**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to include one resident (R8) out of four residents reviewed for limited ROM in the restorative program. Findings include: On 11/13/24 at 11:52 AM R8 was observed sitting in a wheelchair with her right upper extremity resting on a wheelchair arm platform and wearing a right-hand splint. R8 was unable to respond to questions about care. On 11/13/24 at 12:44 PM R8's legal guardian reported that R8 was not receiving therapy services or exercises. Record review of the Electronic Health Record (EHR) revealed R8 admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) and aphasia (difficulty speaking) following cerebral infarction. Review of the Minimum Data Set (MDS) dated [DATE] for R8 revealed a Brief interview for Mental Status (BIMS) of not conducted resident is rarely/never understood. On 11/15/24 at 9:34 AM Certified Nursing Assistant (CNA) G was interviewed and said she did not perform any range of motion exercises with R8. Record review of R8's physical therapy Discharge summary dated [DATE] revealed Functional Maintenance Program Established/Trained = Range of Motion Program ROM to both lower extremities with straight leg raises, ankle dorsiflexion/plantar flexion, hip abduction/adduction 10-20 repetitions 1- 2 sets each 3-5 times a week. Further review of the EHR for R8 revealed no orders, care plan and/or [NAME] for a restorative ROM program. On 11/15/24 at 9:35 AM the Director of Rehab (DOR) H was interviewed and said there wasn't a formal restorative program at the facility. The DOR agreed a ROM program was recommended by R8's discharging therapist on 7/26/24. The DOR further said there was no follow through from therapy to nursing to conduct the ROM program. On 11/15/24 at 9:59 AM the Director of Nursing (DON) was interviewed and said the facility did not have a formal restorative program and that R8 was not receiving a ROM program. The DON agreed R8's discharging therapist wrote a ROM program, and the expectation was that therapy would instruct nursing on what is to be completed with the resident and that did not happen. Review of the facility policy titled Nursing Clinical Subject: Restorative Care adopted 7/11/2018 revealed in part . It is the policy of this facility to ensure that: -Restorative care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. -The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care. -Resident's restorative care requires close intervention and follow-through by physical, occupational and speech therapies and the nursing department. It also requires participation of employees for other departments. -All employees will be informed and trained regarding their responsibility and role in resident restorative care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 86 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 11/13/24 at 09:50 A.M., An initial tour of the food service was conducted with Dietary Manager C. The sole hand sink (hot and cold) water valves were observed misaligned, allowing the handles to invade the sink basin. Dietary Manager C indicated she would contact maintenance for necessary repairs as soon as possible. The garbage disposal overhead spray faucet assembly hot water supply valve was observed leaking, adjacent to the handle packing gland. Dietary Manager C indicated she would contact maintenance for necessary repairs as soon as possible. The garbage disposal overhead spray valve assembly was observed with gray duct tape and beige electrical tape covering the handle and valve assembly connection. Dietary Manager C indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The Magic Cup chest freezer was observed with accumulated ice [NAME]. Dietary Manager C indicated she would have dietary staff remove all frozen food products and defrost the chest freezer as soon as possible. The Frigidaire Freezer #6 exterior surfaces were observed soiled with accumulated and encrusted dirt and food residue. The interior door gasket was also observed soiled with accumulated and encrusted dirt and food residue. Dietary Manager C indicated she would have dietary staff thoroughly clean and sanitize the freezer unit as soon as possible. The Univex stand mixer was observed soiled with accumulated and encrusted food residue. The spindle gear assembly and backsplash were also observed soiled with accumulated and encrusted food residue. The convection oven(s) side panel was further observed soiled with accumulated and encrusted food residue and splash. Dietary Manager C indicated she would have dietary staff thoroughly clean and sanitize the stand mixer and convection oven side panel as soon as possible. The mechanical dish machine exterior surfaces were observed heavily soiled with