Based on observation, staff interviews, and policy review the facility failed to keep flies off the food prior to serving. The facility reported a census of 34 residents. Findings include: During an observation on 9/3/25 at 12:08 PM a fly landed on two (2) bowls of crushed pineapple, then flew over, and landed on pureed peas. The kitchen had (4) flies present during the observation in the kitchen and one (1) dead fly noted on a cupboard door from 11:55 AM to 12:55 AM. During an interview on 9/3/25 at 2:45 PM the Infection Preventionist reported she hadn't completed audits on practices in the kitchen.During an interview on 9/4/25 at 10:37 AM with the Administrator explained the facility had bug traps but didn't know when pest control last came to the facility. She reported flies shouldn't land on the food during food service. Review of the facility's undated General Food Preparation and Handling policy instructed to prepare food items to conserve maximum nutritive value, develop, enhance flavor, and keep free of harmful organisms and substances. Review of the facility's undated policy Pest Control Program directed the facility to use a variety of methods to control certain seasonal pests, i.e. (example) flies. The program would involve indoor and outdoor methods deemed appropriate by the outside pest service, state and Federal regulations.

Based on record review, observation, staff interview, and policy review the facility failed to provide the correct portion size of 8 ounce (oz.) of chicken and pasta alfredo for 32 of 34 residents during a meal observation on 9/3/25 at the noon meal service. The facility reported a census of 34 residents. Findings include:The facility's menu for the noon meal on 9/3/25 titled, Week 2 Wednesday, dated 5/14/25 instructed to provide 8 oz. of chicken and pasta alfredo. During an observation of the noon meal service on 9/3/25 from 11:55 AM to 12:55 AM, Staff D, Cook, used a 6 oz. scoop instead of an 8 oz. scoop as the menu directed for serving 32 servings of chicken and pasta alfredo. During an interview on 9/3/25 at 12:53 PM the Dietary Manager reported they provided a heaping 6 oz. scoop of the chicken and pasta alfredo to all residents instead of using an 8 oz. scoop as they didn't have 8 oz scoops in the facility and needed to order more. She explained she told Staff D he should use 2, four (4) oz. scoops, but he didn't. During an interview on 9/3/25 at 12:55 PM Staff D said he used a 6 oz. scoop of chicken and pasta alfredo instead of the 8 oz. scoop as the facility didn't have any 8 oz. scoops. During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) stated she expected all residents get the intended scoop size of the chicken and pasta alfredo. She added if the facility didn't have an 8 oz. scoop, they should have placed an order to get new ones. During an interview on 9/4/25 at 10:37 AM the Administrator reported she expected the staff to follow the menu and use the scoop size as directed. The facility's undated Select Menu policy lacked direction to use the proper scoop sizes.

Based on observation, staff interviews, and policy review the facility failed to clean the kitchen convection oven and handwashing sink. In addition, the facility failed to ensure staff wore hairnets and didn't touch food with their contaminated gloved hands. The facility reported a census of 34 residents. Findings include: During an initial kitchen walk through on 9/2/25 at 9:18 AM observed the white hand washing sink had a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches. In addition, the convection oven had a brown-like sticky discoloration on the inside and the outside of the doors, throughout the inside of the oven and on the metal racks. An observation of the Dietary Manager wearing a baseball cap without a hair net, and the hair appeared over one inch in length protruding out below the baseball cap. During a follow-up walk through observation on 9/3/25 at 11:56 AM the hand washing sink continued to have a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches. The convection oven also continued to have a brown sticky-like discoloration on the inside and outside of the doors and throughout the inside of the oven and on the metal racks. During an observation on 9/3/25 at 11:59 AM the Dietary Manager held a cool whip container with a gloved hand and a spatula with another gloved hand. As she scooped out the cool whip onto the dessert to serve, she took the gloved hand holding the cool whip container and used her index finger to scrape off the spatula to get the whip cream to cover dessert. During the observation, she continued to wear a baseball cap without a hairnet. During an observation of the noon meal service on 9/3/25 from 11:55 AM to 12:55 AM while wearing gloves, Staff D, Cook, touched the diet name cards, serving utensils, plates, and transportation carts. Staff D proceeded to grab the garlic bread and place one on each residents' plate with the same gloved hands. Staff D served approximately 32 servings of garlic bread with contaminated gloves During an interview on 9/3/25 at 12:55 PM Staff D revealed he didn't use tongs during meal service and instead grabbed each piece of garlic bread and set them on the plates with his gloved hands. He explained as long as he had gloves on, he didn't need to use a tongs to touch the bread. During an interview on 9/3/25 at 2:45 PM the Infection Preventionist said she hadn't completed audits on the kitchen practices.During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) reported she didn't know why Staff D wore gloves during 9/3/25 noon meal service, as that isn't their normal routine. She expected them to use tongs to place the bread on the plates. During an interview on 9/4/25 at 10:37 AM the Administrator revealed she would expect the Dietary Manager to wear a hairnet and not just a baseball cap. She also informed Staff D during the 9/3/25 noon meal service does not normally wear gloves as that is not their normal routine and practice and believe it was due to being nervous, and food should not be touched with contaminated gloves. The facility's undated General Food Preparation and Handling policy directed the following: a. Clean and sanitize the kitchen surfaces and equipment as appropriate. b. Disposable gloves are single use item and should be discarded after each use. Employees should wash hands prior to putting gloves on and after removing gloves. c. Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact with prepared foods. d. Use tongs or other servings utensils to serve breads or other items to avoid bare hand contact with food

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, staff, and resident interview, the facility failed to find or replace 1 of 1 resident (Resident #25) hearing aides when they identified them missing. The facility reported a census of 34 residents. Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] reflected he wore a hearing aid. The MDS identified a Brief Interview of Mental Status (BIMS) of 9, indicating moderately impaired cognition. The MDS included diagnoses of dementia, depression, and need for assistance with personal care. The Progress Note dated 6/13/24 at 9:36 AM reflected he saw his Doctor at the facility. The facilities Social Worker (SW) must review with him regarding lost hearing aids. On 9/13/24 at 11:21 AM Resident #25 reported he lost his hearing aids a few months ago and is hard of hearing. He explained it bothered him and he didn't want to talk because he couldn't hear. On 9/15/24 at 11:52 AM the Director of Nursing (DON) reported she believed the SW had the responsibility of looking into the situation but went on leave and it possibly got overlooked. She explained she expected the staff find or replace Resident #25 hearing aids as soon as possible so he could effectively communicate. During an interview on 9/15/24 at 12:21 PM the Administrator explained he learned the SW last worked on 6/13/24 at the facility and currently taking leave. The Grievance Process policy, reviewed January 2023 instructed residents have the right to file grievances, and the facility will make prompt efforts to resolve grievances.

Based on observation, record review, resident and staff interviews the facility failed to provide routine repositioning for 1 of 3 residents (Resident #19). The facility reported a census of 34 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment date 8/14/24 identified a Brief Interview of Mental Status (BIMS) score of 8, indicating severely impaired cognition. Resident #19 required total assistance from staff for transfers and bed mobility. The MDS reflected he didn't walk. The MDS included diagnoses of hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hip fracture, and a need for assistance with personal care. On 9/14/24 at 1:15 PM Staff A, Certified Nurse Aide (CNA), reported Resident #19 will get up in the morning and staff didn't assist him to lay down or reposition him until after lunch on most days of the week. She added the staff never reposition him when in bed. The Care Plan Focus dated 6/18/21 reflected Resident #19 had limited physical mobility with a high fall risk related to a stroke. The Intervention instructed Resident #19 required assistance of 2 staff to reposition and turn in bed. On 9/14/24 at 2:12 PM Resident # 19 revealed he laid in bed and didn't get get repositioned while in his bed. During an interview on 9/15/24 at 11:56 AM the Director of Nursing (DON) reported they expected all dependent residents to receive routine repositioning.

Based on record review and staff interviews the facility failed to have a full time (40 hours a week) Director of Nursing (DON) at the facility. In addition, the facility failed to have eight (8) hours of consecutive Registered Nurse (RN) coverage a day for 4 of 30 days reviewed. The facility reported a census of 34 residents. Findings include: Record review of nursing schedules from 8/12/24 to 9/12/24 lacked RN coverage for 4 days: 8/16/24, 8/19/24, 8/28/24, and 9/2/24. During an interview on 9/13/24 at 11:16 AM the Administrator confirmed the facility didn't have 8 consecutive hours of RN coverage from 8/12/24 to 9/12/24. The days that the facility didn't have RN coverage: 8/16/24, 8/19/24, 8/28/24, and 9/2/24. During an interview on 9/15/24 at 11:46 AM the DON reported being the current DON as of 9/12/24. She informed she came to the facility for a routine rounding visit, as she is Regional Clinical Quality Specialist for the facilities corporation. She let she let the DON at the time know the state entered the building for the annual recertification survey and the DON said she no longer wanted to be the DON and gave notice effective immediately. She also reported she expected to have a full-time DON employed at the facility and have 8 hours of RN coverage a day. The Administrator informed on 9/15/24 at 12:29 PM the prior DON last worked in the facility on 8/12/24. They said the prior DON hadn't been to the facility since. They wanted her license removed and she would no longer be the DON of the building effective 9/12/24.

Based on observation, record review, staff, and resident interview the facility failed to maintain and promote resident's dignity while serving meals for 3 of 3 residents reviewed (Residents #1, #2 and #3). The facility identified a census of 33 residents. Findings include: During an interview on 7/18/24 at 1:07 PM the Dietary Manager (DM) confirmed the facility had their garbage disposal broken for 2 weeks with the parts on back order. Prior to that their dishwasher had broken down but now functional. The DM also confirmed the dietary staff served all meals with paper products because of the dishwasher not functioning and then the disposal broken, but the residents didn't like it. On 7/18/24 at 12:03 PM observed the dietary staff serve the meal on ceramic plates. During an interview on 7/18/24 at 4:30 PM the DM confirmed the staff only served the noon meal on ceramic plates because of the presence of a Surveyor. On 7/18/24 at 5:30 PM saw the resident's meal served on paper plates with Styrofoam glasses and plastic silverware. On 7/19/24 at 12:10 PM observed the resident's meal served on paper plates with Styrofoam glasses and plastic silverware. During an interview on 7/18/24 at 2:43 PM Resident #1 indicated a month prior to the present the dietary staff served their meals on paper plates and plastic silverware because of a broken disposable and sink. At first the reason started with a broken dishwasher and now the waste disposal. Resident #1 reported if she or the surveyor had the issue, they would have immediately solved the problem. When she questioned the staff members about the repair process, they replied they required corporate approval. Resident #1 felt they used her money she paid every month to reside at the facility but failed to fix the problems. She paid a premium price out of her own pocket while she has resided at the facility. During an interview on 7/19/24 at 11:40 AM Resident #2 indicated the dietary staff served their meals on paper plates, Styrofoam glasses, and plastic silverware for quite a few weeks because of their broken dishwasher. Resident #1 declared she didn't like it. During an interview on 7/19/24 at 11:43 AM Resident #3 indicated the dietary staff served their meals on paper plates, Styrofoam glasses, and plastic silverware for several weeks. She didn't feel this was handy especially with the silverware. During an interview on 7/19/24 at 10:50 AM Staff A, Licensed Practical Nurse (LPN), explained the dietary staff served meals on paper plates with Styrofoam glasses and sporks as silverware which the residents hated. During an interview on 7/19/24 at 10:54 AM Staff B, Certified Medication Aide/Certified Nursing Assistant (CMA/CNA), explained the dietary staff served meals on paper plates with Styrofoam glasses and sporks as silverware. Staff B said the residents didn't like using those items, especially the sporks.

