**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS dated [DATE] for Resident #21 documented a BIMS score of 15/15 indicating no cognitive impairment. It further indicated diagnoses including: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and depression. The Medication Administration Record for September, 2024 noted the following medication orders: a. Aripiprazole oral tablet 5 milligrams (mg) - give 1 tablet by mouth one time a day related to other specified depressive episodes b. Escitalopram oxalate oral tablet 10 mg - give 1 tablet by mouth one time a day related to other specified depressive episodes c. Venlafaxine HCl ER oral capsule 150 mg - give 2 capsules by mouth one time a day for depression d. Buspirone HCl oral tablet 15 mg - give 1 tablet by mouth three times a day related to other specified depressive episodes The facility Care Plan updated 8/13/24 lacked documentation regarding medication side effects, emotional triggers, and behavior monitoring related to depression. Based on observation, record review, and staff interview the facility failed to update the Care Plan for 1 of 2 residents with a pressure sore (Resident #33) and 1 of 5 residents with psychotropic medications ( Resident # 21). The facility reported a census of 73 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #33 indicated a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. It further indicated diagnoses including: anemia, heart failure, and hypertension. The MDS indicated Resident #33 needed partial to moderate assist of staff for transfers, bathing, dressing, and personal hygiene. The MDS indicated Resident #33 had a Stage 3 pressure ulcer and an unstageable pressure ulcer. The MDS indicated the resident was at risk for pressure ulcers. The facility provided a Risk Management assessment dated [DATE] which indicated a possible deep tissue injury to bilateral heels. Review of the Progress Notes dated 5/24/24 revealed the nurse found possible deep tissue areas on both heels. Right heel 1.5 centimeters (cm) by 1.2 cm. Area is flat, intact, with no drainage, purplish gray in color, non tender to the touch. Surrounding skin is dark pink and blanchable. Left heel 1 cm x 1 cm. Area is slightly raised with fluid filled intact blister. Purplish gray in color with surrounding skin dark pink and blanchable. Review of the Care Plan failed to address the bilateral heel pressure ulcers until 6/19/24. On 09/10/24 at 11:33 AM observed Resident #33 sitting in her wheelchair in the main dining room waiting for lunch to be served both lower extremities have heel protector boots in place. On 09/10/24 at 2:15 PM observed Resident #33 in bed both heels floating with bilateral heel protectors in place. On 09/11/24 at 10:32 AM observed Resident #33 in her room in her wheelchair and she had bilateral heel protectors in place she stated she is not having any pain. 09/12/24 at 9:48 AM the Assistant Director of Nursing (ADON), Registered Nurse (RN) stated once the pressure ulcer is identified the Care Plan should be updated. We are notified so once a skin issues is identified the staff do a risk management, the MDS coordinator is responsible to update the Care Plan. The Care Plan should be updated weekly at the Care Plan meeting when something is added or changed. On 09/12/24 at 9:57 AM Staff B, Licensed Practical Nurse (LPN), MDS Coordinator, stated if someone develops a pressure ulcer the Care Plan should be updated immediately. We have a meeting once a week and pressure ulcers are discussed in the clinical meetings. It looks like on 5/7/24 Resident #33 had 'at risk for pressure ulcer' on the Care Plan and on 6/20/24 I added the actual pressure ulcers to the Care Plan and I am not sure why I added them then because they were supposed to be on there but were not. They should have been added right away. On 09/12/24 at 10:04 AM the Director of Nursing (DON), RN stated the interventions should be put on the Care Plan as soon as the change is noted. I would have expected to see it back in May when the pressure ulcer was identified to be on Resident #33's Care Plan. The facility provided a policy titled Care Plan Development Process, updated 11/2023, instructed the following: The Comprehensive Care Plan must be developed no later than 21 days after admission, and will specifically address the following needs: a. Medical b. Nutritional c. Psychological d. Physical e. Functional f. Social g. Educational h. Spiritual i. Condition Impairments j. Disability/Disease 6. Each team member needs to review and revise their portion of the Care Plan in order to prepare for the meeting and to keep Care Plan meeting times concise. The Care Plan will be reviewed and amended as needed. 8. The MDS Coordinator is responsible for ensuring that each portion of the Care Plan is up to date. 9. The Care Plan is reviewed and updated quarterly or with any change in the resident's condition.