accumulated dust and dirt deposits. Dietary Manager C indicated she would have dietary staff thoroughly clean and sanitize the mechanical dish machine exterior surfaces as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 11/15/24 at 02:00 P.M., Record review of the Policy/Procedure entitled: Freezer dated 08/31/2018 revealed under Sanitation and Defrosting Freezers: Frequency: Monthly (1) Unplug freezer of shut off circuit breaker. (2) Remove all foods from freezer and place poultry in another freezer to keep from thawing. (3) Let freezer stand several hours until ice has melted. (4) Drain and wipe up water with sponge or clean cloth. (5) Wash inside racks and fans carefully and thoroughly. Use baking soda and water (mix according to directions). (6) Clean outside with sanitizing solution. (7) When finished, plug in or turn on circuit breaker, set temperature dials, and allow freezer to return to proper temperature. (8) When freezer has returned to proper temperature (0 degrees Fahrenheit to -10 degrees Fahrenheit), replace food. (9) Freezer should be frost free. On 11/15/24 at 02:15 P.M., Record review of the Policy/Procedure entitled: Mixer dated 08/31/2018 revealed under Sanitation of Equipment: (1) Turn off machine. (2) Remove bowl and attachments. Take to pot and pan sink for cleaning. (3) Scrub bowl and attachments in hot detergent. (4) Run through dish machine of use pot and pan sanitizing sink according to procedure. (5) Scrub machine (beater shaft, bowl saddle, shell, and base). Use a sanitizing solution with a brush or clean cloth. (6) Rinse with clean water and clean cloth. (7) Allow to air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant environment effecting 86 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 11/14/24 at 12:20 P.M., A common area environmental tour was conducted with Director of Housekeeping and Laundry Services E and Director of Maintenance F. The following items were note: The facility main entrance concrete surface was observed uneven between the expansion joints. The uneven expansion joint surface measured approximately 8-12 feet-long, creating an approximate 0.5-1.0-inch-high lip between the concrete sections. Director of Maintenance F indicated he would request funding for necessary repairs as soon as possible. B-Hall (North) Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. Director of Maintenance F indicated he would install an atmospheric vacuum breaker as soon as possible. B-Hall Nursing Station: The flooring surface was observed severely worn and stained, exposing the concrete subsurface. The damaged flooring surface measured approximately 12-inches-wide by 24-inches-long and 12-inches-wide by 12-inches respectively. 2 of 8 cabinet drawers were also observed damaged and/or missing. The flooring surface wall/floor junctures and corners were further observed soiled with accumulated and encrusted dust/dirt deposits. Restroom: The commode grab bar was observed loose-to-mount and heavily corroded. B-Hall (South) The Medify Air purification unit air intake side panels were observed soiled with accumulated dust and dirt deposits, adjacent to resident rooms [ROOM NUMBERS]. Director of Housekeeping and Laundry Services E indicated she would have housekeeping staff thoroughly clean and sanitize the purification unit air intake side panels as soon as possible. B-C Hall Dining Room: 2 of 4 window screens were observed missing. 4 of 4 window well tracks were also observed heavily soiled with accumulated dirt and debris (leaves, etc.). Director of Maintenance F indicated he would replace the missing window screens as soon as possible. C-Hall (North) Beauty Shop: The desk fan was observed heavily soiled with accumulated dust and dirt deposits. The return-air-exhaust fan was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The hand sink faucet was also observed loose-to-mount. The entrance door frame and lower door surface was additionally observed (etched, scored, particulate). C-Hall (South) Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The flooring surface was also observed with flex tape covering worn and broken ceramic tiles. The damaged flooring surface measured approximately 6-inches-wide by 18-inches-long. The return-air-exhaust ventilation grill was further observed soiled with accumulated dust and dirt deposits. The entrance door frame and lower door surface was additionally observed (etched, scored, particulate). The oscillating floor fan was observed soiled with accumulated dust/dirt deposits, adjacent to room [ROOM NUMBER] (Unit Managers Office). Director of Housekeeping and Laundry Services E indicated she would have staff thoroughly clean and sanitize the oscillating floor fan as soon as possible. C-Hall The C-Hall Nursing Station flooring surface was observed severely worn and stained, exposing the concrete subsurface. The damaged flooring surface measured approximately 18-inches-wide by 24-inches-long. The desk fan was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. 