back out to them. She stated the facility has offered wage increases to CNAs to be more competitive with salaries in the surrounding area. Recruiter revealed anything farther than a 20 mile range from a potential employee's home is a no for most due to gas prices and distance from home.

Based on observation, interviews, and policy review entitled Cleaning Procedures: Kitchen Area, the facility failed to ensure the walk-in cooler was operating properly and failed to store food in the kitchen under sanitary conditions. The deficient practice had the potential to affect 70 of 72 residents receiving an oral diet. Findings include: During the initial tour of the kitchen on 7/17/22 at 9:00 a.m., revealed the following: * The floor in the main kitchen was in the process of being mopped. The walk-in cooler was observed to have a leak somewhere from the ceiling dripping from the seams onto the overflow food in the cooler. The floor was observed having a thick black substance and water standing on the floor of the cooler. The ceiling was actively dripping water during surveyors' observation. The temperature was observed to be 38 degrees Fahrenheit. The food observed in the walk-in cooler exposed was strawberries, cucumbers, and potatoes. There were several items wrapped in plastic such as muffins and cucumber salad and these items are unconfirmed for contamination from the leak in the ceiling. * The walls in the dishwasher room were observed to have a yellow substance that was dried and appeared in a streaking motion. * Observation of the cooking area revealed the stove eyes were black with debris noted and the oven, when opened, was observed to have a thick black, caked on substance, on the oven racks and inside the oven and on the inside of the oven doors. * The fryer was observed to have a thick yellow grease for frying food and the surface had a yellow substance on the outside of the fryer. Next to the fryer was a double oven that was observed to have a black and brown substance that was dried. The inside of the double oven was observed to have a thick, black substance, on the oven racks and all inside the oven and on the inside of the oven doors. The wall behind the stove/oven observed to have a thick, black substance that was dried and appeared in a streaking motion. * The ceiling tiles in the back of the kitchen were observed and there were yellow stains. The ice machine was observed to have a thick yellow film substance on the inner lip and underneath. Behind the ice scooper was a blackish splattered film across the ice machine. A review of policy entitled Cleaning Procedures: Kitchen Area created 9/2001 and revised 4/2016, revealed, the policy of (the facility) is to maintain a clean and sanitary environment to prepare patient/resident meals. The policy applies to all dietary, housekeeping, and maintenance partners scheduled to assist in cleaning/sanitizing procedures. Splashes and spills should be wiped off surfaces as soon as they occur. Monthly wash the walls, ceilings, doors and vents with hot water and detergent. Heavily soiled surfaces need to be cleaned more often. Mop spills as they occur. All soiled, dirty, dusty, surfaces and/or areas within the kitchen should be cleaned and/or sanitized (as needed) immediately upon identification. Observation on 7/18/22 at 2:00 p.m. of the facility kitchen cleaning schedule revealed the last documented cleaning was on 8/15/21 by a staff member. No further cleaning schedules were provided during the survey and the surveyor was given a book with blank copies of cleaning schedules. During an interview on 7/17/22 at 3:30 p.mm. with the Area [NAME] President, she revealed the areas of concern in the kitchen were being addressed promptly by a crew coming from another facility to assist in cleaning. The facility was in contact with a company for an afterhours service on the walk-in cooler. During an interview on 7/17/22 at 5:30 p.m. with the Dietary Manager (DM), she revealed the cooler has been leaking for approximately a year. The DM stated she has reported the issue to the Maintenance Director (DM) by phone and spoke with the Administrator several times with no resolution. She further revealed not being aware of reporting issue to a work order system. The DM stated she has always reported issues involving the kitchen by phone and maintenance comes to fix the problem. The DM stated she has been with the facility for one year and is still getting the kitchen in order. She does give the staff areas to clean daily but is still working on getting cleaning schedules made up and put together. During an interview with the Maintenance Director on 7/17/22 at 11:00 a.m., he stated this was the first time seeing the cooler leaking, and he was not informed of the leaking cooler by phone or work order. He was under the impression the door may have been left open to long causing condensation in the room. Observation on 7/18/22 at 9:30 a.m. of the kitchen revealed all initial areas of concern during walkthrough were addressed and sanitized. The walls and ice machine were clean along with the ceiling tiles and double oven. The fryer and the area beside the fryer had no sanitation issues. The walk-in cooler had plastic tubs with lids to prevent any leaking water to spill on food. All food previously exposed were discarded. The floors in the cooler were dry and without a black substance buildup. A floor mat is in the dishwasher area. The stove is clean and without black residue. During an interview on 7/18/22 at 10:00 a.m. with the Regional Dietician she revealed her last visit in June found no issues with the kitchen cleaning schedules or the kitchen itself. She further revealed not seeing the leak in the cooler upon observation and feels the kitchen is in good condition today and sees no concern. During an interview with the Administrator on 7/18/22 at 3:00 p.m., he revealed being unaware of the cooler having a leak in the ceiling, and it was brought to his attention by the MD upon the arrival by the surveyors. The Administrator provided an invoice from (name) Commercial Refrigeration Inc. who looked at the cooler and stated the cooler needs to be replaced.