**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in form to meet individual needs related to not making pureed food the correct consistency. This had the potential to affect the 2 residents who received a pureed diet. Finding includes: On 9/5/24 at 11:27 a.m., [NAME] 2 was observed preparing pureed food. She indicated she was going to puree 3 servings of [NAME] Dogs (hot dog with a meat sauce). She placed 3 hot dogs with an unmeasured amount of meat sauce into the blender and blended. She poured the mixture out into a container and indicated it was finished. The cook was asked how she was sure if there were no hot dog chunks in the puree. She then proceeded to take a fork and stir up the puree. There were visible chunks of hot dog still observed. The cook then poured the mixture back into the blender and added an unmeasured amount of water to the blender and blended. She poured the mixture back into another container. She stirred the container with a fork and indicated it was smooth. The container was still observed with chunks of hot dogs. The cook was interviewed if she saw the chunks of hot dog. She indicated no and then she stirred the container again and acknowledged there were still chunks of hot dog in the container. She poured the mixture back into the blender again and added an unmeasured amount of water to the blender and blended. She poured the mixture into a container, stirred it around with a fork, and the food was smooth with no chunks. During an interview after the observation, [NAME] 2 indicated they did not have any puree recipes to follow. The staff followed a food and liquid consistency chart. The chart did not say how much or what liquid to use in pureed food. During an interview on 9/5/24 at 12:57 p.m., the Dietary Manager (DM) indicated the cook should have made sure there were no chunks of hot dog in the puree before indicating she was completed with the puree. The facility did not have any puree recipes. The Dietician told them it did not matter what liquid they used to reach the proper consistency. A recipe, titled [NAME] Dog and received as current from the DM, indicated, .Notes: 1. Pureed Level 4: Smooth texture, NO lumps . 3.1-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were maintained, related to staff touching pills during medication administration for 1 of 12 residents observed during medication administration. (QMA 1, QMA 2, and Resident 9) Findings include: 1. On 9/4/24 at 11:33 a.m., QMA 1 was observed preparing Resident 9's medications. She popped one tamulosin (medication to improve urination) capsule from the medication card into her hand. She then opened up the capsule with her hands and poured the medication into a cup and administered the medication. During an interview at the time, QMA 1 indicated she normally just opened up the capsules with her hands and did not wear gloves. 2. On 9/5/24 at 12:37 p.m., QMA 2 was observed preparing Resident 9's medications. She popped one tamulosin capsule from the medication card into her hand. She then opened up the capsule with her hands and poured the medication into a cup and administered the medication. During an interview at the time, QMA 2 indicated she normally wore gloves when she opened the medication capsules. During an interview on 9/5/24 at 3:04 p.m., the Assistant Director of Nursing indicated the staff are expected to apply gloves and not to touch pills with their hands. A Skills Competency checklist titled, Medication Administration (Medication Pass Procedure) and received as current from the Director of Nursing, indicated, .5. Medications are opened without contaminating . 3.1-18(b)

Based on record review and interview, the facility failed to ensure there were 8 hours of consecutive RN (Registered Nurse) coverage for 9 out of 20 days reviewed. This had the potential to affect all 27 residents in the facility. Finding includes: On 9/6/24 at 11:21 a.m., the Nursing Staff Schedules dated 8/18/24 through 9/6/24 were reviewed. There was no RN scheduled for 8/18/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/27/24, 8/31/24, 9/1/24, and 9/6/24. During an interview on 9/6/24 at 11:49 a.m., the Administrator indicated there was not 8 hours of RN coverage on the above dates. 3.1-17(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/5/24 at 11:58 a.m., [NAME] 2 was observed checking temperatures of the meal being served for lunch. She began by washing her hands with soap and water. She wiped the food temperature probe with a sanitation wipe and proceeded to check the temperature of a hot dog. She removed the probe, wiped it with a new sanitation wipe, and checked the temperature of the [NAME] dog sauce. She repeated this process to check the temperature of mashed potatoes, the [NAME] dog puree, green beans, and pureed green beans. [NAME] 2 then checked the temperature of a hamburger, removed the probe, and then placed the probe directly into a soft bite-sized hot dog. She repeated this process for checking the temperatures of french fries, [NAME] dog sauce, and pureed [NAME] dog sauce without sanitizing the temperature probe between