4 of 8 cabinet drawers were further observed damaged and/or missing. The oscillating wall mounted fan was additionally observed heavily soiled with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor junctures and corners were further observed soiled with accumulated and encrusted dust/dirt deposits. Janitor Closet: The utility sink atmospheric vacuum breaker was observed missing the top cover. The entrance door interior surface and door frame were also observed severely (etched, scored, particulate). Soiled Utility Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. D-Hall Nursing Station: The flooring surface was observed severely worn, adjacent to the restroom. The damaged flooring surface measured approximately 6-inches-wide by 8-inches-long. 1 of 2 overhead lights were also observed non-functional within the restroom. The restroom hand sink faucet cold water valve was further observed leaking water at the valve stem perimeter. The wall/floor vinyl coving was additionally observed missing, adjacent to the restroom entrance door. The missing vinyl coving measured approximately 15-inches-long. Janitor Closet: The flooring surface was observed worn with missing ceramic tiles. The utility sink was also observed heavily soiled with accumulated and encrusted dirt/grime deposits. E-Hall Nursing Station: The flooring surface was observed severely worn exposing the concrete subsurface. The damaged flooring surface measured approximately 12-inches-wide by 24-inches-long. The restroom was also missing 1 of 2 over sink basin light bulbs. E-Hall (North) Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The commode base caulking was also observed stained and missing. Director of Maintenance F indicated he would make necessary repairs as soon as possible. E-Hall (South) Janitor Closet: The utility sink basin was observed heavily soiled with accumulated and encrusted dirt/grime deposits. The entrance door interior surface and metal frame were also observed (etched, scored, particulate). Shower Room: Three ceramic corner tiles were observed missing within the shower stall. Two ceramic corner tiles were also observed damaged. The atmospheric vacuum breaker was further observed missing on the shower wand assembly. Director of Maintenance F indicated he would make necessary repairs as soon as possible. On 11/14/24 at 03:35 P.M., An interview was conducted with Director of Maintenance F regarding the facility maintenance work order system. Director of Maintenance F stated: We have the TELS software system. On 11/14/24 at 03:45 P.M., An environmental tour of sampled resident rooms was conducted with Director of Housekeeping and Laundry Services E and Director of Maintenance F. The following items were noted: 205: The oscillating floor fan was observed soiled with accumulated and encrusted dust/dirt deposits. The drywall surface was also observed (etched, scored, particulate), adjacent to the Bed 1 headboard. The damaged drywall surface measured approximately 12-inches-wide by 30-inches-long. 207: The overbed light assembly pull string switch was observed non-functional. 216: The flooring surface was observed scuffed and black, adjacent to the four Bed 1 rubber wheel castors. 219: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed 1 headboard. The damaged drywall surface measured approximately 12-inches-wide by 18-inches-long. 220: The oscillating floor fan was observed heavily soiled with accumulated and encrusted dust/dirt deposits. On 11/15/24 at 08:15 A.M., An environmental tour of sampled resident rooms was continued with Director of Housekeeping and Laundry Services E and Director of Maintenance F. The following items were noted: 303: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 305: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. 308: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. The perimeter metal radiator cover was further observed (etched, scored, particulate). Director of Maintenance F indicated he would make necessary repairs as soon as possible. 309: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. 310: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. The desk fan was further observed soiled with accumulated dust/dirt deposits. 508: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 509: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 511: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 512: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The Bed 2 desk fan was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. 