Based on clinical record review and staff interview the facility failed to provide an assessment and implement interventions based on that assessment for 1 of 1 resident reviewed for falls (Resident #13). The facility reported a census of 32 residents. Findings include: The Progress Note for Resident #13 written by Staff B, Licensed Practical Nurse (LPN), on 9/5/23 at 10:49 AM documented she heard a noise in the hall and found the resident had fallen to the floor to his left side. Staff assisted the resident into a wheelchair so the ambulance could get through with another resident. Upon assessment the resident was able to move his left leg a small amount independently and voiced discomfort in his hip area. The resident was unable to rate his pain on a 0/10 scale but reported his left leg felt twisted. The Progress Note written by Staff B, LPN, on 9/5/23 at 1:42 PM documented the fall occurred at 8:00 AM. The Progress Note written by Staff B, LPN, on 9/5/23 at 11:02 AM documented the resident had a left femoral neck fracture. The Progress Note written by Staff B, LPN, on 9/5/23 at 12:29 PM documented the resident would be having surgery to repair the fracture. During an interview on 10/4/23 at 12:28 PM Staff B, LPN, explained she was in the next room when she heard a noise in the hall. She entered the hall, to see the end of the fall. The resident landed on his left side across the hall. The ambulance crew was needing to get past the resident with another resident. Staff B stated she asked the resident if he could move his extremities. She noted he could only move the left leg a little bit. The resident did not complain of pain. Staff B explained that her and another staff member lifted the resident off the floor and placed him in a wheelchair. Upon further assessment Staff B noted the resident was grimacing and complained of a little bit of pain. Staff B, LPN, explained she knew putting him in the wheelchair might be a problem. During an interview on 10/4/23 at 5:11 PM the Director of Nursing (DON) explained she would not have expected the resident to be put in a wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review the facility failed to complete assessments for 1 of 1 residents before and after dialysis treatments received at a certified dialysis facility (Resident #34). The facility reported a census of 32 Residents. Findings include: Record review of Resident #34 Dialysis Assessment log revealed assessments were completed, in progress, or incomplete on the following dates: 10/2/2023 Dialysis Pre and Post Assessment In Progress 9/29/2023 Dialysis Pre and Post Assessment In Progress 9/25/2023 Dialysis Pre and Post Assessment Complete 9/20/2023 Dialysis Pre and Post Assessment In Progress 9/11/2023 Dialysis Pre and Post Assessment Complete 9/1/2023 Dialysis Pre and Post Assessment Complete 8/30/2023 Dialysis Pre and Post Assessment Complete 8/25/2023 Dialysis Pre and Post Assessment Incomplete 8/21/2023 Dialysis Pre and Post Assessment Complete 8/18/2023 Dialysis Pre and Post Assessment Complete 8/16/2023 Dialysis Pre and Post Assessment Complete 8/14/2023 Dialysis Pre and Post Assessment Complete 8/9/2023 Dialysis Pre and Post Assessment Complete 8/7/2023 Dialysis Pre and Post Assessment Complete 8/4/2023 Dialysis Pre and Post Assessment Complete Review of Resident #34 Dialysis Pre and Post Assessments revealed multiple assessments where the facility failed to get current vital signs and instead used ones not taken on the days of the assessments. Record review of Resident #34 Care Plan, created on 7/30/23 and revised on 10/4/2023, instructed she received dialysis at a local dialysis center on Monday, Wednesday, and Friday. Record review of Resident #34 Census revealed she was in the hospital from [DATE] to 9/8/23. Record review of Resident #34 Progress Notes from 8/1/23 to 10/3/23 revealed no documentation of dialysis appointments missed or rescheduled. Through review off the Resident #34 Census, Care Plan dialysis dates, and Progress Notes the facility failed to complete assessments on: a. 8/2/23 b. 8/11/23 c. 8/23/23 d. 8/28/23 e. 9/13/23 f. 9/15/23 g. 9/18/23 h. 9/22/23 i. 9/27/23 Record review of a policy provided by the facility, Dialysis Care Plan and Treatment Sheet dated February 2019, lacked instruction to nursing staff on if pre and post dialysis assessments are needed and how to complete them. During and interview on 10/5/23 at 11:19 AM the Director of Nursing (DON) revealed she would expect a pre and post dialysis assessment be completed on dialysis days.

Based on observation, record review, and staff interviews the facility failed to provide 3 of 37 medications as ordered by the provider. The facility reported a census of 32 residents. Findings include: During an observation on 10/3/23 at 11:57 AM Staff A, Certified Medication Aid (CMA), set up Resident #10's medications revealed she took out the following medications and put them into a medication cup. a. Iron b. Thiamine (Vitamin) c. Creon Delayed Release (enzyme for digestion) Staff A then proceeded to take the Iron and Thiamine and crush them together. She then opened the Creon capsule and mixed all three (3) medications together with applesauce. Staff A then on 10/3/23 at 12:01 PM gave the crushed medications in applesauce to Resident #10 and he swallowed them. Record review of Resident #10 Orders dated 10/4/23 lacked an order for him to have crushed medications. In an e-mail correspondence 10/4/23 at 11:36 AM the Director of Nursing (DON) revealed Resident #10 should receive his medications whole (in applesauce per his preference). He does not have an order to crush his medications, unfortunately that was in error. During an interview on 10/4/23 at 4:55 PM the DON revealed they do not have a medication administration policy they follow best practices and pharmacy recommendations. During an interview on 10/5/23 at 11:14 AM the DON stated she plans to contact the Doctor and discuss if he can have an order to crush his medications as needed. She went by a cheat sheet that was not correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The admission MDS for Resident # 8 dated 2/8/23 documented an admission date of 2/1/23. The MDS coded the resident as not receiving hospice services prior to admission or since admission. The resident's payor source beginning on 2/1/23 and not changing through 10/5/23 listed Hospice as the only payor. During an interview on 10/2/23 at 1:41 PM, the resident's son explained the resident was receiving hospice services prior to admission and since admission. 4. The quarterly MDS for Resident #8 dated 8/9/23 did not code the resident as receiving hospice services. During an interview on 10/4/23 at 3:31 PM, Staff E, Registered Nurse(RN), MDS nurse, confirmed the MDS's for Resident #8 were coded incorrectly. During an interview on 10/4/23 at 4:56 PM, the Director of Nursing (DON) explained they do not have an MDS policy, they follow the Resident Assessment Instrument (RAI) manual. Based on record review and staff interviews the facility failed to accurately code Minimum Data Set (MDS) Assessments when they inaccurately coded 1 of 1 residents Preadmission Screening and Resident Review (PASRR) (Resident #1), 1 of 1 residents use of anti-coagulant (blood thinner) medication (Resident #20), and 1 of 2 residents Hospice status on two different MDS assessments (Resident #8). The facility reported a census of 32 residents. Findings include: 1. Record review of Resident #1 PASRR dated 6/27/2023 documented she was a Level II PASRR and needed specialized services. Record Review of Resident #1 MDS dated [DATE] documented her as a Level I PASRR. During an interview on 10/4/23 at 3:12 PM with the facilities MDS Nurse revealed Resident #1 is a PASRR Level II and her 9/28/23 MDS assessment was coded incorrectly. 2. Record review of Resident #20 MDS dated [DATE] documented he received anti-coagulation medication for the 7 days of the look-back period. Record review of Resident #20 Medication Administration Record for September revealed he had not receive anti-coagulation medication during the 7 day look back period. During an interview on 10/4/23 at 1:49 PM with the facilities Director of Nursing (DON) revealed it was an error in coding and the facility was going to make a modification to the MDS and fix it. During an interview on 10/5/23 at 11:17 AM the facilities DON stated she would expect for the MDS to be coded accurately.

Based on record review, observations, staff interviews, and policy review the facility failed to keep kitchen equipment clean and sanitary for 32 of 32 residents that receive meals from the kitchen. The facility reported a census of 32 residents. Findings include: During an interview on 10/3/23 at 12:47 PM the Dietary Manager revealed she had cleaning schedules in place and there are no issues with them getting completed. During an observation of meal service on 10/4/23 from 11:53 AM to 12:25 PM revealed the following: a. Convection oven with brown substance baked on the wire racks, crumbs and debris throughout the bottom and unable to see through the window due to brown discoloration. b. Top of the convection oven with visible debris, dust, and a sticky substance. c. Four (4) slice toaster with black, brown, and yellow discoloration throughout the top. d. Steam table with brown and yellow spill marks by all knobs, the bottom with dust, debris, and yellow spills. e. Oven griddle with brown discoloration throughout the top and sides and brown substance down the front. f. Oven burners with black residue and brown splatters/spills down the front. g. Inside the oven a black substance and brown substance throughout. h. Microwave with a yellow substance on the bottom and brown splatters on the door. i. Air conditioning unit with black/gray dust covering the vent. j. Fan above the clean dishes with dust hanging from it. k. Floors with visible debris and collections of black buildup by kitchen equipment. During an observation on 10/4/23 at 11:45 AM revealed a large plastic bag of hot dogs on the counter. Staff C, Cook, grabbed the hot dogs with a gloved hand and divided the hot dogs into four (4) separate plastic bags and sealed the bags, the bags she put the hot dogs into had visible liquid dripping from them that came from the large hotdog bag. Staff C then continued to grab a container with her hands that still had gloves on, place the bags in the container, open a refrigerator, and place them in the refrigerator. She then removed her gloves. During an observation on 10/4/23 at 12:00 PM Staff D put on gloves and grabbed 3 slices of bread from a bread bag and placed them on a plate, she opened multiple single serving butter packets and buttered the breading without removing her gloves she then tore the slices in half and brought to Staff C. During an observation on 10/4/23 at 12:11 PM the Dietary Manager informed the staff she would get the bread and butter for the meal. She applied gloves, then for multiple observations she would grab bread from the bread bag, touching the outside of the bread bag, open individual single serve butter containers to butter the bread, then pick them up and take over to the cook on a plate. During an interview on 10/4/23 at 10:47 AM the facility Dietician revealed she would expect the staff to do regular cleaning with cleaning schedules. She then informed she would expect the fan and air conditioner to be clean because they blow on clean dishes. Record review of the facilities Weekly Cleaning Schedules for 8/23, 9/23, and 10/23 revealed the facility does not have a plan in place to clean the following: a. Toaster b. Steam table d. Microwave f. Air Conditioner g. Floors The facilities policy titled General Sanitation of Kitchen from 2021 documented the following: 1. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigation, policy review, and staff interviews, the facility failed to ensure all alleged abuse violations were reported immediately, and no later than two hours after the allegation was made for 1 of 10 residents reviewed for abuse (Resident #4). The facility identified a census of 35 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive loss. The Resident required extensive assistance of one staff member for bed mobility, transfer, dressing, and toilet use. The MDS listed diagnoses of anemia, hypertension, diabetes mellitus, arthritis, cataracts, and anxiety. The Resident received 7 days of antidepressant and opioid medications. The Care Plan dated 6/18/23 documented Resident #4 required one assist with walking with a front wheeled walker, assist of 1 for repositioning in bed and transferring. The Resident required the staff to propel her in a wheelchair. A Progress Note dated 5/24/2023 at 1:13 p.m. documented by Staff E, Registered Nurse (RN), detailed Resident #4's neighbor reported Resident #4's checkbook as missing. The Resident took her purse to her appointment at the local hospital yesterday. He had called local hospital and they did not see it. The neighbor stated he was going to put a hold on all the Resident's accounts and continue to look for the checkbook. A Facility Investigation Report documented on 5/24/23 Resident #4's family informed the nursing staff that the Resident's checkbook was missing from her purse. The family member stated the Resident had taken her purse along with her to a doctor's appointment the day before and they had called the hospital but the hospital stated they did not see a checkbook. The nursing staff did not inform the facility management of the missing checkbook. On 5/31/23 the Social Service Director notified the Executive Director (ED/Administrator) that she had just gotten off the phone with Resident #4's daughter and the daughter informed her that a checkbook, gift card, and credit cards were stolen out of Resident #4's purse. The ED did a room search on 6/01/23 and asked the Resident if the facility could lock up her purse in the business office which the Resident agreed to. The ED tried to call the family and left messages on 6/01/23 and 6/02/23. On 6/05/23 the Resident's family was visiting and the family asked where the Resident's purse was. The ED informed the family the purse was locked up in the business office and then the family proceeded to say the gift