Based on observation, staff interviews, and policy review the facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items. The facility reported a census of 72 residents. Findings include: In an interview on 9/10/24 at 8:50 AM Staff A, Laundry aide explained dirty laundry comes in bags. Whites are separated as are personal items. Laundry from isolation rooms comes in a red bag and they get washed by themselves in the washer. Staff wear gloves and an apron for isolation laundry, and only gloves for regular dirty laundry. In an observation on 9/10/24 at 9:17 AM Staff A put on gloves, took the cover off the soiled laundry bin, and placed soiled linens into two washers without donning a gown. She shook out the soiled pads prior to placing them in the washer. She then closed the washer doors and started the machines. Staff A then removed her gloves. In an interview on 9/11/24 at 8:50 AM the Housekeeping Supervisor explained she expected staff to always wear a gown and gloves and then place soiled linens in the washer. The facility policy titled Infection Control Manual: Laundry, revised 11/2023 documented laundry personnel must wear gown and gloves when handling any soiled linens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review the facility failed to notify a family of an area of skin breakdown in 1 of 3 residents reviewed for pressure sores (Resident #16). The facility reported a census of 70 residents. Findings include: The Minimum Data Set, dated [DATE] revealed Resident #16 had a Brief Interview for Mental Score (BIMS) of 6 which indicates severe cognitive impairment. The MDS indicated the resident required substantial to moderate assistance with repositioning in bed and transfers. Review of the Progress Notes dated 4/24/24 at 4:57 AM revealed Resident #16 had a 4 centimeter by 5 centimeter open blister on left lateral ribs 6-8. Superficial wound bed, pink with clear drainage. Covered area with non-adherent dressing and mepilex dressing. The nurse practitioner was notified via facsimile. The family needs notification. During an interview on 05/02/24 at 8:39 AM the Director of Nursing (DON) stated she did not find any documentation that family was notified of the change in skin condition for Resident #16. There was documentation of communication with the family on the chart but nothing specific to the new skin area. My expectation is they would notify family of any change in condition including any new skin areas. During an interview on 05/02/24 at 8:50 AM Staff E, Registered Nurse (RN) stated Resident #16 had an open area of skin on his side by his ribs. I know the nurse before me had told me she had found an open skin area on his rib. Usually if you find a skin area you do a risk management for new skin area and then notify the nurse practitioner and the family. I did not see the area or do an assessment. I did not talk to the family about it at all. Usually the person who finds it notified the family, even if it is on third shift. The facility provided an undated policy titled Nurse Notification of Physician, Resident and Representative of Changes, it directed staff it is the responsibility of licensed nurses employed at this facility to notify the resident's physician/designee, the resident and the representative if/when the resident's clinical condition may require or requires physician intervention to consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; any significant change in the resident's physical, mental or psychosocial status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility. When making notification, the facility will ensure that all pertinent information is available and provided upon request to the physician, the resident and/or the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review the facility failed to follow up with interventions for a skin problem for 1 out of 3 residents with pressure sores (Resident #16). The facility reported a census of 70 residents. Findings include: The Minimum Data Set, dated [DATE] revealed Resident #16 had a Brief Interview for Mental Score (BIMS) of 6 which indicates severe cognitive impairment. The MDS indicated resident