Based on observations, staff interviews, and policy review, the facility failed to prepare pureed food items with the most nutritional content, provide a full serving of pureed meat and failed to hold hot food at appropriate temperatures. The facility reported a census of 26 residents. Findings include: On 1/3/23 at 11:30 PM, observed the puree food process with Staff A, Cook. Staff A reported there were two residents that received puree food (Resident #4 and #10). Staff A reported she would need to puree 6 items (two servings of green beans, two servings of rice, one serving of salmon and one serving of barbeque (BBQ) ribs). Observations revealed the following: A. Staff A took two servings of rice from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the rice and added some thickener. Staff A split the pureed rice into two servings and scooped it into two bowls. Staff A placed a plastic lid on each bowl and placed it in the steam table without labeling or taking a food temperature. B. Staff A took two servings of green bean from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the greens beans and added some thickener. Staff A split the pureed green beans into two servings and scooped it into two bowls. Staff A placed a plastic lid on each bowl and placed it in the steam table without labeling it or taking a food temperature. The green beans appeared very runny in consistency. C. Staff A took one serving of salmon from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the Salmon, then added more water and some thickener to the mixture and blended it again. Staff A put the pureed salmon into a bowl. Staff A did not scrape out the blender to ensure the entire meat serving was obtained. Staff A placed a plastic lid on the bowl and placed it in the steam table without labeling the container or taking a food temperature. D. Staff A took one serving of BBQ ribs from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the BBQ ribs and added some thickener. Staff A placed the pureed BBQ ribs in a bowl filled to the top. Staff A took the blender to the sink and discarded the remainder of the pureed BBQ ribs. Staff A acknowledged and verified that she had discarded the remainders of the BBQ. Staff A placed a plastic lid on the bowl and placed it in the steam table without labeling the container or taking a temperature of the pureed BBQ ribs before placing it back in the steam table. E. Observed Staff A use cold tap water and hot tap water from the sink when adding the water to the blender. Staff A did not check the water temperature before adding it to the blender. On 1/3/24 at 12:00 PM, surveyor requested Staff A, [NAME] to take food temperatures on the pureed food items in the steam cart in the serving kitchen prior to serving. The food temperatures for the pureed food revealed the following temperatures: a. [NAME] Beans- 111.5 degrees Fahrenheit b. Rice- 114.6 degrees Fahrenheit c. Salmon- 106.9 degrees Fahrenheit d. BBQ ribs- 104.8 degrees Fahrenheit On 1/3/24 at 12:10 PM, Staff A, [NAME] reported she was not sure what to do about the pureed food temperatures. Staff A stated she would call her Supervisor for direction. Staff A reported Staff C, Dietary Supervisor told her to reheat the pureed food items in the microwave before serving. Staff A reported she had taken food temperatures prior to leaving the main kitchen. Staff A stated that the food must have lost temperature on the way down from the main kitchen to the serving kitchen. On 1/3/23 at 2:30 PM, Staff C, Dietary Supervisor reported they had been having some issue with the steam table in the serving kitchen and had plans to replace it. Staff A reported when she arrived to the serving kitchen the steam table wells were out of water so she had to add water to each well before placing the food in the steam table. She stated the food sat on the cart for a little bit before going into the steam table. On 1/4/24 at 8:50 AM, Staff D, Dietary Manager reported she would expect staff to blend the food in the blender first before adding any liquids to see if the liquids were needed. Staff D stated she expected gravy or sauces to be used for meat and to use the green bean juice for the green beans. Staff D reported her expectations are for staff not to take water directly out of the tap. She stated if cold water was taken out of the tap, she would expect staff to take a food temperature before putting the food back into the steam table. Staff D stated if the sauces, gravy or juice were used from the steam table then a temperature would not need to be taken. Staff D stated she expected the staff to use a rubber spatula to get all the pureed food out of the blender. Staff D stated any measurable amount of food needs to be removed from the blender and offered to the resident to ensure a full serving was given. Staff D stated Staff A was a newer cook and would be provided education and training regarding the puree process. A facility policy titled Food Production- Puree food policy reviewed 11/07/22 documented the following: 1. The pureed foods will be prepared using the serving in/serving out method. 2. The standardized recipe will be followed to puree the food to the appropriate consistency. -The employee will add the desired amount of servings of the food needing to be pureed into the blender. Liquids and/or thickener will be added per the recipe. -After the product has reached the appropriate texture and consistency per IDDS guidelines, the employee will divide the pureed product evenly to equal the total amount of servings that were originally added to the blender. -If extra serving were prepared, these will be discarded for quality and infection control. The policy did not address taking temperature prior to placing the pureed food items back into the steam table. The policy did not address what type of liquids to be used during the puree process. A facility policy titled Food Production-Proper food preparation and handling revised 7/13/2015 documented hot foods shall be held and served at 140 degrees Fahrenheit.