516: One acoustical ceiling tile was observed (cracked, chipped, missing), adjacent to Bed 1. The damaged ceiling tile measured approximately 18-inches-wide by 24-inches-long. On 11/15/24 at 01:30 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns. On 11/15/24 at 01:45 P.M., Record review of the Policy/Procedure entitled: Physical Environment Environmental Services Cleaning Schedule dated 07/01/2022 revealed under Policy: To establish a schedule which ensures the building and equipment is maintained in a clean and sanitary manner. All items may be cleaned more frequently, if necessary.

Based on interview, and record review the facility failed to ensure R250 a resident with a known history of PICA (an eating disorder that involves eating or craving nonfood items) from access to an object that could be swallowed and choked on resulting in the swallowing of gauze requiring an emergency procedure. Findings include: On 6/14/24 at 1:15 PM, R250 was observed resting in a specially designed reclining wheelchair in the main dining and television area. Resident with eyes open, a wandering gaze, and with a relaxed facial expression. Resident was nonverbal. Upon record review, R250 had an initial admission date of 12/12/2023 and a recent admission date of 6/7/24. R50 had the following pertinent diagnoses: Cerebral Palsy (a group of conditions that affect movement and posture caused by brain damage before birth), Antiphospholipid Syndrome (a condition that causes the immune system to attack tissues and form blood clots), Other Specified Eating Disorder, Metabolic Encephalopathy (a brain disfunction also affecting the metabolism), Cerebral Infarction (a condition in which poor blood flow to the brain causes cell death), Dysphagia, Oropharyngeal Phase (a swallowing dysfunction), Gastrostomy Status (an insertion site surgically created for a feeding tube), and Adjustment Disorder with Mixed Disturbance of Emotions and Conduct. According to Minimum Data Set (MDS) documentation entered on 6/5/24 in the electronic medical record (EMR) a cognitive assessment was not performed and included a notation that resident was severely impaired. On 6/3/24 R250 was transferred to an emergency room due to aspiration which was noted in the facility EMR. emergency room notes stated that resident was seen for evaluation of respiratory problem, and further stated: . EMS state patient bit PEG tube off 1 hour ago. Prior to EMS arrival, staff suctioned airway and noted crackles in the lungs and discoloration in the feet and hands. Further record review revealed primary diagnoses at the hospital listed as Impacted foreign body in esophagus, initial encounter. Aspiration into respiratory tract, initial encounter. PEG tube malfunction. On 6/14/24 at 3:10 PM, during interview with the Director of Nursing (DON) the 6/3/24 hospitalization was discussed: DON explained that R250 had aspirated on gauze (the gauze that had been around the PEG tube insertion site) which was found in R250's esophagus at the hospital and removed by esophagogastroduodenoscopy (EGD). The staff took precautions by keeping resident in areas where resident could be easily observed. The DON said that the potential of resident swallowing the gauze had not been considered. On 6/14/24 at 4:15 PM, care plan review revealed that the facility failed to identify interventions to prevent R250 from coming into contact with nonfood items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain orders for a suprapubic catheter (catheter inserted through the abdomen and into the bladder) and failed to ensure the catheter had a securement device (prevents pulling of catheter tubing), for one (R269) of one resident reviewed for catheter care, resulting in the potential for urinary tract infections and skin trauma. Findings include: In an observation and interview on 12/12/23 at 9:30 a.m., R269 was observed with a catheter drainage bag while seated in a wheelchair. Certified Nursing Assistant (CNA) A transferred R269 into bed to perform peri care. At this time, it was observed that R269 had a suprapubic catheter without a securement device. When queried if R269 should have a securement device in place, CNA A stated, Probably, I would think so. Review of an admission Record revealed, R269 originally admitted to the facility on [DATE] and readmitted o 12/7/23 with pertinent diagnoses which included Cirrhosis of the liver. Review of a Minimum Data Set (MDS) assessment, with a reference date of 11/27/23 revealed R269 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 7, out of a total possible score of 15. Review of a progress note with a date of 11/24/2023 at 10:00 p.m., revealed, Admit/Readmit . Resident re-admitted back