required substantial to moderate assistance with repositioning in bed and transfers. Review of the Progress Notes dated 4/24/24 at 4:57 AM revealed Resident #16 had a 4 centimeter (cm) by 5 centimeter (cm) open blister on left lateral ribs 6-8. Superficial wound bed, pink with clear drainage. Covered area with non-adherent dressing and mepilex dressing. The nurse practitioner was notified via facsimile. The family needs notification. Review of the Change in Condition report sent to the nurse practitioner 4/24/24 revealed the facility notified the nurse practitioner of a 4 cm by 5 cm open blister on left lateral ribs. The nurse practitioner signed the report but did not include an order for treatment of the wound. During an interview on 05/02/24 at 10:05 AM the Director of Nursing (DON) stated when a wound is found staff should fill out the skin sheet and notify physician and family. We would review myself or admission nurse would review the skin sheet. The admission nurse follows all the skin areas on the transitional care unit. I am wondering if it could have been more of a friction area from the gait belt. It typically is reviewed at the morning meeting. I saw Resident #16 wound in the report the morning it was identified, looking back I am not sure what happened in the morning meeting. The nurse should fax the physician the wound information and typically as in this case they should clarify if there is no treatment. I would expect staff to obtain a treatment for a new wound. During an interview on 05/02/24 at 10:13 AM Staff F, Licensed Practical Nurse (LPN), Admissions Nurse stated she is responsible for skin issues in the transitional care unit. She stated she does remember something about Resident #16 and a skin issue on his side. She stated usually the nurse that finds it gets an immediate treatment and then from there I just monitor it weekly. I did not look at the area or assess it. I just make sure they have an order to check/measure the wound every week and make sure there are no changes. On a new admission I will get new orders. The nurse who found the wound will do the assessment. The nurse should start a risk management. We check the risk management every morning, if its a skin issue we don't look for an order for a treatment, I assume the floor nurse did it because that is their job. I put it on the Care Plan and when they heal I remove it. I also make sure weekly measurements are being done. The facility provided an undated policy titled Skin Assessments which directed staff all impairments will be noted and addressed by the facility and resident physician.

2. During an observation of the noon meal on 4/29/30 at 11:04 AM Staff A, Dietary Aide served 5 glasses with her hand on the side of the glass and fingers touching the drinking rim surface of the glass. She served 4 glasses with her hand over top of the glass and fingers touching the drinking rim surface of the glass. This affected 9 residents. Based on observation, document review and staff interview the facility failed to keep hands off of the drinking rim of cups for 2 of 3 dining rooms observed and failed to contain hair during meal preparation and serving for 2 of 5 staff observed. The facility reported a census of 70 residents. Findings include: During an observation of the noon meal on 4/29/24 from 11:17 AM through 11:53 AM in the Transitional Care Unit (TCU), Staff D, Dietary Aide was noted to have hair outside her hairnet on the side in front of her ears. She was serving residents food and drink from the steam table. During the same observation, Staff D was observed serving 18 cups to 11 residents while touching the drinking rim of the cups. During an observation on 5/1/24 at 11:49 AM Staff E, Dietary Aide, did not have his facial hair contained or covered while preparing and serving food. During an interview on 5/1/24 at 12:06 PM, the Dietary Manager explained the cups could not be touched at the top, where the resident would drink, the cups needed to be handled by the side or the bottom. She further explained hair nets are to be worn from the beginning to the end of the shift and all facial hair should be covered.