Based on observations and staff interviews the facility failed to cover food items when transported. The facility identified a census of 26 residents. Findings include: On 1/3/24 during the noon meal service, observed 5 room trays leave the serving kitchen after Staff A, [NAME] and Staff B, Dietary Aide assembled each tray. The following items were not covered on each room tray: 1. Resident #9- garden salad and pineapple upside down cake 2. Resident #12- garden salad and pineapple upside down cake 3. Resident #13- garden salad 4. Resident #5- garden salad and pineapple upside down cake 5. Resident #6- pineapple upside down cake. On 1/3/24 at 1:00 PM, Staff A, [NAME] acknowledged and verified all items on a room tray should be covered. On 1/3/24 at 1:02 PM, Staff B, Dietary Aide reported she does not usually cover the salads or anything like that. Staff B stated she was not told to do that. On 1/3/24 at 1:30 PM, Staff C, Dietary Supervisor stated he thought every item on a room tray needed to be covered but would need to look at a policy. On 1/3/24 at 2:30 PM, Staff C, Dietary Supervisor reported the facility did not have a policy that addressed room trays and covering food items. On 1/3/24 at 4:40 PM, The Director of Nursing (DON) reported she could not locate a policy regarding room trays. The DON stated her expectations were all food items to be covered on the room trays during transport. The DON stated the dietary staff are responsible for covering the items before leaving the serving kitchen and her staff delivers the room tray. On 1/4/24 at 8:50 AM, Staff D, Dietary Manager stated she expected all items on the room tray to be covered when transported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, the facility failed to assure residents were treated with dignity and respect for 3 of 5 residents reviewed (Resident #1, #4, and #5). The facility reported a census of 25 residents. Findings include: 1.) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility, transfer, dressing, and toilet use, and limited assistance with personal hygiene. The resident had diagnoses including hemiplegia (paralysis of 1 side of the body). The Care Plan dated 2/28/23 included Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The resident had impaired cognition related to short term memory loss from a car accident and difficulty with speech at times. The interventions included communication: identifying self at each interaction, facing the resident when speaking to him and making eye contact, and reducing any distractions such as turning off the television and radio, and shutting the door. The resident understood consistent, simple, directive sentences. A statement written by Staff A Certified Nursing Assistant (CNA) documented on 10/3/23 Staff B CNA asked her to assist with Resident #1's transfer from the wheelchair to the recliner. Staff A noticed the resident must have had a nose bleed. Staff B stated it was off and on all day. Staff B said he had Kleenex and for him to clean up. She said it was just a nose bleed, nose bleeds happened, probably not his first nose bleed nor his last nose bleed, and she walked out of his room. Staff A was getting something to clean him when the Activity Director (AD) came in the room. She saw the resident had dried blood on his nose and shirt. The facility investigation included an interview by the Director of Nursing (DON) with Staff A on 10/5/23 at 2 p.m. Staff A stated she had reported a concern about how Staff B had interacted with the resident in his room when he had a bloody nose and in the hallway. The investigation further revealed on 10/4/23 the DON pulled Staff A in the office as she wanted to talk to her on 10/3/23 as she was leaving for the day. The DON told her she was running late to an obligation and asked if she could call her later or talk the following day. She said they could talk the following day. Staff A voiced concerns to the DON regarding an interaction on 10/3/23 when the resident had a nosebleed and thought that Staff B did not interact with the resident with compassion. She stated that Staff B told the resident everyone gets nose bleeds, get a Kleenex and clean it up. Staff and Resident interviews were completed on 10/5/23 and 10/6/23. During staff and resident interviews, vague concerns were voiced to the DON regarding Staff B. Reports of a snarky tone, bossy, working to fast, were voiced. Staff stated they did not feel this was intentional or malicious but did bring it up due to the nature of the conversation. Prior to staff and resident interviews, these concerns had not been reported previously to the DON, the nurses or any other employees. A statement written by Staff C Licensed Practical Nurse (LPN) documented Staff A told him that Staff B yelled at the Resident #1 about a nose bleed and making a mess. Staff A stated feeling bad for the resident and how awful we would feel if it was us or our family being treated that way. The resident confirmed the interaction. On 11/16/23 at 2:40 p.m. the resident stated Staff B was mad he had a bloody nose. He could not expand beyond she was just mad. On 11/20/23 at 10:02 a.m. Staff C stated he was the overnight nurse and the alleged incident occurred on the previous shift. He didn't witness anything himself. But the resident did say something happened. On 11/20/23 at 10:52 a.m. the AD stated when she entered the resident's room, he was in the room alone and she could see he had a bloody nose. Staff A came in also. She got him a wash cloth. The resident seemed embarrassed about the bloody nose. On 11/20/23 at 2:16 p.m. Staff B stated the day Resident #1 had the bloody nose she may have said there's a Kleenex and made a comment about cleaning it but she would have helped him. She did not recall any issue. She said she was not mad about anything. She said she didn't notice the bloody nose until after the transfer. On 11/20/23 at 5:10 p.m. the DON stated the resident said nothing happened when they asked him about the day in regards to his nose bleed. 