to facility at 2000 (8:00 pm) . Resident admitted back via stretcher with a suprapubic catheter . Review of Physician orders revealed R269 had no suprapubic catheter orders. In an interview on 12/12/23 at 11:13 a.m., Licensed Practical Nurse (LPN) B reported there should be orders if a resident has a catheter. LPN B then reported there should be an anchor (securement device) on R269's catheter and stated, So it doesn't get pulled. In an interview on 12/12/23 at 11:17 a.m., the Director of Nursing (DON) reported orders for R269's catheter should have been started on readmission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the standards of infection control for proper PPE (personal protective equipment) use, disposal of PPE, and hand hygiene, for three residents (R65 and R269) out of a 20 sampled residents reviewed for infection control, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: R65 In an observation on 12/11/23 at 2:12 p.m., Housekeeper C exited R65's room, wore gloves and carried a wet cloth. R65's room door had a droplet precaution sign. Housekeeper C reported a gown does not have to be worn in the room because I am double masked. Housekeeper C stated, What do you want me to do? Change my gloves every time. Houskeeper C then reentered R65's room with the same gloves she exited the room with. Review of an admission Record revealed, R65 admitted to the facility on [DATE] with pertinent diagnosis which included COVID-19. Review of a MDS assessment dated [DATE] revealed R65 had no cognitive impairment with a BIMS score of 15, out of a total possible score of 15. Review of Physician orders revealed, R64 had an order, Droplet Precautions for Covid + every shift for patient monitoring for 10 Days . dated 12/7/23. R269 In an observation on 12/12/23 at 9:26 a.m., Certified Nursing Assistant (CNA) A wore a N95 mask, put on a gown, booties, gloves, and entered R269's room. CNA A did not wear eye protection and hand hygiene was not performed before application of PPE. Review of an admission Record revealed, R269 originally admitted to the facility on [DATE] and readmitted o 12/7/23 with pertinent diagnoses which included COVID-19. Review of a MDS assessment dated [DATE] revealed R269 had cognitive impairment with a BIMS score of 7, out of a total possible score of 15. In an interview on 12/13/23 at 1:22 p.m., the Director of Nursing (DON) reported that the required PPE for droplet precaution is a gown, N95, face shield or eye protection. The DON then reported staff should wash their hands before putting on and removing PPE. Review of a Droplet Precaution policy updated on 2/22/21 revealed, It is the policy of this facility that Droplet Precautions shall be used in addition to standard precautions for residents with infections that can be transmitted by droplets . Droplets may be generated by the resident's coughing, sneezing, talking, or during the performance of procedures . Procedure as follows: 3. A mask should be worn when entering a resident's room. 4. Eye protection should be worn when entering a resident's room (e.g., google or face shield) . Review of a Hand Hygiene policy updated on 3/24/22 revealed, It is the policy of this facility that hand hygiene be regarded as the single most important means of preventing the spread of infection. Purpose: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a resident. Proper hand hygiene should be performed between services to residents . After touching a resident or the resident's immediate environment. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. To cleanse hands to prevent transmission of possible infectious material. To provide a clean, healthy environment for residents and staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R5 On 12/11/23 at 11:19 AM, R5 was observed lying in bed with nasal canula tube around the neck with oxygen machine running on 3 liters per minute. R5's oxygen tubing was observed without a label with the date (indicating the number of days in use.) On 12/12/23 at 9:25 AM R5 was observed on the side of R5's face. R5's tubing was not labeled or dated. On 12/13/23 at 10:15 AM Licensed Pratical Nurse (LPN) F confirmed R5's oxygen concentrator was set at 3 liters. When asked how many liters of oxygen should be administered to R5, LPN F stated,the machine says 3L but she is supposed to be on 2L. Review of electronic medical record, R5 orders documented, O2 @ (at) 2 liters per minute via nasal cannula every shift for monitoring and Oxygen Equipment Management-change out, date & label all tubing/bags/set ups .clean filter and wipe down machine, as applicable every night shift A review of R5's medical record revealed an admission date of 12/15/22 with pertinent diagnoses of Dementia, Anxiety