card had $200.00 on it plus $30 had been taken that was in a white envelope. Resident #4 had been unaware of how much money the gift card contained and she didn't know about the $30 in the purse. The family reported they did not have a receipt for the gift card. The facility informed the family that money and anything valuable should not be kept in the facility and that they are welcome to take the Resident's purse with them. The family did not take the purse from the business office. The ED left voice mail messages on 6/06/23 and 6/07/23 to the Iowa Department of Inspections and Appeals to turn in a self-report due to not being able to get access to the online account. A Call Summary Report dated 6/16/23 at 12:02 p.m. documented the Administrator filed a report with the local county police department at 10:55 a.m. for a theft of a missing checkbook, gift card, and money. The Report detailed the resident had her purse with her when she went out to an appointment on 5/31/23. During an interview on 7/13/23 at 12:50 p.m. the Administrator reported she started at the facility on 6/5/23. She had not been the Administrator at the facility when the family reported the missing items. She stated it started off with her missing a checkbook and seemed to grow to her missing more and more items. She stated she had questioned why the facility had not filed a police report since there had been a missing checkbook, money, and a gift card. She placed a call to the family and got permission to report the incident to the local county police department. On 7/13/23 at 1:30 p.m. Staff G, Social Services Director reported she became aware of the situation on 5/31/23. She reported the situation to the Administrator and the Director of Nursing (DON) around 8:45 p.m. on 5/31/23. The Administrator directed her to see who had worked last Tuesday and Wednesday and call the neighbor. She followed up with the neighbor who said he notified staff at the nurse's station on 5/24/23 between noon and 12:30 p.m. The Resident had gone out to a radiology appointment at the local hospital. He had called the hospital and they looked at the camera footage. The Resident had her purse when they were wheeling her in and out of the hospital. She had talked with the daughter via phone and Resident #4's daughter stated the resident had a checkbook and a credit card missing from her purse. The facility had been notified last Wednesday (5/24/23) and she notified the Administrator and the DON as this was the first she had heard of it. On 7/13/23 1:50 p.m. Staff E reported she doesn't recall the actual day, but the neighbor had reported probably around noon time that Resident #4 had a checkbook missing. He stated he planned to call the local hospital as the resident had gone out to a radiology appointment the day before. He didn't know if her checkbook may have fallen out of her purse at the hospital. Staff E doesn't recall having any staff look in the Resident's room or purse at that time as the neighbor said he was going to look for it. Staff E stated she thought she had reported it to the ED (Administrator) at that time. She didn't know what had happened after she reported it to the ED. During an interview on 7/17/23 at 11:41 a.m. Staff H, prior Executive Director (Administrator) voiced she first became aware of the missing items on 5/31/23 when Staff G texted her the Resident had a checkbook, credit cards, and a gift card stolen out of her purse. She and the DON had been at a corporate meeting in Des Moines that Tuesday and Wednesday. She stayed at the meeting on Thursday and the DON came back Wednesday night. She texted back direction to Staff G to follow up on. No one from the facility notified her right away and the ball got dropped. She then took it upon herself to start an investigation. She went down with Staff I, Laundry and Housekeeping Manager, to do a full search of the Resident's room on 6/01/23. Staff H interviewed all staff that worked on 5/23/23 and 5/24/23. They did not know of the items in the purse. Staff H explained the documented interviews should be at the care facility, but she didn't know where the interview documentation would be. She didn't notify the police as she was trying to get an accurate story from the family on what went missing. She left the facility and went to a different facility on 6/07/23. As far as she knew, the facility continued to work on the investigation. She talked to all the interdisciplinary team members at one morning meeting and informed them they cannot wait to report or address these types of situations. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, updated 10/19/22, provided by the facility documented all Resident's have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident's must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultant, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy defined misappropriation of resident property as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The Policy directed all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible to immediately report the allegations of abuse to the administrator, or designated representative. All allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation shall be reported to the Iowa Department of Inspection and Appeals, not later than two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. If there is reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement. If the allegation of abuse (that results from a crime) does not result in serious bodily injury, a report must be made to law enforcement not later than twenty-four hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigation, policy review, and staff interviews, the facility failed to complete a thorough investigation following an incident of a Resident missing a checkbook, credit card, debit card, petty cash, and a gift card of $200 to ensure protections for all residents for 1 out of 10 residents sampled (Resident #4). The facility identified a census of 35 residents. Findings include: Resident #4's MDS assessment dated [DATE] showed a BIMS score of 13 indicating intact cognition. The Resident required limited assistance of one staff member for bed mobility, transfer, dressing, and toilet use. The MDS listed diagnoses of anemia, atrial fibrillation, hypertension, diabetes mellitus, arthritis, cataracts, and anxiety. The Care Plan dated 6/18/23 documented Resident #4 required one assist with walking with a front wheeled walker, assist of 1 for repositioning in bed and transferring. The Resident required the staff to propel her in a wheelchair. A Progress Note dated 5/24/2023 at 1:13 p.m. documented by Staff E, Registered Nurse (RN), detailed Resident #4's neighbor reported Resident #4's checkbook as missing. The Resident took her purse to her appointment at the local hospital yesterday. She had called local hospital and they did not see it. The neighbor stated he was going to put a hold on all the Resident's accounts and continue to look for the checkbook. A Facility Investigation Report documented on 5/24/23 Resident #4's family informed the nursing staff that the Resident's checkbook was missing from her purse. The family member stated the Resident had taken her purse along with her to a doctor's appointment the day before and they had called the hospital but the hospital stated they did not see a checkbook. The nursing staff did not inform the facility management of the missing checkbook. On 5/31/23 the Social Service Director notified the Executive Director (ED/Administrator) that she had just gotten off the phone with Resident #4's daughter and the daughter informed her that a checkbook, gift card, and credit cards were stolen out of Resident #4's purse. The ED did a room search on 6/01/23 and asked the Resident if the facility could lock up her purse in the business office which the Resident agreed to. The ED tried to call the family and left messages on 6/01/23 and 6/02/23. On 6/05/23 the Resident's family was visiting and the family asked where the Resident's purse was. The ED informed the family the purse was locked up in the business office and then the family proceeded to say the gift card had $200.00 on it plus $30 had been taken that was in a white envelope. Resident #4 had been unaware of how much money the gift card contained and she didn't know about the $30 in the purse. The family reported they did not have a receipt for the gift card. The facility informed the family that money and anything valuable should not be kept in the facility and that they are welcome to take the Resident's purse with them. The family did not take the purse from the business office. The ED left voice mail messages on 6/06/23 and 6/07/23 to the Iowa Department of Inspections and Appeals to turn in a self-report due to not being able to get access to the online account. A Call Summary Report dated 6/16/23 at 12:02 p.m. documented the ED filed a report with the local county police department at 10:55 a.m. for a theft of a missing checkbook, gift card, and money. The Report detailed the resident had her purse with her when she went out to an appointment on 5/31/23. During an interview on 7/13/23 at 12:50 p.m. the ED reported she started at the facility on 6/5/23. She had not been the ED at the facility when the family reported the missing items. She stated it started off with her missing a checkbook and seemed to grow to her missing more and more items. She stated she had questioned why the facility had not filed a police report since there had been a missing checkbook, money, and a gift card. She placed a call to the family and got permission to report the incident to the local county police department. On 7/13/23 at 1:30 p.m. Staff G, Social Services Director reported she became aware of the situation on 5/31/23. She reported the situation to the ED and the Director of Nursing (DON) around 8:45 p.m. on 5/31/23. The ED directed her to see who had worked last Tuesday and Wednesday and call the neighbor. She followed up with the neighbor who said he notified staff at the nurse's station on 5/24/23 between noon and 12:30 p.m. The Resident had gone out to a radiology appointment at the local hospital. He had called the hospital and they looked at the camera footage. The Resident had her purse when they were wheeling her in and out of the hospital. She had talked with the daughter via phone and Resident #4's daughter stated the resident had a checkbook and a credit card missing from her purse. The facility had been notified last Wednesday (5/24/23) and she notified the ED and the DON as this was the first she had heard of it. On 7/13/23 1:50 p.m. Staff E reported she doesn't recall the actual day, but the neighbor had reported probably around noon time that Resident #4 had a checkbook missing. He stated he planned to call the local hospital as she had gone out to a radiology appointment the day before. He didn't know if her checkbook may have fallen out of her purse at the hospital. Staff E doesn't recall having any staff look in the Resident's room or purse at that time as the neighbor said he was going to look for it. Staff E stated she thought she had reported it to the ED at that time. She didn't know what had happened after she reported it to the ED. On 7/13/23 at 1:58 p.m. Staff D, Certified Nursing Assistant (C.N.A.) reported the resident kept her purse right by her in her wheelchair, then after she declined she kept her purse on her bedside table. Staff D didn't know the Resident had been missing items until today. A review of the May 2023 schedule on 7/17/23 revealed Staff D had worked 6:00 a.m. - 2:00 p.m. on 5/22/23, 5/23/23, and 5/24/23. On 7/13/23 at 2:13 p.m. Staff J (housekeeping) voiced the ED had never questioned her regarding any resident missing property that she could recall. She did not know anything about any missing resident property. They clean each resident room every day. During an interview on 7/13/23 at 2:27 p.m. Resident #4's neighbor reported the Resident's purse had been under lock and key at the local hospital. They checked the film footage and got back to him the day after the checkbook went missing. Resident #4 had been handed a key after placing her purse in the lock up at the hospital. The Neighbor expressed the checkbook had been in the Resident's purse the day before the appointment on 5/23/23. She had gotten a notice of being delinquent on her post office box. She had to get that paid or they would stop sending her mail. He had gone up the day before her appointment 5/22/23 (Monday) and got a check from her to pay her delinquent homeowners' insurance. The Homeowners insurance had been the last check she wrote. When he went to see her 5/24/23 to get money to pay her post office box, she dug and dug in her purse and couldn't find her checkbook. He reported the missing checkbook to the nurse that day. The Resident did not have to register at the hospital. The doctor's office already had everything set up. The nursing home transported her to and from the hospital. He went to the bank and told them the last check written and had the bank freezer her account that same day (5/24/23). The following Tuesday, after Memorial Day he went to the bank, they told him there had been no activity on her account. The Social Worker called a week later and said it needed to be reported. Seven days went by before the Social Worker got a hold of him with the information to start an investigation. He felt the administrative change over caused a lag in things being taken care of. On 7/13/23 at 2:54 p.m. Staff K, C.N.A. reported the prior Executive Director did not interview her regarding any missing items for Resident #4. On 7/13/23 at 3:25 p.m. Staff L, C.N.A. reported Resident #4 did have a black purse that she kept on her bedside table in her room. Staff L voiced never being questioned by the ED regarding any missing items for the Resident. A review of the May 2023 schedules on 7/13/23 showed Staff L worked 5/23/23 from 2:00 p.m. - 10:00 p.m. On 7/13/23 at 3:30 p.m. Staff M, Certified Medication Aide (C.M.A.) reported Resident #4 had a black purse that she usually kept on her bedside table. She didn't recall the prior ED asking her about any missing items for the resident. A review of the May 2023 