Based on record review and staff interview the facility failed to submit Payroll Based Journaling (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) as required for the quarter of October 1 through December 31, 2023. The facility reported a census of 70 residents. Findings include: The CMS PBJ Staffing Data Report for Federal Year (FY) Quarter 1 2024 (October 1- December 31) triggered for failure to submit data for the quarter. During an interview on 4/30/24 at 11:40 AM, the Administrator confirmed the corporate office did not submit the data. The corporate office submits the data to CMS. This time the corporate office was waiting for additional information from a 3rd party and submitting the facility data slipped her mind. The Administrator was not aware the data was not submitted until 4/29/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to ensure the comprehensive care plan included all services required to ensure the medical and nursing needs were met for 3 out of 3 residents with incidents of coffee being spilled onto skin (Resident #10, # 29 and #45). The facility census was 76 residents. Findings include: 1.)The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognitive status. Resident #45 's diagnoses included anemia, hypertension and renal insufficiency. The MDS indicated Resident #45 was independent with eating. Review of the incident report dated 9/13/22 at 3:09 PM revealed Resident #45 was outside with husband and spilled coffee on her lap. Resident received burn to right and left inner thigh. Review of the care plan failed to reveal any interventions to prevent further incident of spilling coffee until 12/20/22 after surveyor requested information. Intervention added to provide my coffee in a sturdy coffee cup on 12/20/22. 2.) 1.)The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive status. Resident #29 's diagnoses included coronary artery disease and hypertension. The MDS indicated Resident #29 required set up help with eating. Review of the incident report dated 11/13/22 at 11:10 AM revealed Resident # 29 spillled coffee down the right side of her hip and received a two centimeter blister. During an observation on 12/20/22 at 11:43 AM Resident # 29 ate meal independently in the main dining area. She drank from insulated coffee cup with a lid on it. Review of the care plan failed to reveal any interventions to prevent further incident of spilling coffee until 12/20/22 after surveyor requested information. Intervention added to require a lidded cup for my coffee on 12/20/22. 3.) The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12 indicated mild cognitive impairment. Resident #10 's diagnoses included coronary artery disease, hypertension and heart failure. The MDS indicated Resident #10 required set up help with eating. Review of the incident report dated 11/15/22 at 1:19 PM revealed Resident # 10 spilled hot coffee on his left upper leg. There was a 6 inch by 2 inch red area with some blistering. Review of the care plan for Resident #10 failed to reveal any interventions to prevent further incident of spilling coffee until 12/20/22 after surveyor requested information. Intervention added to require a lidded cup for my coffee on 12/20/22 to prevent spilling. During an observation on 12/20/22 at 11:40 AM Resident #10 fed self independently in the main dining room. He drank from glasses without incident and no spillage. Resident #10 did have coffee in front of him in insulated cup no lid on the cup. During an interview on 12/21/22 at 1:30 PM with the Director of Nursing she stated the incidents with coffee spilled on residents would be addressed by staff would notify myself or the administrator or designee if someone is on call then we would discuss with our clinical meetings in the morning. Typically we would do care plan updates with any changes and then communicated to the [NAME] to inform staff. The interventions to the care plan should have been added at the time of the intervention and when the coffee was spilled to prevent any further incidents. The facility provided a policy dated 2/20/16 titled Care Plan Frequent Update, it directed staff the resident care plan will be updated whenever there is a change in the plan of care. The process directed staff whenever a change in physician orders and/or nursing interventions occur, the care plan is to be reviewed for an update to reflect the change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide tubi grips to a resident per the physician order for 1 out of 1 residents reviewed (Resident #34). The facility reported a census of 76 residents. Findings include: Minimum Data Set (MThe DS) assessment dated [DATE] recorded Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognitive status. Resident #34's diagnoses included hypertension, diabetes, stroke, and depression. He required limited assistance of one staff