Disorder, and Covid-19. According to the facility's 4/27/2018 Infection Prevention and Control Oxygen Use Policy/Procedure: It is the policy of this facility to promote resident safety in administering oxygen. Procedure: 1. The oxygen tubing is to be replaced every seven days. R40 In an observation on 12/11/23 at 11:08 a.m., R40 wore a nasal cannula and the tubing had no date to indicate the number of days the tubing was in use. Review of the electronic medical record revealed, R40 admitted to the facility on [DATE] with pertinent diagnoses which included Respiratory Failure with hypoxia, and Chronic Obstructive Pulmonary Disease (COPD). Review of a MDS assessment dated of 11/13/23 revealed R40 had cognitive impairment with a BIMS score of 8, out of a total possible score of 15 and required oxygen therapy. R40's Physicians orders dated 9/27/23 included O2 @ (at) 3L per nasal cannula for COPD every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, maintain SpO2 above 90% and Oxygen Equipment Management--change out, date & label all tubing/bags/set ups .clean filter and wipe down machine every night shift every Sun for cleaning routine. R269 In an observation on 12/11/23 at 10:38 a.m., R269 laid in bed and had a nasal cannula in the mouth. In an observation on 12/11/23 at 11:07 a.m., R269's O2 tubing had no date and the O2 concentrator was set to 5 liters per minute. Review of an admission Record revealed, R269 originally admitted to the facility on [DATE] and readmitted o 12/7/23 with pertinent diagnoses which included Respiratory Failure with hypoxia, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), and COVID-19. Review of a MDS assessment dated [DATE] revealed R269 had cognitive impairment with a BIMS score of 7, out of a total possible score of 15 and required oxygen therapy. Review of Physician orders revealed R269 did not have any orders for oxygen therapy. In an observation on 12/12/23 at 9:25 a.m., R269's O2 concentrator was set to 3 liters per minute. In an interview on 12/12/23 at 11:13 a.m., Licensed Practical Nurse (LPN) B reported R269 is on three liters of oxygen. LPN B was asked how was she aware R269 was on 3 liters of oxygen. LPN B stated, it is on the orders. LPN B was observed to review R269's Physician orders, LPN B then stated, (R269) does not have any orders. In an interview on 12/12/23 at 11:17 a.m., the Director of Nursing (DON) reported orders for oxygen use should have started when R269 admitted to the facility. The DON then reported R269 had a previous order for O2 at 4L/min for COPD, but the order was not restarted when R269 readmitted to the facility. Based on observation, interview, and record review the facility failed to obtain physician's orders for oxygen maintenance (R269), properly date and change oxygen tubing in 4 of 4 residents (R5, R40, R218, and R269) reviewed for oxygen therapy, resulting in the increased potential for lung infections, and adverse side effect from oxygen administration. Findings include: R218 On 12/11/2023 at 11:24 a.m., R218 was observed with a nasal cannula (a device used to deliver supplemental oxygen) inserted into the nostrils. R218's oxygen tubing was observed with the date of 9/24/2023. When queried, R218 was unable to recall when the last time the oxygen tubing was changed. On 12/11/2023 at approximately 11:30 a.m., Licensed Practical Nurse (LPN) E verified the oxygen tubing that R218 was dated 9/24/2023 and explained the oxygen tubing should have December date not September's. LPN E said the oxygen tubing should be changed once a week on Sunday's midnight shift. According to the electronic medical records, R218 was initially admitted into the facility on 8/24/2021 with Diagnoses of chronic obstructive pulmonary disease (COPD) and atrial fibrillation. R218's admission Minimum Data Set (MDS) with a reference date of 8/22/2023 indicated R218 cognition was intact with a BIMS (brief interview for mental status) score of 15/15. A respiratory care plan revision on 12/6/2023 documented R218 had altered respiratory functioning and/or difficulty breathing related to COPD and depending on oxygen. Review of the Physician's orders revealed Oxygen at three liters per minutes via Nasal cannula every shift for COPD and oxygen equipment management change out, date & label all tubing/bags/set ups .clean filter and wipe down machine every night shift every Sunday with a start date of 12/10/2023. Interview with the Director of Nursing (DON) on 12/13/2023 at approximately 2:30 p.m. confirmed the oxygen tubing should be dated and changed weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a care plan for a urinary indwelling catheter was implemented on admission for Resident #266 (R266) of 23 residents reviewed for baseline care