schedule on 7/13/23 showed Staff M worked 8:00 a.m. - 2:00 p.m. on 5/23/23. On 7/13/23 at 3:35 p.m. Staff N, C.N.A. reported Resident #4 had a black purse that usually sat on the bedside table or in the room chair. Resident #4 would take her purse with her in the wheelchair if the family took her outside or if she went out to an appointment. Resident #4 preferred to each most meals in her room. Staff N voice she had not been interviewed by the ED regarding any missing items for Resident #4. On 7/17/23 at 10:15 a.m. Staff N reported she remembered a necklace and a checkbook that were missing, but doesn't know what ever came of that. There had been a note posted up at the nurses' station directing them to keep their eyes open, but she never actually talked to the administrator about that situation. During an interview on 7/17/23 at 11:41 a.m. Staff H, prior ED voiced she first became aware of the missing items on 5/31/23 when Staff G texted her the Resident had a checkbook, credit card, and a gift card stolen out of her purse. She and the DON had been at a corporate meeting in Des Moines that Tuesday and Wednesday. She stayed at the meeting on Thursday and the DON came back Wednesday night. She texted back direction to Staff G to follow up on. No one from the facility notified her right away and the ball got dropped. She then took it upon herself to start an investigation. She went down with Staff I, Laundry and Housekeeping Manager, to do a full search of the Resident's room on 6/01/23. Staff H interviewed all staff that worked on 5/23/23 and 5/24/23. They did not know of the items in the purse. Staff H explained the documented interviews should be at the care facility, but she didn't know where the interview documentation would be. She didn't notify the police as she was trying to get an accurate story from the family on what went missing. She left the facility and went to a different facility on 6/07/23. As far as she knew, the facility continued to work on the investigation. She talked to all the interdisciplinary team members at one morning meeting and informed them they cannot wait to report or address these types of situations. On 7/18/23 at 6:26 a.m. Staff P, C.N.A. reported Resident #4 had a purse that she kept by her beside on the floor. She had been alert but had more confusion as time went on as her condition declined. She went hospice before she discharged home. If a resident claims they have something stolen, staff are to report to the charge nurse. She also reports directly to the DON. That makes her feel better that she went that extra mile by reporting to the DON. The staff look for the missing items. Staff P hadn't been aware Resident #4's family had alleged she was missing any items. The prior ED back in May did not interview her about any resident missing items. A review of the May 2023 schedule on 7/18/23 showed Staff P worked 10:00 p.m. - 6:00 a.m. on 5/22/23, 5/23/23 and 5/24/23. On 7/18/23 at 6:32 a.m. Staff Q, LPN reported there had been an allegation of a missing check at one time. They were passing through shift to shift reports and looking for it. They thought it was just lost. She had gone to the hospital around that time. They called the hospital and asked if something had been left there. They just passed the word around. That was all she was aware of. If a resident reports something missing, she leaves a message for the department head and leaves a note as well. They alert the C.N.A.'s to look for the missing item. Whenever agency comes in, they tell them their stuff is safe as they haven't had anything missing for a long time. It had been years since something had gone missing. On 7/18/23 at 7:02 a.m. Staff O, C.N.A. stated she had never heard anything about Resident #4's missing property until the last week or two from the gossip chain that goes around the facility. The prior ED never interviewed her on any resident missing property back in May 2023. They are to report to the charge nurse if a resident alleges they are missing property or their property has been stolen. The nurses have them do a search for the missing item. Staff O voiced ultimately if she reports in and nothing is done about it, she would call the State. On 7/18/23 at 8:58 a.m. the prior ED reported she did not interview any additional alert residents on missing items as part of the facility investigation. She had only interviewed staff. During an interview on 7/18/23 at 11:14 a.m. the DON reported she had not heard about the missing property for Resident #4 until late one night. She didn't recall the actual date. She received a message from Staff G around 10 p.m. saying there was a complaint that Resident #4's checkbook went missing. She had heard the checkbook went missing, then she heard the checkbook had been found a few weeks prior. Then the checkbook and a gift card for $200 were missing. The ED asked her to get a list of staff members that had worked during that time frame. The time frame included the day the resident went to the local hospital and the day after. She turned that information over to the ED. The ED takes care of doing the investigation. The current ED stated she had called the family and the family wanted a police report filed, so the ED did that. Other than that, she had not been asked to do anything more regarding the investigation by the ED. She did not interview any other residents to find out if they were missing any items as part of the facility investigation. The facility process is to search for the missing item(s). Staff lets management know if the item(s) are not found. Then they check with family to see if family has the items(s). If it is not found at that time, then they follow the direction of the ED. The ED reports to the Regional Director and then the ED reports the situation to the police. They make out a grievance form. She doesn't believe that a grievance form had been filled out in this case for Resident #4. She didn't know why there had been a delay in the facility investigating or in reporting to the Iowa Department of Inspection, Appeals and Licensing (DIAL). If the allegation is theft, the ED completes the investigation. She would only complete the investigation if it pertained to nursing. On 7/18/23 at 11:22 a.m. Staff G reported she did not interview any other alert residents to see if they were missing any personal belongings. If someone reports something missing or stolen, depending on the severity of the issue, she fills out a grievance form. The Grievance Officer is the ED. The ED takes the grievance form and addresses the investigation from there. She reported the facility has two hours to report if it is resident abuse. The ED would be the one to report to the State of Iowa. She does not have access to be able to do that. She follows their facility policy of filling out a grievance form and notifying the ED. If she is delegated any tasks by the ED, then she would proceed with that. She didn't know if a grievance form had been filled out when it had been reported by the neighbor. She did not fill out a grievance form when she became aware of the situation. She didn't know why there had been a delay from the time the neighbor reported the missing checkbook (5/24/23) to when she became aware of the issue (5/31/23). She had called Resident #4's daughter on potential discharge plans when the daughter informed her of the stolen items. The investigation is completed by the ED. On 7/18/23 at 12:08 p.m. Staff R, Laundry, reported she didn't recall the ED ever talking to her in May (2023) about any missing resident items. She stated if there are any billfolds that come through laundry she gives them back to the ED. A review of the May 2023 schedule on 7/18/23 showed Staff R had worked on 5/22/23 and 5/23/23. During an interview on 7/18/23 at 12:11 p.m. the [NAME] President of Operations reported he had been made aware of the situation. It involved a gift card and a missing checkbook. The prior Executive Director talked to all the staff that worked around that time period. No one had seen or been given any of the items by the Resident. The Resident had not gifted any of the items to her family. They were not really sure what happened to the missing items. If there is an allegation of missing or stolen items the staff report the allegation into the ED. The ED talks to the resident and family to gather more information. The standard process is they interview all staff that worked during the identified time frame to try to verify the resident had the items and get as much information as possible. The staff interviews should be documented. They would interview family members, routine visitors, interview anyone that would have had contact with the resident as part of the investigation. They would not necessarily interview other residents to see if there were additional missing or stolen items. The ED is responsible for reporting to DIAL with the DON as backup. The facility is expected to follow the reporting requirements per current regulations. He didn't know why there had been a delay in the prior ED reporting to DIAL. On 7/18/23 at 12:28 p.m. Staff S, Transport Driver, reported he really didn't remember Resident #4. He didn't recall the prior ED asking him about any resident missing property back in May 2023. He doesn't recall any resident dropping their purses in the transport van. During an interview on 7/18/23 at 1:01 p.m. the ED stated she questioned a lot of it and wished she could find more regarding the investigation that had been completed. During her first days when the prior ED was handing off to her, she questioned if the family should be contacted regarding filing a report of the missing items with the police. She then called the [NAME] President of Operations on the issue after the prior ED was done at the facility. She reported she felt that more needed to be done. The [NAME] President of Operations approved to make a police report. The Daughter reported she wanted to press charges if anything was found. The family never provided a receipt for the gift card. The ED didn't know if Resident #4 had been asked about a receipt on the gift card. She was in the facility, but the prior ED came back to the facility to report the incident into DIAL. She did not interview any residents as part of the facility investigation. Per her observation the communication portion was bad, there was a lack of direction to the team on what to do. Staff vocalized things, but there was no true leadership in the investigation which led to them not reporting timely. It is her expectation that the regulations will be followed for resident missing items. Regarding this investigation, a thorough investigation was not completed. There is a procedure that their corporate has established with forms that are followed. There is a structured investigative process that was not followed. To her knowledge there was no grievance form filled out for Resident #4. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, updated 10/19/22, provided by the facility documented all Resident's have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident's must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultant, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy defined misappropriation of resident property as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The Policy directed all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible to immediately report the allegations of abuse to the administrator, or designated representative. All allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation shall be reported to the Iowa Department of Inspection and Appeals, not later than two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation, but do not result in serious bodily injury. The Policy, under Investigation Protocols documented should an incident or suspected incident of resident abuse be reported or observed, the administrator or his/her designee will designate a member of the management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident. a. Review documentation in the resident record. b. Assess the resident for injury. c. Provide proper notifications to primary care provider, responsible party, etc. d. Attempt to obtain witness statements from all known witnesses. e. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview the facility failed to implement the dietary care plan as written for 3 of 8 resident's reviewed (Residents #1, #2, and #24). The facility identified a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive loss. The Resident required supervision of one staff member with eating. The MDS listed a diagnosis of unspecified dementia. The Care Plan dated revised 6/20/21 documented Resident #1 with a potential nutritional problem related to dementia and directed the staff to serve eight ounces of Lactaid milk with meals and peanut butter on toast at breakfast for added protein. A Progress Note dated 2/28/23 at 9:21 a.m. documented by the Dietician directed to give peanut butter on toast at breakfast for added protein. A Progress Note dated 5/30/23 at 10:55 a.m. by the Dietician documented the Resident as stable and recommended no dietary changes only to continue to monitor regularly. A Diet Type Report provided by the facility on 7/11/23 documented Resident #1 on a regular diet with additional directions to serve no milk due to mild lactose intolerance and cut up meats. The Diet Report lacked documentation to serve peanut butter toast with breakfast for added protein. During an observation on 7/13/23 at 8:40 a.m. Resident #1 sat at the dining room table eating cereal and scrambled eggs. The resident did not receive toast with peanut butter per the plan of care. During an interview on 7/13/23 at 8:41 a.m. Staff D, C.N.A. reported she didn't think she had ever seen the kitchen serve her peanut butter for breakfast. During an interview on 7/12/23 at 1:07 p.m. the Dietician stated she expected the dietary staff to serve the residents the approved menu as written and dietary recommendations should be followed. She planned to provide some in-service education at her next visit. During an observation on 7/17/23 at 8:57 a.m. Resident #1 finished eating her breakfast. Observation revealed toast with peanut butter had not been served to her. During an interview on 7/17/23 at 1:29 p.m. the DON reported the Dietician is responsible for updating care plans quarterly. They had their long term dietician quit in early March and the company sent a gentleman to fill in for a few weeks, then we were notified we would be switching to our current dietician. The DON expressed she felt the care plans had not been updated appropriately due to the fluctuation in dieticians. She voiced the care plans should be updated. The Person Centered Care Plan Policy, revised 10/2017, documented person-centered care planning focuses on the resident as the locus of control and supports the resident in making their own choices and having control over their daily lives. The Guidelines detailed person centered care planning is an ongoing process which actively encourages the resident and/or the resident's representative to be an active participant in the care planning process and addresses the development and implementation of individualized person care. The Comprehensive Person Centered Care Plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Areas to address on the care plan include: swallowing disorders/difficulties, nutritional supplements, mechanically altered and therapeutic diets, food intolerance's, allergies and/or specific food preferences. 