with bathing and dressing. The treatment administration record for December 2022 revealed an order for tubi grip stockings to both lower extremities on in the AM and off at bedtime. Hand wash and hang to dry two times a day. The physician order sheet dated 11/28/22 revealed an order dated 9/7/22 for tubigrips bilateral lower extremites on in the AM and off at bedtime, hand wash and hang to dry. The care plan with a date initiated of 7/1/22 failed to address the tubi grip stockings. During an observation on 12/19/22 at 11:54 AM Resident #34 at lunch in his wheelchair in the main dining room and no tubi grip noted to both lower extremities. During an observation on 12/19/22 at 3:30 PM Resident #34 in the main dining area of unit playing cards with other residents sitting in his wheelchair and no tubi grip on both lower extremities. During an observation on 12/20/22 at 7:49 AM propelling self to breakfast in wheelchair and no tubi grip on both lower extremities. During an observation on 12/21/22 at 8:58 AM Resident # 34 in bed with both lower extremity regular socks on and does not have any tubi grips on both lower extremities. He states he is not aware of any kind of special socks that he wears but would have to ask the staff. During an interview on 12/21/22 at 1:19 PM with Staff A, Certified Medication Aide (CMA) states she is not aware of Resident #34 having tubi grips but I am not assigned to this hall very often. During an interview on 12/21/22 at 1:19 PM Staff B, Licensed Practical Nurse ( LPN) states Resident #34 needs to have tubi grips on [NAME] and off at bedtime. I think he is using them because of edema. The certified nurses aides put them on in the morning and take them off at night . I sign them off on the treatment administration record. I typically see them when he comes out for breakfast. During an interview on 12/21/22 at 1:28 PM the Director of Nursing (DON) states she would expect staff to follow physician order and by signing the treatment administration record it would indicate the treatment is completed . On 12/21/22 at 3:05 PM the DON stated they do not have a policy for following physician orders but she would expect the nurse to follow as written by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview and facility policy review, the facility failed to follow physician orders to provide the correct amount of fluids and to perform an enteral (feeding) tube placement check according to current standards of practice for 1 of 1 residents reviewed who required an enteral tube (Resident #1). The facility identified a census of 76 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive loss. Resident #1's diagnoses included cerebral palsy, seizure disorder. The resident required total assist of one staff for eating. The MDS documented the resident utilized a feeding tube for fifty one percent (%) or more of her total calories and 501 cubic centimeters (cc's) per day or more of fluid while residing at the facility. The order summary report dated active orders as of 11/28/22 directed staff to provide four ounces of cranberry juice with eight ounce of water four times daily. The orders also directed staff to provide enteral feed order four times a day related to cerebral palsy give 237 milliliter Promote with fiber via gastronomy tube four times a day for supplement and flush with eight ounces of water with administration. The care plan intervention dated 2/18/18 directed staff to administer four ounces of cranberry juice with eight ounces of water per the gastronomy tube. The interventions also directed staff to check placement verification prior to feedings and medications with a date initiated 2/18/18. During an observation on 12/20/22 at 10:02 AM Staff B, Licensed Practical Nurse (LPN) entered Resident # 1 room resident sitting in wheelchair he opened the resident's [NAME] button (stomach tube for nutrition) and connected syringe with tubing. He provided 90 cc cranberry juice then administered fiber 1.0 cal 8 ounces by gravity and then followed with a 2 ounce water flush. Staff B failed to aspirate for residuals or check for placement of the tube. During an interview on 12/21/22 at 1:22 PM Staff B, LPN stated prior to doing the tube feeding staff should check for residuals. He admitted he did not do it 12/20/22 for Resident # 1 prior to initiating her tube feeding. During an interview on 12/21/22 at 01:24 PM Director of Nursing (DON) stated for a tube feeding the expectation is follow the physician order to give the appropriate fluids. She would expect staff prior to administering feeding to check for residual or placement. They should follow physician order on what to administer for residents tube feeding. The facility provided a policy dated 2/20/16 titled Enteral Feeding which directed staff to verify physicians order for bolus feeding and to check tube placement per policy.