plans resulting in the potential for unmet care needs. Findings include: On 01/09/23 at 02:10 PM, R266 was observed, up in dining room with am indwelling catheter bag (foley) hanging beneath wheelchair. R#266 was at table during activities with minimal interaction. During interview, R266 was alert and nonverbal. Record review revealed, a physician order written on 12/31/2022, to Change foley catheter . as need for obstruction and/or dysfunction, Maintain foley catheter .every shift for retention, Change catheter securement device .as needed . On 01/10/23 at 03:30PM LPN U was queried on R266 foley catheter. LPN U reported R266 was admitted with a foley catheter for urinary retention. Record review revealed there was no plan of care for an indwelling urinary foley catheter within the 48 hours of admission. On 01/11 23 at 12:30 PM Unit Manager (UM) T was queried regarding R266 indwelling foley and care plans. UM T explained resident R266 was transferred from hospital to facility with a foley for neurogenic bladder. UM T explained that baseline care plans for new admits should be written within 48 hours of admission. During record review, with UM T, when asked to identify care plans for the indwelling foley catheter, UM T said it was not written and she must have forgotten to develop a care plan for R266 on admission. Record review revealed, that R266 was admitted on [DATE] with the medical diagnosis that included Fracture Femur, Diabetes Mellitus , Dementia, and Unspecified Sepsis. Record review of the Minimum Data Set (MDS), dated [DATE], revealed R266 required extensive assistance with one person support for mobility, toilet use, and activities of daily living. The MDS documented R266 was admitted without an indwelling foley. However, the LPN U had acknowledged that the R266 was admitted with an indwelling foley.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform adequate catheter care for one resident (R15) out of two residents reviewed with indwelling catheters, resulting in the potential for the development of urinary tract infections (UTI). Findings include: Review of the electronic medication record documented the following medical diagnoses include multiple sclerosis (disease where the body attacks the nervous system), neuromuscular dysfunction of the bladder (no nerve and muscle function in the bladder), urinary tract infection, and extended spectrum beta lactamase resistance (antibiotic resistance). R15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R 15's Brief Interview of Mental Status (BIMS) score was a 12/15 (mildly impaired cognition). R15 required a two-person extensive assist for toileting and personal hygiene tasks. A care area for an indwelling catheter was developed due to R15 being fully incontinent. R15's Care Plan dated 12/27/22 stated, (R15) has an ADL (activity of daily living) self-care performance deficit .provide supportive care/ assistance with daily care needs as needed .encourage and/or assist resident with completion of perineum care after each void/defecation . (R15) utilizes suprapubic catheter (a tube inserted into an area above the pubis) r/t disorders of the bladder, Neuromuscular Dysfunction Of Bladder, chronic cystitis, hx of UTI's, MS .Monitor for s/sx of discomfort on urination and frequency Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview on 1/9/23 at 1:22 PM, R15 said they just came back from the hospital at the very beginning of the new year. R15 said that they have been hospitalized in the past approximately 2-3 times for UTI reoccurrence. A review of a lab document titled, Panel UTI Dx revealed a positive E. coli urinary swab result was reported on 12/18/22. E. coli is located in the intestinal tract. On 1/10/23 at 1:32 PM, R15's suprapubic catheter and perineum care were observed being performed by Certified Nursing Assistant (CNA) E and CNA F. CNA F did not perform hand hygiene prior to performing care. CNAs E and F were observed to used the same gloves to position R15 for care and then began catheter care. CNA E was observed to wash around the supra pubic catheter in a clockwise motion working from the outer portion of the skin towards the insertion cite of the catheter. This practice of suprapubic catheter care can cause bacteria from a more contaminated portion of skin to be moved to a portion of skin that is less contaminated (the catheter site) and more susceptible to infection. CNA E used the same washcloth to wash the catheter site to wash the perineum (the space between the vulva and anus). CNA E washed R15's perineum area. Without performing hand hygiene and changing washcloths, CNA E was then observed to return to the area near R15's indwelling catheter site and wash the area. In an interview with CNA E and