2. Resident #2's MDS assessment dated [DATE] showed a BIMS score of 15 indicating intact cognition. The Resident ate meals independently. The MDS documented diagnoses of heart failure, end stage renal disease, diabetes, and hyperlipidemia. A Nutritional Assessment note dated 6/08/23 documented by the Dietician directed the staff to offer double protein at meals due to a skin area on the left buttock for healing. The Care Plan revised 6/12/23 by the Dietician identified Resident #2 with a potential nutritional problem related to diabetes mellitus, a chronic wound, chronic kidney disease, stage 3, chronic obstructive pulmonary disease, and congestive heart failure. The Care Plan detailed to provide double meat and 2 boiled eggs at breakfast. See the kitchen list for details. The Diet Type Report provided by the facility on 7/11/23 showed Resident #2 as a carbohydrate controlled regular diet with no additional directions. During an observation on 7/12/23 at 8:45 a.m. Resident #2 sat in the dining room eating a breakfast of scrambled eggs and sausage. The Resident had approximately 3 ounces of scrambled eggs and three sausage links. The resident did not receive two boiled eggs with his breakfast per the care plan. On 7/12/23 at 12:25 p.m. Staff B plated up Resident #2's lunch meal with an 8 ounce serving of spaghetti, 1 cup of meat sauce, 1 slice of garlic toast, and 4 ounces of broccoli. Staff B failed to serve or offer the resident double protein for the lunch meal per the care plan. During an interview on 7/12/23 at 1:07 p.m. the Dietician reviewed her progress note from 2/23/23 and reported she usually makes out a fax sheet to the physician to get orders for her recommendations. She reviewed and stated it was on her as she had not followed through with ensuring the the recommendation got physician ordered, but the Resident needed to be offered two servings of protein. A review Resident #2's dietary card on 7/12/23 at 12:35 p.m. lacked direction on the card for staff to offer double protein at meals. During an interview on 7/12/23 at 1:07 p.m. the Dietician stated she expected the dietary staff to serve the residents the approved menu as written and dietary recommendations should be followed per the care plan. She planned to provide some in-service education at her next visit. 3. Resident #24's MDS assessment dated [DATE] showed a BIMS score of 8 indicating moderate cognitive loss. The Resident ate independently with setup assistance. The MDS listed diagnoses of diabetes mellitus, diabetes with unspecified diabetic retinopathy, hypertension, anemia, and non-Alzheimer's Dementia. The MDS documented Resident #24 received insulin injections 7 days per week. The Care Plan dated revised 1/20/23 identified Resident #24 at a potential for a nutritional problem related to diabetes and dementia. The Care Plan directed the staff to serve the diet as ordered, observe intake and record each meal. The Care Plan directed to serve a regular diet. The Diet Type List report provided by the facility on 7/11/23 documented Resident #24 on a carbohydrate controlled diet, regular texture and fluids. The Week 4 Thursday Dietary Spreadsheet listed the following controlled carbohydrate menu: a. 6 ounces (oz.) of Spaghetti with meat sauce b. 4 oz. seasonal vegetables c. 1/2 slice garlic toast d. 1/2 serving of seasonal fresh fruit e. 8 oz. milk On 7/12/23 at 12:39 a.m. Staff B, Dietary Cook, plated up Resident #24 lunch meal. Staff B using tongs placed a small amount, approximately 2.5 inches by 1 inch of spaghetti, on the plate and covered with a small amount of spaghetti sauce. Staff B explained she gives a little bit of the main carbohydrate and gives a larger portion of the vegetable. Staff B placed two servings of broccoli on the plate. She then explained she looks for the smallest piece of bread that she can find and serves that. Staff B placed a full size piece of garlic bread on the plate, touching the garlic bread with the same gloves she had touched various other surfaces with, then held the bread with her left gloved hand to hold the garlic bread and cut the garlic bread in half. She handed the plate to Staff C who placed the plate on the serving cart to go out to Resident #24. A dessert bowl containing a full serving of canned peaches was also served to Resident #24 for dessert. The Care Plan failed to identify Resident #24 physician ordered carbohydrate controlled diet. During an interview on 7/12/23 at 1:07 p.m. the Dietician voice she expected the staff to follow and serve the correct menu extension and care planned interventions should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, the facility failed to follow the Dietician recommendation diet plan, failed to follow the Dietician approved menu exchange for a carbohydrate controlled diet and failed to serve the Dietician approved menus to meet the needs of 2 of 8 residents sampled (Resident #2 and #24). The facility reported a census of 35 residents. Findings include: 1. Resident #2's MDS assessment dated [DATE] showed a BIMS score of 15 indicating intact cognition. The Resident ate meals independently. The MDS documented diagnoses of heart failure, end stage renal disease, diabetes, and hyperlipidemia. A Nutritional Assessment note dated 6/08/23 documented by the Dietician directed the staff to offer double protein at meals due to a skin area on the left buttock for healing. The Care Plan revised 6/12/23 by the Dietician identified Resident #2 with a potential nutritional problem related to diabetes mellitus, a chronic wound, chronic kidney disease, stage 3, chronic obstructive pulmonary disease, and congestive heart failure. The Care Plan detailed to provide double meat and 2 boiled eggs at breakfast. See the kitchen list for details. The Diet Type Report provided by the facility on 7/11/23 showed Resident #2 as a carbohydrate controlled regular diet with no additional directions. During an observation on 7/12/23 at 8:45 a.m. Resident #2 sat in the dining room eating a breakfast of scrambled eggs and sausage. The Resident had approximately 3 ounces of scrambled eggs and three sausage links. The resident did not receive two boiled eggs with his breakfast. On 7/12/23 at 12:25 p.m. Staff B plated up Resident #2's lunch meal with an 8 ounce serving of spaghetti, 1 cup of meat sauce, 1 slice of garlic toast and 4 ounces of broccoli. Staff B failed to serve or offer the resident double protein for the lunch meal. During an interview on 7/12/23 at 7:01 p.m. the Dietician reviewed her progress note from 2/23/23 and reported she usually makes out a fax sheet to the physician to get orders for her recommendations. She reviewed and stated it was on her as she had not followed through with ensuring the the recommendation got physician ordered, but the Resident needed to be offered two servings of protein. A review Resident #2's dietary card on 7/12/23 at 12:35 p.m. lacked direction on the card for staff to offer double protein at meals. During an interview on 7/12/23 at 1:07 p.m. the Dietician stated she expected the dietary staff to serve the residents the approved menu as written and dietary recommendations should be followed. She planned to provide some in-service education at her next visit. The Accuracy and Quality of Tray Line Service, dated 2021, provided by the facility documented the Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the food and nutritional services staff, and by the service staff prior to serving the meal to the individual. The Policy Procedure documented the following: 1. The menu extensions display food items and amount for each regular or therapeutic diet. 2. The director of food and nutrition services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time. 3. Each meal will be checked for: a. Correct name, room number and diet order b. Accuracy of following the therapeutic diet extension c. Proper portion sizes d. Food and beverage preferences, allergies, intolerance's and/or special food requests e. Neatness of tray and attractiveness of the food served. 4. Problems with meal accuracy should be resolved immediately. 5. Ongoing problems should be brought to the attention of the director of food and nutrition services The Meal Identification and Preference Cards/Tickets Policy, dated 2021, provided by the facility documented a meal identification and food preferences card will be used to properly identify each individual's needs including food and beverage preferences. The meal ID card/ticket may be a permanent card that is gathered, cleaned, and sanitized after each meal or may be printed daily from a data base and disposed of after meals. The Procedure directed the following: 1. The meal ID cards/tickets will be used during meal service to assure the correct diet is being served and food preferences are honored. 2. The director of food and nutritional services or designee will be responsible for keeping permanent meal ID cards/tickets up-to-date and for replacing when appropriate. 2. Resident #24's MDS assessment dated [DATE] showed a BIMS score of 8 indicating moderate cognitive loss. The Resident ate independently with setup assistance. The MDS listed diagnoses of diabetes mellitus, diabetes with unspecified diabetic retinopathy, hypertension, anemia, and non-Alzheimer's Dementia. The MDS documented Resident #24 received insulin injections 7 days per week. The Diet Type List report provided by the facility on 7/11/23 documented Resident #24 on a carbohydrate controlled regular diet. The Week 4 Thursday Dietary Spreadsheet listed the following controlled carbohydrate menu: a. 6 ounces (oz.) of Spaghetti with meat sauce b. 4 oz. seasonal vegetables c. 1/2 slice garlic toast d. 1/2 serving of seasonal fresh fruit e. 8 oz. milk On 7/12/23 at 12:39 a.m. Staff B, Dietary Cook, plated up Resident #24's lunch meal. Staff B using tongs placed a small amount, approximately 2.5 inches by 1 inch of spaghetti, on the plate and covered with a small amount of spaghetti sauce. Staff B explained she gives a little bit of the main carbohydrate and gives a larger portion of the vegetable. Staff B placed two servings of broccoli on the plate. She then explained she looks for the smallest piece of bread that she can find and serves that. Staff B placed a full size piece of garlic bread on the plate, touching the garlic bread with the same gloves she had touched various other surfaces with, then held the bread with her left gloved hand to hold the garlic bread and cut the garlic bread in half. She handed the plate to Staff C who placed the plate on the serving cart to go out to Resident #24. A dessert bowl containing a full serving of canned peaches was also served to Resident #24 for dessert. During an interview on 7/12/23 at 1:07 p.m. the Dietician voice she expected the staff to follow and serve the correct menu extension. The Portion Control Policy, dated 2021, documented individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. The Portion Control Policy Procedure directed the following: 1. The menu should list the specific portion size for each food item. Menus should be posted at the tray line so staff can refer to the proportions of each diet. 2. Food should be served with ladles, scoops, spoodles, and spoons of standard sizes. Scale should be used as needed to weigh meat portions. Scoops should be leveled off for the most accurate portion size. a. Portions that are too small result in the individual not receiving the nutrients needed. 3. The director of food and nutrition services, registered dietician nutritionist or designed will observe meals on a routine basis to assure quality control of portion sizes. 3. During a walk through observation of the kitchen on 7/11/23 from 8:45 a.m. to 10:20 a.m. no peanut butter blondie desserts were noted being prepared or stored in the kitchen. During an interview on 7/11/23 at 9:40 a.m. Staff C showed the location of the dietician approved menu in the kitchen for Tuesday, Week #3. The Menu listed Chicken Pasta Alfredo, tossed salad, roll, and peanut butter blondie dessert. Staff C reported she did not know anything about a substitution list. They had an alternate menu which was posted on the bulletin board out in the dining room. On 7/11/23 at 11:00 a.m. observation of the dining area revealed no posting of the lunch menu for the Residents. The Week #3 Tuesday Menu provided by the facility on 7/11/23 documented the following Dietician approved menu: a. 6 ounces (oz.) of Chicken Pasta Alfredo b. 8 oz. tossed salad with dressing c. 1 slice garlic toast d. 1 square of peanut butter blondie e. 8 oz. milk Observation on 7/11/23 at 12:45 p.m. revealed the meal served out with chicken pasta Alfredo, tossed salad and garlic toast. During an interview on 7/13/23 at approximately 1:30 p.m. Staff C reported she didn't serve the peanut butter blondie dessert listed on the week #3 menu. She didn't have what she needed to prepare it. She couldn't recall if the resident's received fruit or ice cream for dessert that day, but she thought she had served one of those items. 