Based on clinical record review, resident and staff interviews and facility policy review the facility failed to complete pre and post dialysis assessment for 1 out of 1 residents reviewed (Resident #124). The facility reported a census of 76 residents. Findings included: The Minimum Data Set (MDS) assessment for Resident # 124 dated 12/12/22, included diagnoses of end stage renal disease (ESRD) and hypertension. The MDS reflected Resident's 124's Brief Interview for Mental Status (BIMS) as 15 (intact cognition). The Care Plan for Resident # 124 dated 12/19/22, directed dialysis days: Monday-Wednesday-Fridays. Nursing will complete an assessment prior to leaving and upon return from dialysis. The Clinical Assessments in the Electronic Health Record (EHR) dated 12/9-17/22, lacked pre and post dialysis assessments. The Health Status Note dated 12/16/22, Friday lacked dialysis pre and post assessment. The Health Status Note dated 12/14/22 at 2:59 PM, read Resident # 124, returned from dialysis, with no new orders. The Health Status Note dated 12/14/22 failed to include a pre dialysis assessment. The Health Status Note dated 12/12/22 failed to show a post dialysis assessment. The Health Status Note dated 12/9/22 failed to show a pre and post dialysis assessment. On 12/21/22 at 8:42 AM, Staff D Registered Nurse, (RN) reported she is expected to complete dialysis pre and post assessment for the resident that go to dialysis and they are documented in the resident Progress Notes. On 12/21/22 at 11:38 AM, the Director of Nursing, (DON) reported she expected the nurses to complete pre and post dialysis assessment and document them in the Progress Notes. The facility provided a policy titled Standards and Processes, Pre and Post Dialysis Assessments and Documentation of the Dialysis Resident dated 11/22, directed to assess for and evaluate any changes of condition related to the residents physical condition prior to dialysis and upon return after receiving Dialysis treatment. The Process directed; 1. Obtain a set of vitals signs (VS) prior to leaving the facility and upon return to the facility- (report any abnormalities from resident's normal range to the physician. 2. Assess residents physical condition prior to leaving the facility and upon returning (skin temperature- does resident complain (c/o) of feeling cold- c/o pain- alertness-level of lethargy c/o nausea. 3. Assess residents vascular site- reporting any bleeding swelling- document condition pf the site and/or dressing dry and intact. 4. Administer any medications as ordered. 5. Re-assess resident's physical conditions and VS as warranted with any change in condition and report to the resident's Physician or physician on call. 6. Document VS and assessment in the Progress Notes- report to physician any abnormalities and report to the on-coming Nurse to ensure follow up. Document any contact with the Physician and /or family members. 7. If dialysis report sheets are not received upon return to the facility, notify Dialysis unit to send to the facility or notify the DON.

Based on observations, policy reviews and staff interviews the facility failed to implement infection control standards for intravenous antibiotic therapy and straight catheterization for 1 of 1 resident (Resident #33). The facility reported a census of 76 residents. 1. The Minimum Data Set (MDS) assessment tool, dated 10/27/22, listed diagnosis for Resident #33 included: Type 2 diabetes mellitus, neurogenic bladder (lack control), and muscle weakness. The MDS stated the resident required extensive assistance with one staff for toilet use, and personal hygiene. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 99, indicating a severe cognitive impairment. A record review revealed escherichia coli (a common bacteria that causes urinary tract infections) found in residents' urine during a hospitalization on 12/13/22. On 12/16/22 the resident discharged from the hospital with a physician's order to receive IV (temporary tubing placed in a vein for delivery of liquid medication) antibiotic therapy twice daily. The physician placed an order for the antibiotic Imipenem-Cilastatin 500 mg. The resident had a midline IV catheter placed in her right arm prior to returning to the facility. During an observation on 12/20/22 at 6:00 AM, Staff E, Registered Nurse began the process to administer the IV medication. During the process, Staff E could not remove the cap on the IV tubing. In the process of attempting to remove the cap, Staff E twisted and handled the IV tubing after touching the resident's bed, and touching her face with gloved hands. At 6:11 AM, Staff E removed the cap from the IV tubing. Staff H used an alcohol prep to clean the resident ' s IV line connection tip, and then without scrubbing