2) According to the MDS assessment dated [DATE] Resident #4 scored 15 on the BIMS indicating no cognitive impairment. The resident required extensive assistance for bed mobility, transfer, dressing, and personal hygiene. The resident had diagnoses including heart failure and pulmonary disease. The Care Plan initiated 6/28/22 included the focus the Resident #4 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. On 11/20/23 at 1:59 p.m. Staff D CNA stated she had a concern one day when Staff B had a tone with the Resident #4 and told the resident she knew what she was doing. On 11/20/23 at 2:12 p.m. Resident #4 stated she had issues with Staff B several times. She thought she could come in and start bossing her and other aides around. Staff B thought things would be done her way. The resident said that was not going to work. She said that happened a couple times and then Staff B left. 3) a) According to the MDS assessment dated [DATE] Resident #5 scored 3 on the BIMS indicating severe cognitive impairment. The resident required assistance for dressing, toileting and personal hygiene. The resident had diagnoses including anxiety disorder. The Care Plan initiated 10/9/23 included the focus Resident #5 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. b) According to the MDS assessment dated [DATE], Resident #2 scored 15 on the BIMS indicating no cognitive impairment. On 11/20/23 at 10:25 a.m. Resident #2 stated Staff B was never mean to him, but he had heard her be verbally mean to his roommate (Resident #5). He clarified it was just verbal. The facility policy, Dignity and Respect approved 7/14/15 documented it was the policy of the facility to treat all residents with kindness, dignity and respect. The facility promoted care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his/her individuality. Staff should display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician of a significant weight loss (5%) for one of one resident reviewed, (Resident #20). The facility reported a census of 22 residents. Findings include: A Minimum Data Set (MDS) dated [DATE] for Resident #20, included diagnoses of Depression, Diabetes Mellitus Type 2, Hypothyroidism, and Gastroesophageal Reflux Disease (Acid Reflux). The MDS identified the resident was independent with eating after set up, and was extensive assistance of 2 staff for bed mobility, transfers, toileting, and dressing. The MDS documented the resident had a Brief Interview for Mental Status score of 14, indicating intact cognitive response. Record review showed on 10/01/2022, the resident weighed 160 pounds. On 11/01/2022, the resident weighed 151 pounds, which was a -5.63 % weight loss in one month. No documentation of physician notification was found in the record. Review of facility policy titled Weight Loss of Residents, modified 3/01/22, documented physician and family to be notified monthly, and as needed, of significant weight loss and current interventions. Policy also documented significant weight loss considered 5% for one month.

Based on observation, record and policy review, and staff interview the facility failed to provide complete incontinence care for one of three residents reviewed, (Resident #14). The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #14, dated 7/8/22, included diagnoses of Alzheimer's and Renal (kidney) Insufficiency. The MDS identified the resident needed extensive assistance of one staff for bed mobility, transfers, dressing and toilet use. The MDS identified the resident was frequently incontinent of urine. The MDS documented a Brief Interview for Mental Status of 6, indicating major cognitive impairment. During an observation on 11/9/22 at 12:47 PM, with the Director of Nursing (DON) present, Staff A, Certified Nurse's Aide assisted the resident to the toilet with a walker. Staff A removed the resident's wet pull-up brief and pants. Staff A wiped between the resident's leg and groin on each side, using a new wipe for each side. Staff A did not cleanse the penis or scrotum. Staff A cleansed the buttocks and hips using a new wipe for each swipe. Staff A removed gloves, sanitized hands, and applied a new pull-up brief and clean pants. Staff A confirmed the old pull-up brief was wet with urine. Review of facility policy titled, Perineal Care , modified 5/18/21, documented: for male resident wash the penis from the urethral opening or tip of the penis and wash the scrotum, pay attention to skin folds, dry. Immediately following the observation on 11/9/22, the DON stated her expectation was to cleanse the penis and scrotum with cares.