4. The Week #3 Wednesday Dietician approved menu provided by the facility on 7/11/23 listed the following lunch menu: a. 3 oz. smoked pork loin b. 1 tablespoon barbeque sauce c. 1 each baked sweet potato d. 1 teaspoon brown sugar with margarine e. 4 ounces buttered peas d. 1 each bread and margarine f. #8 scoop of strawberry rhubarb cobbler g. 8 oz. milk Observation on 7/12/23 at 11:13 a.m. revealed the Week #3 Wednesday lunch menu had not been posted in the dining area for the residents. Kitchen observation on 7/12/23 (Wednesday) at 11:15 a.m. revealed the Week #3 Lunch menu had not been prepared. Staff C, Cook, went to the front counter and pulled out the menu and reported the lunch menu as follows from the Week #4 Thursday menu: a. 8 oz. spaghetti with meat sauce b. 4 oz. seasonal vegetables c. 1 slice garlic toast d. 1 serving seasonal fresh fruit e. 8 oz. milk On 7/12/23 at 11:16 p.m. Staff C reported the wrong menu must have gotten flipped forward last night. They were serving spaghetti. Staff C continued to serve the Week #4 Thursday menu using canned peaches as the fresh fruit. On 7/12/23 at 3:30 p.m. the Dietician asked Staff B, Cook, which weekly menus they were following. Staff B voiced whichever menus were up there, pointing to the counter. Observation revealed two sets of menus on separate d-rings for week #3 and week #4. Staff B couldn't identify which set of menus was being followed. The menus failed to match up with the corresponding week and day of the menus for what was served for lunch on 7/11/23 and 7/12/23. The Dietician voiced the menus were all messed up and she was currently handwriting the menus to get the staff back on track and many of the food items for the menus were not on hand in the kitchen. She reported she did not find a substitution list and she had not approved a menu substitution list. She reviewed the handwritten alternative menu posted on the bulletin board and reported she had emailed an approved menu list, but the alternative menu list hanging on the dining room bulletin board had not been approved by her. She was trying to get the dietary staff back on track until they could resume the regular approved menus. During an interview on 7/18/23 at 1:11 p.m. the Executive Director reported she had been in contact with the Dietician. There is a lack of competency in the kitchen. There is education planned next Tuesday on types of diets and how to follow the menu. She expects the staff to serve the correct resident diets, with the correct portion sizes following the menu extensions. If they can't find the food item right away, they just pick something else to make even if it isn't on the menu. The Accuracy and Quality of Tray Line Service Policy directed all meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. The Policy Procedure directed the following: 1. The menu extensions display food items and amounts for each regular or therapeutic diet. 2. The director of food and nutrition services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time. 3. Tray line and/or meal service positions for breakfast, lunch and dinner will be planned and determined according to the menu. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based clinical record review, observation and staff interview, facility failed to serve the correct diet to provide food in the form to meet the resident needs for 2 of 2 residents requiring a special texture diet (Residents #11 and #25). The facility identified a census of 35 residents. Findings include: 1. Resident #11's MDS assessment dated [DATE] showed a BIMS score of 11 indicating moderate cognitive loss. The Resident required extensive assistance of 1 person for eating. The MDS listed diagnoses of Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), bipolar (a mental health condition that causes extreme mood swings), and morbid obesity. The MDS documented Resident #11 required a mechanically altered diet. The Care Plan revised 5/04/23 documented Resident #11 with a potential for a nutrition problem of inadequate intakes related to dependency on staff to assist with feeding, difficulty with chewing at times, history of behavioral issues, depression, bipolar, and schizophrenia (Schizophrenia is a chronic brain disorder that has symptoms including delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation). The Care Plan directed the staff to provide and serve the diet as ordered. A Progress Note directed to the Provider on 7/4/23 at 9:55 a.m. documented Resident #11 continued to have swallowing problems and speech therapy had seen her. The facility inquired about a pureed diet and to continue with regular liquids for the Resident. The Progress note detailed the facility had trialed this and the Resident had done very well. The Resident had been unable to do well even on a mechanical soft diet as she pocketed food. The Provider approved the order on 7/06/23. A Diet Type Report provided by the facility on 7/11/23 documented Resident #11 on a physician ordered regular pureed diet. During an observation on 7/12/23 at 12:05 p.m. Staff B placed a 1/2 cup of canned peaches into a mini chopper. Staff B pureed the peaches and scraped the peach puree mixture into a small bowl. Staff B failed to scrap the mini chopper base fully, leaving approximately 2 tablespoons of the mixture in the bottom of the chopper base. Staff B proceeded to take the mini chopper to the hand sink and washed the base and blade out with her hands in the hand sink and brought back to the preparation table. Staff B then placed a 4 ounce serving of broccoli in the small four cup work bowl with added water to blend. Staff B added some additional water to the broccoli mixture to blend a second time. The broccoli puree had a chunky texture throughout the entire mixture. Staff B scraped the chunky broccoli mixture into a bowl leaving approximately 1/4 cup of the mixture in the bottom of the blender. Staff B took 1 piece of garlic bread from the steam table and placed in the mini chopper with some milk. The final texture of the garlic bread appeared gritty and chunky. Staff B scraped the bread mixture into a serving bowl. Staff B took the four cup work bowl to the dishwasher to wash. She returned to the preparation table with the four cup work bowl without washing her hands. She placed an 8 ounce serving of spaghetti and a cup of meat sauce into the blender. Staff B pureed the mixture. The final spaghetti mixture had small pieces of noodles and meat sauce chunks in the final mixture. The meal was served out to Resident #11 as prepared. During an interview on 7/12/23 at 1:07 p.m. the Dietician reported she expects the choppers and blenders to be sanitized between each pureed prep item. She expected the staff to prepare puree consistency to be smooth like pudding. On 7/13/23 at 12:39 p.m. Staff F, Speech Language Pathologist reported the puree food texture should be that of applesauce or pudding. The texture should be all one consistency. During an interview on 7/18/23 at 1:11 p.m. the Executive Director reported she had been in contact with the Dietician. There is a lack of competency in the kitchen. There is education planned next Tuesday on types of diets, following menus, and how to prepare pureed food. She expects the staff to serve the correct diets and the correct consistency in the correct portions following the diet menu extensions to meet the residents needs. The Select Menu Policy, dated 2021, documented select menus are offered, they will be provided to meet each individual's dietary modifications and preferences. Menus may be reviewed to assure therapeutic correctness and nutritional adequacy while respecting the individual's food preferences. Select menu sheets may be used for meal/tray identification. Those who are not able to make meal choices independently will be provided with assistance, or a non-select menu will be provided (and altered for individual food preferences and physician ordered diet). The Policy directed to refer complicated therapeutic diets to the registered dietitian nutritionist (RDN) or designee as needed to review and approve. The Accura Healthcare Policy and Procedure Manual, Food and Nutritional Services in Healthcare Facilities did not contain a pureed food preparation policy or procedure. 2. The MDS Assessment for Resident #25 dated 6/10/23 showed a BIMS score of 10 indicating moderate cognitive loss. The Resident ate meals independently. The MDS listed diagnoses of hypertension, diabetes, end stage renal disease, and stroke with hemiplegia (paralysis on one side of the body). The MDS identified the resident had a significant weight loss. The Care Plan revised 5/04/23 documented Resident #25 with an increased nutritional risk related to variable intake of meals with low body weight, a history of alcohol abuse, and stroke with decreased ability to take care of self. The Care Plan directed the dietary staff to provide the diet as physician ordered: mechanical soft diet with pureed meats per the speech language pathologist recommendations. The Diet Type Report provided by the facility on 7/11/23 showed Resident #25 ordered on a regular mechanical soft diet with pureed meat. On 7/12/23 at 12:05 p.m. Staff B, Dietary Cook, voice they only had one resident on a pureed diet, Resident #11. Staff B continued to prepare a pureed food serving of each menu item for Resident #11. Staff B failed to puree any meat for Resident #25. On 7/12 23 at approximately 12:25 p.m. Staff B plated an 8 ounce serving of spaghetti, 1 cup of spaghetti sauce containing ground beef, 4 ounces of broccoli and a piece of garlic bread. Resident #25 was served the plate of spaghetti with sauce containing ground beef. During an interview on 7/12/23 at 1:07 p.m. the Dietician reported she expected the staff to serve diets as ordered and the menus as written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interview, the facility failed to honor the Resident's dietary preferences for 1 of 2 residents sampled (Resident #23). The facility reported a census of 35 residents. Findings include: Resident #23's MDS dated [DATE] showed a BIMS score of 12 indicating moderate cognitive loss. The Resident required set up for independence in eating meals. The MDS listed diagnoses of hypertension, thyroid disorder, unspecified dementia, and received anticoagulant medication 7 days a week. A Progress Note dated 6/29/23 documented the following orders: a. Warfarin dose 2.5 milligrams (mg) on Monday and Thursdays for Coumadin. b. Warfarin dose 5 mg all other days. The Anticoagulant Flow Sheet documented Resident #23's INR (international normalized ratio) is a type of calculation based on PT test results. Prothrombin is a protein made by the liver) at 2.49 (high) on 6/29/23. The INR moderate-intensity range is 2.0 - 3.0. The June 2023 Medication Administration Record showed the following Warfarin (Coumadin/Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat. The medication carries a risk of excessive bleeding) orders: a. Warfarin Sodium Oral Tablet (Warfarin Sodium) give 2.5 mg by mouth in the evening every Monday and Thursday for Coumadin until 07/13/2023. b. Warfarin Sodium Oral Tablet (Warfarin Sodium) give 5 mg by mouth one time a day every Tuesday, Wednesday, Friday, Saturday and Sunday related to other persistent atrial fibrillation until 7/12/23. A Diet Type Report provided by the facility on 7/11/23 showed Resident #23 received regular diet. A review of Resident #23's Dietary Card on 7/12/23 revealed dislikes listed as broccoli. During a meal observation on 7/12/23 at 12:47 p.m. Staff B, Cook, plated up 8 ounces of Spaghetti with meat sauce, 1 slice garlic bread and a 4 ounce serving of broccoli on Resident #23's plate. Staff B handed the plate to Staff C, [NAME] who placed Resident #23's plate and dietary card on a serving cart to go out to the Resident. During an interview on 7/13/23 at 1:30 p.m. Resident #23 reported she cannot eat broccoli as it interferes with her blooding thinning medication Coumadin. She reported she had been served broccoli yesterday (7/12/23) at lunch but she did not eat it. She just went without a vegetable. She reported she has received broccoli several times on her meal trays. She believes she has told the dietary staff she cannot have broccoli. The 36th Edition Nursing 2016 Drug Handbook by Wolter's Kluwer, provided by the Director of Nursing as the drug reference guide in the facility nurses station, directed foods, multivitamins, and other enteral products containing vitamin K may impair anticoagulation. Tell patients to maintain consistent daily intake of foods containing vitamin K. The Patient Teaching included instructing patients to eat a daily, consistent diet of food and drinks containing vitamin K, as eating varied amounts may alter the anticoagulant effects. The Meal Identification and Preference Cards/Tickets Policy, dated 2021, provided by the facility documented a meal identification and food preferences card will be used to properly identify each individual's needs including food and beverage preferences. The meal ID card/ticket may be a permanent cart that is gathered, cleaned, and sanitized after each meal or may be printed daily from a data base and disposed of after meals. The Procedure directed the following: 1. The meal ID cards/tickets will be used during meal service to assure the correct diet is being served and food preferences are honored. 2. The director of food and nutritional services or designee will be responsible for keeping permanent meal ID cards/tickets up-to-date and for replacing when appropriate. The Policy Procedure directed the following: 1. The menu extensions display food items and amounts for each regular or therapeutic diet. 2. The director of food and nutrition services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time. 3. Tray line and/or meal service positions for breakfast, lunch, and dinner will be planned and determined according to the menu. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. 4. Staff will refer to the meal identification (ID) card/ticket for food dislikes, allergies, and other details and substitute appropriately for those items.