the IV tubing connected the tubing to the midline. During an interview on 12/20/21 at 1:52 PM, Staff E stated the connectors on the midline IV and the IV tubing needs to be scrubbed for 30 seconds with an alcohol prep. Staff E stated the cap of the IV tubing had been difficult to see and she had difficulty getting it off. Staff E stated she should have scrubbed the IV tubing connector. During an interview on 12/21/21 at 2:00 PM, the Director of Nursing (DON), stated when staff administer an IV medication she expects they will scrub the connector to the resident IV before connecting the IV tubing. When asked if the IV tubing should be scrubbed after being handled for 11 minutes due to difficulty with the cap, the DON stated yes, the IV tubing connector should be scrubbed under the circumstance. The facility lacked a policy on the use of intravenous supplies. 2. The Minimum Data Set (MDS) assessment tool, dated 10/27/22, listed diagnosis for Resident #33 included: Type 2 diabetes mellitus, neurogenic bladder (lack of control) and muscle weakness. The MDS stated the resident required extensive assistance with one staff for toilet use, and personal hygiene. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 99, indicating a severe cognitive impairment. A record review revealed a physician order for a straight catheterization (catheter in to drain bladder and then removed) three times daily due a neurogenic bladder. During an observation on 12/20/22 at 1;25PM , Staff E , Registered Nurse (RN) applied left sterile glove by placing her right hand under the cuff on the outside of the glove. Staff E ' s bare hand touched the outside of the glove. At 1:29 PM, while waiting for the urine to completely drain into the catheter bag, Staff E placed her clean left glove hand on the resident's bed three times. Staff E used her left hand to manipulate the catheter tubing in and out of the urethra in an attempt to ensure complete drainage of the bladder. During an interview on 12/20/22 at 1:56 PM, Staff E stated she did not realize she put her bare right hand under the outside cuff of the left glove. Staff E stated she should have placed her hand on the inside of the glove to put it on. Staff E stated she did place her left hand on the bed and then manipulated the catheter tubing to ensure complete drainage. During an interview on 12/21/22 at 2:05, the Director of Nursing (DON0 stated a straight catheterization is a sterile procedure, She stated she would expect the staff to put on gloves by placing their clean hand on the inside of the glove, never touching the outside. The DON stated during a catheterization she would expect staff to keep their clean hand off the bed as that is a source of contamination. The facility policy, reviewed and updated 11/2022, titled Straight Catheter Protocol staff are directed to don (put on) sterile gloves. The protocol does not address maintaining a clean hand during the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interviews the facility failed to maintain sanitary conditions due to inadequate dishwasher temperatures, food temperatures and a lack of monitoring systems. The facility reported a census of 76 residents. Findings include: 1. During an observation on 12/19/22 at 10:07 AM the main kitchen dishwasher wash cycle temperature read 140 degrees Fahrenheit (F), with a rinse cycle temperature of 160F. The Model CMA-180 VL Installation and Operation manual, page 4 specified 155F as the minimum temperature for the wash cycle, and 180F the minimum rinse cycle temperature During an interview on 12/19/22 at 10:09AM, Staff D, Cook, stated she had not done any breakfast dishes and would inform a maintenance staff of the low temperatures. Staff D stated the staff document the wash and rinse temperatures in a log book three times a day. Staff D could not present the log book after two requests. During an observation on 12/21/22 at 8:18 AM the main kitchen dishwasher rinse cycle after a warm up cycle read 174F. During an interview on 12/21/22 at 8:20 the Food Services Director (FSD) stated she would get a maintenance staff to adjust the temperature. Upon request, the FSD presented a dishwasher temperature log for December 2022. All temperatures for the wash and rinse cycle were within the recommended manufacturer perimeters. When asked for previous months dishwasher temperature logs, the FSD stated she does not keep logs more than several days. When asked if the staff consistently document dishwasher temperatures daily, the FSD stated they do, but she does not keep the logs. During an interview on 12/21/22 at 12:46 PM Staff F, Dining Services Aide stated she does document temperatures when there is a log sheet available. When asked if there is always a log sheet available Staff F stated