uses. During an interview on 9/5/24 at 12:05 p.m., [NAME] 2 indicated she needed to sanitize the temperature probe between each use, and she wanted to wash it. She proceeded to wipe the temperature probe with a cloth located inside of a sanitizer bucket. During an interview on 9/6/24 at 11:36 a.m., the Dietary Manager indicated the temperature probe should have been wiped in between each use and she would provide some in-servicing to her staff. A Policy titled, Proper Use of a Food Thermometer, indicated, Probe Thermometer .Thermometer is cleaned and sanitized before use. Thermometer is inserted, up to the dimple, into the thickest part of the food. Thermometer is left in the food item until the needle has stopped moving .Thermometer wiped with sanitizing wipe and allowed to dry before inserting into the next food item. 3.1-21(i)(3) Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen related to expired foods, undated and/or unlabeled food, and foods open to air in the refrigerator and freezer. The facility also failed to ensure a cook cleaned a food thermometer probe correctly before checking temperatures of food. This had the potential to affect 27 residents who received meals prepared in the kitchen. Findings include: 1. On 9/3/24 at 10:46 a.m., during the initial kitchen tour with [NAME] 1, the following was observed: a. First refrigerator - There were 3 bags of lettuce. The best by used date was 8/27/24. - There was a sealable bag of chicken [NAME] dated 8/29/24. The use by date was 9/1/24. - There was a sealable bag that was open to air. The bag contained scrambled eggs and was dated 9/1/24. b. First freezer - There was a sealable bag with an unknown meat in the bag. There was no label on the bag that included the contents or when it was frozen. During an interview at the time of the tour, [NAME] 1 indicated she had not worked for the past couple of days and the items should have been labeled or thrown out when they expired. A sheet titled, Labeling and Dating and provided as current from the Dietary Manager, indicated, .The date the product must be consumed or discarded may not exceed the manufacturer's use-by-date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a Physician's order was in place for a wound treatment for 1 of 2 residents reviewed for non-pressure skin issues. (Resident 4) Finding includes: On 8/18/22 at 4:10 p.m., Resident 4's right foot and leg wound treatment was observed with the Director of Nursing (DON) and the Clinical Nurse Specialist (CNS). The resident had wounds on the second and third toes, the top of the right foot, and in the middle of his calf. The DON completed the treatment to the right foot and calf. The toes were wrapped with gauze. The resident's record was reviewed on 8/17/22 at 3:09 p.m. The resident was admitted on [DATE]. Diagnoses included, but was not limited to, dementia and chronic obstructive pulmonary disease. The current Physician's Order indicated the the right foot and lower leg were to be cleansed with wound wash, apply Calazine around wound, cover with an ABD pad (thick dressing pad) and wrap in gauze daily. There was no treatment order for the toes. The Wound Monitoring indicated the resident had abrasions to the right second and third toes and the top of the right foot that were initially found on 7/12/22. The CNS indicated at the time of the wound treatment, they did not have a treatment order for the toes and the Physician would need to be contacted. 3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure an intervention was in place for the treatment and prevention of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 27) Finding includes: On 8/17/22 at 12:01 p.m. and 8/18/22 at 2:58 p.m., Resident 27 was observed in his bed. He had a cushion under his knees, and his heels were resting on the mattress. On 8/19/22 at 1:00 p.m., a staff member was talking to the resident while he was in bed. The cushion was on the chair, and his heels were resting on the mattress. At 1:44 p.m., the cushion remained on the chair and the resident's heels were resting on the mattress. The resident's record was reviewed on 8/18/22 at 3:52 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, dementia and Diabetes Mellitus. The admission Minimum Data Set assessment, dated 7/25/22, indicated the resident had moderate cognitive impairment and required extensive assistance from staff for bed mobility and transfers. The Wound Monitoring log indicated the resident had a stage 2 (partial-thickness skin loss into but no deeper than the dermis, includes intact or ruptured blisters) pressure ulcer to his right heel that was first identified on 7/26/22. A Physician's Order, dated 8/4/22, indicated the resident was to have a Heeleze cushion (to keep the heels off the bed to reduce pressure) at all times when in bed. The Pressure Ulcer Care Plan, dated 7/26/22, included the intervention to have Heeleze cushion in place to offset pressure to heels when in bed. Interview with LPN 1 on 8/19/22 at 1:44 p.m., indicated the resident was to have the cushion at all times when in bed to elevate heels off the mattress. 3.1-40