Based on observation, document review, staff interview and facility policy review, the facility failed to maintain sanitary practices by improperly preparing/serving food and failed to maintain a sanitary kitchen. The facility identified a census of 35 residents. Findings include: During an initial observation of the serving area and kitchen on 7/11/23 the following findings were identified: a. On 7/11/23 at 8:30 a.m. observation revealed a drink cart in the serving area ahead of the kitchen. The cart contained a gallon jug ¾ full of orange juice, 5 chocolate milk cartons, 3 white milk cartons, 1 pitcher ½ full of lemonade, 1 pitcher ½ full of grape juice, one pitcher of apple juice. One container of Thick and Easy water and 1 container of Thick and Easy juice all sitting on the cart without being on ice or in any type of cold container. b. On 7/11/23 at 8:50 a.m. Staff T, dietary aide, prepared eight room trays and took the three milks from the drink cart and placed them on the room trays and poured one chocolate milk into a glass and placed on a room tray. At 8:56 a.m. Staff C, Cook, plated the room trays, placed covers over the plates and gave the covered plates to Staff T to place on each room tray. c. On 7/11/23 at 8:59 a.m. the following room trays went with the following items: 1. Resident #19 - 1 carton of white milk 2. Resident #26 - 1 carton of white milk 3. Resident #27 - 1 glass of chocolate milk, uncovered and 1 carton of white milk 4. Resident #28 - three cups of fluids, all uncovered. 5. Resident #29 - 1 carton of white milk, 1 glass of juice and 1 glass of water, uncovered. 6. Resident #15 - 1 carton white milk, 1 glass water and 1 glass cranberry juice, uncovered. 7. Resident #30 - 1 glass orange juice, uncovered and 1 carton of white milk 8. Resident #18 - 1 medium glass of white milk, uncovered. 9. Resident #31 - 1 carton of white milk and 1 cup of tea, uncovered. d. The Victory refrigerator had the June 2023 Temperature Log hanging on the front of the refrigerator. The June 2023 Temperature Log only had temperatures recorded from 6/1/23 - 6/21/23. The prior record hanging on the front of the refrigerator dated February 2023 revealed blanks for 2/4/23 and 2/5/23. e. The Glenco refrigerator had a June 2023 Temperature Log posted on the front of the refrigerator. The Log had temperatures recorded from 6/1/23 - 6/21/23. No July 2023 refrigerator or freezer Temperature Logs observed in the kitchen during initial walk-thru. The Glenco refrigerator had a large amount of food debris built up on the bottom of the refrigerator. All three handles on the Glenco refrigerator had crusty particle build up on the handles to open the refrigerator. f. The freezer had an approximate 18 inch by 5 inch frozen area of water from the top of the freezer to the second shelf of the freezer present. g. The freezer contained a ½ open bag of undated hash browns and cinnamon rolls. h. At 9:06 a.m. the primary hand wash sink ran for 1.5 minutes and water was cool to the touch. Staff U, Dietary Aide, washed her hands and went back to the dirty side of the kitchen. She voiced the hand wash sink is weird. There is never any hot water from that one. She stated there is hot water at the three-bin sink and at the dishwasher. She stated the other sink also has hot water. The other kitchen sink in the prep area was not marked as a hand wash sink. At 9:13 a.m. the hand wash sink, after 40 seconds, started to have warm water. The temperature registered after the 40 seconds at 100.4 degrees. i. On 7/11/23 at 9:16 a.m. Staff C reported the Dietary Supervisor has the responsibility of monitoring that the kitchen is getting cleaned and the cleaning is documented. j. At 9:30 a.m. the dishwasher felt luke warm to touch. Staff C tested the first sanitizer strip. The strip failed to show the dishwasher sanitized the dishes. The dishwasher machine temperature gauge did not move or register any temperature on the wash or rinse cycle. The National Safety Machine Operational Requirements as manufactured by American Dish Service documented the machine required a wash and rinse temperature of 120 degrees Fahrenheit (F) at a minimum and required a 50 Parts Per Million (PPM) available chlorine to sanitize. Staff C performed two separate checks on the sanitation of the machine on two separate loads of dishes and the dishwasher did not show appropriate parts per million for sanitation or the required water temperature for the wash/rinse cycle. She stated she could not answer any questions regarding how often the dishwasher is checked as she doesn't normally do that. She stated Staff T, the Dietary Supervisor or the maintenance guy that comes periodically to check the machine are the ones to check the machine. k. At 10:10 a.m. the Executive Director (ED) check the kitchen hand wash sink and the dishwasher. She confirmed the water temperature and sanitation on the dishwasher was not working right. At 10:45 a.m. the ED reported the maintenance main found a tripped breaker and he was working on the hot water. The ED reported they had the water temperature up to 102 degrees at this time for the hand wash sink and the kitchen would be serving on Styrofoam dishes until the dishes could be properly washed and sanitized. During a return visit to the kitchen the following observations were made on 7/12/23 at 11:10 a.m.: a. The hand wash sink, after 1 minute, temped at 114 degrees. After additional run time at 11:20 a.m. the hot water temperature went up to 121 degrees. b. Observation on 7/12/23 at 11:13 a.m. revealed the Week #3 Wednesday lunch menu had not been posted in the dining area for the residents. c. Kitchen observation on 7/12/23 (Wednesday) at 11:15 a.m. revealed the Week #3 Lunch menu had not been prepared. Staff C, Cook, went to the front counter and pulled out the menu and reported the lunch menu as follows from the Week #4 Thursday menu: 1. 8 oz. spaghetti with meat sauce 2. 4 oz. seasonal vegetables 3. 1 slice garlic toast 4. 1 serving seasonal fresh fruit 5. 8 oz. milk d. On 7/12/23 at 11:16 p.m. Staff C reported the wrong menu must have gotten flipped forward last night. They were serving spaghetti. Staff C continued to serve the Week #4 Thursday menu using canned peaches as the fresh fruit. Further observation showed the Week #4 Thursday menu did not have a small portions exchange listed on the menu. e. At 11:21 p.m. the dishwasher wash cycle tested at 110 degrees, rinse cycle of 128 degrees and tested at 100 PPM for sanitation. The ED reported they were still working on the dishwasher. f. At 11:30 Staff C had half inch tendrils of hair hanging out each side of her hairnet and a small portion of her bangs handing out the top, front of her hair net. Staff U had small side sections of her hair hanging outside of the hairnet as she prepared drinks for the room trays. g. At 11:34 a.m. Staff B asked Staff C how they were planning to do the pureed food, if she should puree the spaghetti with meat sauce and broccoli together. Staff C instructed Staff B to prepare each food item separately. h. At 11:55 a.m. Staff C utilized hand sanitizer on her hands prior to entering the kitchen. Staff C went to the cupboard and pulled a stack of the resident's dietary cards from the cupboard and prepared to start plating food. Staff C reported the kitchen does not have a substitution list. The Dietician instructed them to replace food categories with like food. They call the Dietician to get her approval on substitutions. The carbohydrates have to be balanced so the resident doesn't get too many carbohydrates. i. On 7/12/23 at 12:05 p.m. Staff B, Dietary Cook, voice they only had one resident on a pureed diet, Resident #11. Staff B failed to puree any meat for Resident #25. During an observation on 7/12/23 at 12:05 p.m. Staff B placed a 1/2 cup of canned peaches into a mini chopper. Staff B pureed the peaches and scraped the peach puree mixture into a small bowl. Staff B failed to scrape the mini chopper base fully, leaving approximately 2 tablespoons of the mixture in the bottom of the chopper base. Staff B proceeded to take the mini chopper to the hand sink and washed the base and blade out with her hands in the hand sink and brought back to the preparation table. Staff B then placed a 4 oz. serving of broccoli in the small four cup work bowl with added water to blend. Staff B added some additional water to the broccoli mixture to blend a second time. The broccoli puree had a chunky texture throughout the entire mixture. Staff B scraped the chunky broccoli mixture into a bowl leaving approximately 1/4 cup of the mixture in the bottom of the blender. Staff B took 1 piece of garlic bread from the steam table and placed in the mini chopper with some milk. The final texture of the garlic bread appeared gritty and chunky. Staff B reheated the garlic bread to 149.4 degrees and scraped the bread mixture into a serving bowl. Staff B took the four-cup work bowl to the dishwasher to wash. She returned to the preparation table with the four-cup work bowl without washing her hands. She placed an 8 oz. serving of spaghetti and a cup of meat sauce into the blender. Staff B pureed the mixture. The final spaghetti mixture had small pieces of noodles and meat sauce chunks in the final mixture. Staff B reheated the spaghetti to a temperature of 151 degrees. The meal was served out to Resident #11 as prepared. j. At 12:20 a fan with a large amount of thick black grime build-up blew down on the clean dishes coming out of the dishwasher. k. At approximately 12:25 p.m. Staff B plated an 8 oz serving of spaghetti, 1 cup of spaghetti sauce containing ground beef, 4 oz of broccoli, and a piece of garlic bread. Resident #25 was served the plate of spaghetti with sauce containing ground beef. The Diet Type Report provided by the facility showed Resident #25 was ordered on a regular mechanical soft diet with pureed meat. l. At 12:27 Staff B had gloves on and had plated out several plates of food touching plates, utensils, handles of the serving cart, then picked up a slice of garlic bread with her right gloved hand and held the slice of garlic bread with her left hand to cut the bread in half to serve the garlic bread out to Resident #30. Staff B continued to wear the same gloves. m. At 12:28 Staff B picked up a slice of garlic bread with her right gloved hand and held the slice of garlic bread with her left hand to cut the bread in half to serve the garlic bread out to Resident #19. Staff B continued to wear the same gloves. n. At 12:30 p.m. Staff U completed serving milk in the dining room from milk in a cold container with no ice. The milk sample tested at 49.8 degrees. o. At 12:34 Staff B picked up a slice of garlic bread with her right gloved hand and held the slice of garlic bread with her left hand to cut the bread in half to serve the garlic bread out to Resident #18. Staff B continued to wear the same gloves. p. At 12:35 p.m. Staff B used tongs to place 8 oz. of spaghetti on a plate. She then used her left gloved hand to take the spaghetti that spilled off the plate and pile it back on the plate. Resident #15 received the plate of spaghetti. q. At 12:36 p.m. Staff T asked Staff C if they needed to cover the food going out of the kitchen. Staff C instructed Staff T they did not need to cover the food going directly to resident in the dining room. r. At 12:38 Staff B picked up a slice of garlic bread with her right gloved hand and held the slice of garlic bread with her left hand to cut the bread in half to serve the garlic bread out to Resident #32. Staff B continued to wear the same gloves. s. On 7/12/23 at 12:39 a.m. Staff B, Dietary Cook, plated up Resident #24's lunch meal. Staff B using tongs placed a small amount, approximately 2.5 inches by 1 inch of spaghetti, on the plate and covered with a small amount of spaghetti sauce. Staff B explained she gives a little bit of the main carbohydrate and gives a larger portion of the vegetable. Staff B placed two servings of broccoli on the plate. She then explained she looks for the smallest piece of bread that she can find and serves that. Staff B placed a full-size piece of garlic bread on the plate, touching the garlic bread with the same gloves she had touched various other surfaces with, then held the bread with her left gloved hand to hold the garlic bread and cut the garlic bread in half. She handed the plate to Staff C who placed the plate on the serving cart to go out to Resident #24. A dessert bowl containing a full serving of canned peaches was also served to Resident #24 for dessert. The Week 4 Thursday Dietician approved menu exchange for a carbohydrate-controlled diet directed the staff to serve 6 oz. of spaghetti with meat sauce, 4 oz. seasonal vegetables, ½ slice of garlic toast and a ½ serving of fresh fruit. t. During a meal observation on 7/12/23 at 12:47 p.m. Staff B, Cook, plated up 8 oz of spaghetti with meat sauce, 1 slice garlic bread, and a 4 oz. serving of broccoli on Resident #23's plate. Staff B handed the plate to Staff C who placed Resident #23's plate and dietary card on a serving cart to go out to the Resident. A review of Resident #23's Dietary Card on 7/12/23 revealed dislikes listed as broccoli. No substitution offered. u. At 12:57 p.m. Staff B asked Staff C for a spatula to mix the meat sauce into the spaghetti more for a resident. Staff C handed the spatula to Staff B. Staff B grabbed by the spatula end of the utensil with her dirty glove and continued to mix the meat sauce into the spaghetti before serving out the plated food. During an interview on 7/12/23 at 1:03 p.m. Staff B reported hot food temperatures should be held between 140 - 165 degrees and cold foods should be held at 33-40 degrees. She reported she had received training on food temperatures and serving diets. She had been trained by a prior employee. She reported there were no temperature logs for the refrigerators or freezer and no cleaning lists. They really should do a better job of that. The logs are not assigned to any specific person. Anyone can fill them out. They are trying to do better in the kitchen. During an interview on 7/12/23 at 1:07 p.m. the Dietician reported she had been consulting at the facility for 4 months. She acknowledged the Week #4 Thursday meal had been served and would make a note to go back and review it. The days meals are balanced if served according to the menu. The dietician reported she expected the staff to have cleaning schedules and to sign off the cleaning lists when cleaning is complete. She expected the staff to maintain a clean kitchen. The freezers and refrigerators should be checked for proper temperature daily and temperatures should be recorded. They have temperature logs on the front of each appliance. The Dietician was unaware the kitchen didn't have a July 2023 logs posted. She expected all food and drink to be covered before items are delivered to the resident rooms. She expected the drinks, milk and juices to be in a cold tube with ice if the items would be out for any length of time. Staff should complete a full hand wash before they start serving, not using hand sanitizer. She reported she had not told staff to call her with meal substitutions. If they have questions on substitutions, they should call her. She isn't sure if there is a substitution list, but she had not signed off on any substitution food list. When she started, she had the dietary manager meet with residents upon admission and each quarter to ask resident about likes and dislikes. She expects the care plan interventions to be followed. She expects the choppers and blenders to be sanitized between each pureed prep item. She expected the puree consistency to be smooth like pudding. She