no, there is not. Staff F stated she services meals on the [NAME] Unit and would use the dishwasher in the unit, however it is out of order. The staff stated since the machine is out of order she used the kitchen dishwasher. During an observation on 12/21/22 at 12:47 PM, after several cycles completed by Staff F, Dining Services Aide, the kitchen dishwasher rinse cycle read 174 F. When asked to use a test strip to measure the of the dishwasher, Staff F stated test strips are not used. During an interview on 12/21/22 at 12:54 PM, the FSD stated the kitchen dishwasher temperatures have been a concern and maintenance regularly makes adjustments to bring up the temperature to the recommended minimum. When asked about the December 2022 dishwasher temperature log, the FSD stated the logs were made up results. The DM stated she did this for all operational unit dishwashers. When asked how sanitation is maintained, the FSD stated [NAME] Brothers services the all kitchen equipment monthly and sends a report. A dining observation completed on 12/21/22 at 11:11 AM, revealed dietary staff used washable dinner plates, small salad bowls, coffee cups, plastic 8 ounce cups, and silverware to service the noon meal to 13 residents in the [NAME] dining room. During an interview on 12/21/22 at 2:00 PM, the Administrator stated she had been unaware the dishwasher temperature logs were documented, and logs maintained. The Administrator stated she would expect staff to document dishwasher temperatures after each meal, and logs maintained since the last annual recertification. The Administrator stated the facility does not have a policy for dishwashing temperatures, and would use the Model CMA-180 VL Installation and Operation manual for guidance. 2. A record review of the December 2022 facility food logs on the [NAME], [NAME] and TCU units revealed the results to be the same for each food item, for each meal, for each day documented from breakfast on December 1, 2022 thru lunch on December 19, 2022. The daily temperature log for TCU lacked documented temperatures for the supper meal on 12/19/22, and 12/20/22, and breakfast and lunch meals on 12/21/22. The daily temperature log for [NAME] lacked documentation for all meals after supper on 12/10/22. During an interview on 12/21/22 at 12:00 PM, Staff G, Certified Nursing Assistant and Dietary Aid on the [NAME] Unit stated she did not take food temperatures prior to serving the noon meal. An observation on 12/21/22 at 12:07 PM, revealed seven lunch trays plated with beef stroganoff, buttered noodles, carrots and pea salad. Each tray sat on a cart, uncovered. The beef stroganoff appeared dried out. During an interview on 12/21/22 at 12:08 PM, Staff H, Certified Nursing Assistant stated she prepared the plates to be delivered to rooms five minutes ago and had been unable to find plate covers. Staff H could not find a food thermometer in the unit kitchenette when asked to take the food temperatures. Staff H stated she is a CNA, but had recently started serving meals. Staff H denied completing any training requirements, and did not know she needed to take food temperatures, or to document the results. At 12:17PM, the Administrator arrived at the unit and agreed the trays cannot be served to residents. At 12:19PM the results of food temperatures taken with the Administrator present. Hot items: beef stroganoff 130 degrees Fahrenheit (F), buttered noodles 78F, carrots 85 F Cold items: pea salad 70F. At 12:30PM, the Administrator reviewed the December 2022 food logs for each unit. During an interview on 12/21/22 at 12:35 PM, the Administrator stated the food logs are a problem and she can see they are the same. The Administrator stated she is very disappointed. The Administrator stated she would expect food temperatures for each item served during a meal are taken, and documented. The Administrator stated she would expect the logs to be kept from recertification year to recertification year. During an interview on 12/21/22 at 12:54 PM, the Food Services Director stated she and a co-worker filled out the log sheets and made two copies. The FDS stated she placed a copy in a binder and put one binder on each unit. The FSD stated staff take food temperatures but due to being short staffed they have not been documenting the temperatures. An undated facility policy, titled Food Temperatures - Serving Line procedure stated: A. Hot foods are maintained at or above 135F, so that items arrive at approximately at or above 120F when serviced. B. Cold foods are maintained and serviced at 41F or less. C. Temperatures are taken prior to each service to ensure hot foods and cold foods are maintained at the specified temperatures D. Temperatures are recorded on the Food Temperature form and kept on file for 1 year.