expected food would not be touched with dirty gloves. She expected reheated food to be above 165 degrees. She expects food preferences to be honored and followed as on the dietary card. She expects they should be following the physician ordered diet and therapy recommendations. She expects the fan should be clean if over the clean dish area. She plans to follow up and schedule some dietary education with her next visit. She expected the dietary staff to serve the residents the approved menu as written and to follow the Dietician recommendations. On 7/12/23 at 4:22 p.m. the ED submitted the following Daily Refrigerator/Freezer/Storage Room Temperature Logs: a. February 2023 Freezer 2 with holes in the log for 2/04/23 and 2/05/23. b. February 2023 Freezer 3 log with blanks in the record for 2/04/23 and 2/05/23. c. March 2023 Freezer 2 with temperatures recorded from 3/01/23 0 3/21/23. d. March 2023 Freezer 3 log with temperatures recorded from 3/01/23 - 3/21/23. e. June 2023 Kitchen 1 freezer with temperatures recorded from 6/01/23 - 6/21/23. f. Undated refrigerator log with temperatures recorded from the 1st to the 22nd of the month. On 7/12/23 at 4:22 p.m. the ED reported she had submitted all the temperature logs she could find. She had no kitchen cleaning documentation to submit. During an interview on 7/18/23 at 1:11 p.m. the ED reported she had been in contact with the Dietician. There is a lack of competency in the kitchen. There is education planned next Tuesday on types of diets and how to follow the menu. She explained the kitchen staff may have been documenting the refrigerator and freezer temperatures and the kitchen cleaning and throwing the monthly sheets away at the end of the month. She expects the staff to serve the correct resident diets, with the correct portion sizes following the menu extensions. She expects the kitchen staff to serve food at the correct temperatures for food safety and follow all kitchen sanitary practices for meal service and maintain a sanitary kitchen. The Displaying the Menu Policy, dated 2021, directed the daily menus will be posted daily in an area where patients/residents and visitors can see them. The Procedure detailed daily menus will be clearly posted outside each dining area on a menu board. The Accuracy and Quality of Tray Line Service Policy, dated 2021, outlined all meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. The Procedure directed the menu extensions display food items and amounts for each regular or therapeutic diet. The director of food and nutrition services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. Staff will refer to the meal identification (ID) card/ticket for food dislikes, allergies, and other details and substitute appropriately for those items. Each meal will be checked for: a. Correct name, room number, and diet order and accuracy of following the therapeutic diet extension, proper portion sizes, and food and beverage preferences, allergies, and intolerances. General Guidelines for Food Safety Refrigerator/Freezer Temperatures, dated 2021, directed the following: a. Take the internal temperatures of each unit. b. Periodically, take internal temperatures of foods in the unit. c. Consistently schedule a plan to take the internal temperature of cooling foods to assure proper cooling. d. If temperatures are not acceptable (refrigerators should be 41° F or less and freezers should be 0° F or less), call immediately for repair. Assess safety of foods in the unit and discard any questionable foods. Transfer safe foods to a temperature-controlled refrigerator/freezer. Dishwashing: a. Be sure the wash and rinse temperatures are appropriate for the dish machine (see manufacturer's information). b. Document temperatures regularly on a temperature log. c. Use one staff person to load dirty dishes and another to pull clean dishes. d. Air dry. Use drying racks if needed; do not stack dishes immediately before or after washing. e. Silverware - special guidelines: run silverware through twice (once with silverware spread out on a dish rack and once with bowls of the silverware upright in a holder). Train staff to pull silverware without touching mouthpieces with their hands. Prevent Cross Contamination and Employee Contamination: a. Preparation: avoid the temperature danger zone (TDZ), prevent cross contamination and employee contamination. b. Hot holding: greater than 135° F, cover and stir often. c. If food drops less than 135° F, reheat to 165° F for minimum of 15 seconds. The Food Storage Policy, dated 2021, specified: a. Refrigerated food storage: a. All refrigerator units should be kept clean and in good working condition at all times. Refrigerators/freezers on nursing units should be supplied with thermometers and monitored for appropriate temperatures. b. All freezer units should be kept clean and in good working condition at all times. Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. (See Sample Freezer and Refrigerator Temperature Forms on the following pages.) Check for proper functioning of the unit at the same time. Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid. c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. General Food Preparation and Handling Policy, dated 2021, directed the following: a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. b. Staff will handle utensils, cups, glasses, and dishes in such a way as to avoid touching surfaces that food or drink will come in contact with. c. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food. The Food Temperatures Policy, dated 2021, directed the following: the temperatures of all food items will be taken and properly recorded prior to service of each meal. The Procedure listed the following: a. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135° F. b. Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. c. Hot food items may not fall below 135° F after cooking, unless it is an item which is to be rapidly cooled to below 41° F and reheated to at least 165° F (for a minimum of 15 seconds) prior to serving. Caution should be taken to avoid serving food and liquids at temperatures that are too hot to avoid the risk of burns. d. All cold food items must be stored at a temperature of 41° F or below. 3. Temperatures should be taken periodically to assure hot foods stay above 135° F and cold foods stay below 41° F during the holding and plating process and until food leaves the service area. The Handling Cold Foods for Tray Line Policy, dated 2021, detailed proper cold food temperatures will be maintained during meal service. Milk will be placed on ice to chill it for use at meal service. Cold food temperatures will be taken and recorded prior to and halfway through service to assure foods are less than or equal to 41° F. Food Safety and Sanitation Policy, dated 2021, specified all local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services. Hair restraints are required and should cover all hair on the head. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination. The General Sanitation of Kitchen Policy, dated 2021, outlined the food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The Procedure defined the following: a. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. b. Tasks will be assigned to be the responsibility of specific positions. c. Frequency of cleaning for each task will be defined. d. Methods and materials/cleaning compounds to be used for cleaning/sanitizing will be written for each task. e. Employees will be trained on how to perform cleaning tasks. The Bare Hand Contact with Food and Use of Plastic Gloves Policy, dated 2021, specified Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. The Procedure directed the following: a. Staff will use good hygienic practices and techniques with access to proper hand washing facilities (available soap, hot water, and disposable towels and/or heat/air drying methods). Antimicrobial or antiseptic gel will not be used in place of proper hand washing techniques. b. Staff will use clean barriers such as single-use gloves, tongs, deli paper, and spatulas when handling food. c. Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. d. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single use gloves. e. Clean barriers such as single-use gloves are to be used when: 1. Handling ready-to-eat foods. 2. Handling raw meat, poultry, raw eggs, fish, and shellfish. 3. Preparing foods such as meatloaf or meat salads. 4. Hand tossing salad, mixing coleslaw, potato or macaroni salad. 5. Bagging bread or cookies. 6. Anytime hands would otherwise touch food DIRECTLY. f. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Cleaning Dishes/Dish Machine Policy, dated 2021, specified all flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The Policy further outlined staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures. Those machines installed after the Food Code 2001 was implemented must automatically dispense detergents and sanitizers, and must incorporate visual means or other visual audible alarm to alert the user to any concerns (such as the soap or sanitizer not dispensing properly). The Cleaning and Sanitation of Dining and Food Service Areas Policy, dated 2021, defined the food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The Procedure directed the following: a. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. b. Tasks shall be designated to be the responsibility of specific positions in the department. (See sample forms). c. Staff will be trained on the frequency of cleaning, as necessary. d. The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. (See sample forms). e. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. (See Sample Cleaning Schedule on the following pages.) f. Staff will be held accountable for cleaning assignments. Policy & Procedure Manual Chapter 5: Cleaning Instructions.

Based on observation, staff and resident interviews, record review and policy review the facility failed to complete an investigation into the cause of skin tear for Resident #12's right forearm that occurred on 6/22/2022. The facility also failed to implement interventions to prevent the reoccurrence in the future. The facility reported a census of 32 residents. Findings include: During an observation on 7/18/22 at 2:57 PM Resident #12 was sitting in her recliner, multiple bruises to arms observed and a white dressing in place to her right upper forearm/elbow. During an interview on 7/18/22 at 2:57 PM Resident #12 revealed she received the skin tear when she almost fell a few weeks ago. She stated a Certified Nursing Aide (CNA) grabbed her to prevent her from falling. Record review of Resident #12's Progress Note dated 6/22/22 at 12:38 PM, documented a skin tear to Resident #12's right elbow was identified. The facility applied Steri-Strips (medical tape to hold skin in place) and a nonstick Telfa (medical dressing used to cover wounds) and wrapped with Kerlix (bandage roll to secure and protect the dressing). Resident #12's Progress Note dated 6/22/22 at 6:13 PM, documented the primary care provider (Doctor) noted the skin tear to the right elbow and treatment initiated per protocol. Record review on 7/21/22 of Resident #12's Assessments completed by facility staff lacked investigation and future interventions into cause of the skin tear identified on 6/22/22. Record review on 7/21/22 of Resident #12's Progress Notes lacked investigation and future interventioons put in place for the cause of the skin tear identified on 6/22/22. Interview on 7/21/22 at 8:56 AM with the facility Administrator and Director of Nursing (DON) revealed they completed an untitled Incident Report for Resident #12 on 7/20/22 and dated for 6/22/2022. It was revealed they completed interviews with employees and Resident #12 on how the skin tear occured on 6/22/22. Policy review of a policy titled, Skin Management Program with a revision date of 02/2019 documented the following direction to staff: a. Establish individual intervention needed to promote and/or prevent alteration in skin integrity b. Comprehensive Skin and Positioning Evaluation will be completed: upon admission, quarterly, annually, and with significant change in status or with new alteration in skin integrity excluding bruises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and staff interview the facility failed to follow the manufacturer's directions for use of a mechanical lift for safe transfer for one of 1 of 3 residents reviewed, (Resident #20). The facility identified a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 5 indicating a severe cognitive loss. The Resident required extensive assistance of two with transfers and bed mobility. The MDS listed a diagnosis of cerebrovascular accident (CVA), hemiplegia (paralysis of one side of the body) or hemiparesis (weakness or the inability to move on one side of the body) and Non-Alzheimer's Dementia. The Care Plan revised 6/16/21 directed Resident #20 required a full mechanical lift with use of a large divided leg sling. The sling may stay on while in wheelchair for safety as removing/placing sling while in wheel chair creates fall risk due to impaired sitting balance. During an observation on 7/19/22 at 1:15 p.m. Staff A and B, Certified Nursing Assistants (C.N.A.s), completed a wheelchair to bed transfer using the Volaro mechanical lift with a blue hoyer sling. Staff B attached the upper loops and lower loops of the lift sling to the Volaro lift (mechanical lift) J hooks (J hook are hooks that allow a lift sling to attach to the mechanical lift). Staff A walked around the resident's wheel chair and tugged on the sling loop attachments to ensure the loops were firmly attached to the lift. Staff A and B transferred Resident #20 from the wheel chair to the bed. After the resident had been lowered onto the bed it was revealed the right bottom leg strap was connected by a blue loop and the left bottom leg strap was connected by a black loop. The black and blue loops were approximately 8 inches different in length which could cause the resident to be uneven in the sling during movement. Staff A stated the loop placement had not been correct and it could cause a potential hazard (with the mechanical transfer). During an interview on 7/20/22 at 1:18 p.m. Staff C, C.N.A. stated she had received mechanical lift training on the Volaro lift just about 6 weeks ago. She stated if a resident is transferring from the wheelchair to the bed, the blue loops are the best lower looper to hook onto the J hooks on the lift. She stated the same color of loops have to be used on both sides of the lift sling upper and lower. During an interview on 7/20/22 at 1:21 p.m. Staff D, Registered Nurse, reported the aides received training on the Volaro lift just a few weeks back after newer slings were ordered. She stated the same color of loop are to be used on the lower part of the sling. If a black loop is used on one side and a blue loop is used on the other side it could cause an imbalance with the resident in the lift which could cause problems. During an interview on 7/20/22 at 3:22 p.m. the Administrator and the DON reported they would expect the staff to use the same loops on the bottom of the lift sling following the (Volaro) manufacturer's directions for use. The Volaro Series 4 Lift PC450/HD450 Operator ' s Manual, dated 3/2019, page 8, documents the loops on the straps are color coded to match each side in positioning the sling to the desired location. Make sure you use the same color loop on the J hook directly across from each other to keep the sling even. Changing the orientation of these loops will change the angle of the person being transferred.