CNA F on 1/10/23 at 1:50 PM, CNA F acknowledged that they did not perform hand hygiene after positioning the resident for care and before putting on clean gloves. CNA E acknowledged that they did not perform hand hygiene when they removed their gloves after providing care. CNA E explained how a supra pubic catheter should be cleaned and acknowledged they did not clean the catheter area using the proper technique. In an interview on 1/11/23 at 1:16 PM, the Director of Nursing (DON) said hand hygiene is to be performed before and after catheter care. The DON explained staff should use the proper technique and catheter site cleaning should be started at the catheter site and then clean going outward. The DON said improper hand hygiene and catheter care can be contributing factors in causing an urinary tract infection. In an interview on 1/11/23 at 3:00 PM the Infection Control Nurse explained that when providing perineum and catheter care nursing staff should use separate wash clothes for each area being cleaned. In addition the Infection Control Nurse said when cleaning the catheter site, nursing should perform hand hygiene and change gloves as appropriate.

Based on observation, interview and record review, the facility failed to ensure procedures for the Controlled Medication Shift Change Log were followed on 2 of 5 units., resulting in the potential for loss or diversion of resident controlled medications. Findings include: On 01/10/23 at 12:31 PM, during observation of medication administration with LPN U on North B Hall, the Controlled Medication Shift Change Logs (CMSCL) were not completed. The CMSCL sections were blank in sections for cards containers, count sheets, and nurse signatures. On 01/10/23 at 12:54 PM, during interview, the Director of Nursing (DON) was queried regarding the blank areas on the Controlled Medication Shift Change Log. The DON said, nurses should sign and the count should be completed on the sheet. The DON also stated, Unfortunately, they did not fill those areas in. At this time the DON was asked for B North medication sheets. The Controlled Medication Shift Change Log sheets for Unit Med B North were reviewed with the DON. The following discrepancies were identified: Unit Med Cart B North, was missing sections for counts and nurse signatures on the Controlled Medication Shift Change Log from 12/1/22 through 1/2/23. On 12/1 at 7 A (0700), 12/2 at 7P (1900) Total # of Count Sheets section was left blank. On 12/3 at 7 A (0700) Total # cards/Containers section was blank. On 12/3 at7P (1900), 12/5 7A (0700), Total # of Count Sheets section was blank. On 12/24 at 3A (0300) Total # cards/Containers was marked 29 and Total # of Count Sheets section was 29. The quantity of six narcotics were added to the controlled log. However, it was not reflected on the count sheet. The following shift on 12/24 at 8P (2000) Total # cards/Containers repeated the count of 29 and the Total # of Count Sheets section were blank. On 12/27 at 7A (0700) Total # cards/Containers were blank. The next shift on 12/27 at 7A, for each section with Date, Shift time, On Nurse/ Witness 2, Total # cards/Containers and Total # of Count Sheets were blank. Record review revealed two log sheets with the same dates of 12/28 and 12/29 for Unit/Med Cart B North with discrepancies in card counts and count sheets. One of the log sheets card/containers and count sheets sections were documented at 11. The other log sheet had the same date with counts documented at 32. Further review revealed, on 12/28 at 3A (0300), 12/28 at 7A (0700) and 12/28 at 7P (1900) the Total # of Count Sheets section was blank. On 12/29 at 7A (0700) the Total # cards/Containers section was blank, and Total # of Count Sheets section was blank. On 12/29 at 7P (1900) Off Nurse/Witness 1 section was blank. On 12/29 at 7A (0700) the Total # cards/Containers section was blank, and Total # of Count Sheets section was blank. On 12/31 at 7A (0700), 12/31 at 7P (1900), 1-1 at 7P (1900) the Total # of Count Sheets section was blank. 01/10/23 at 2:38 PM during observation and record review with LPN V revealed two sheets for (facility name) unit/med cart E, 2023. LPN V said that cart E had two narcotic drawers and two log sheets. One sheet was for the upper drawer and one sheet for the lower drawer. One sheet on cart E revealed on 1/8/23 at 7PM (1900), 1/8 at 7A (0700), 1/9 at 7P (1900), Total # cards/Containers section was Blank, and Total # of Count Sheets section was blank. The other log sheet on cart E revealed on 1/8 at 7PM (1900), 1/9 at 7AM (0700) Total # cards/Containers section was Blank, and Total # of Count Sheets section was blank. On 1/9 7PM (1900) card count, sheet count and off going signature were blank. During interview, LPN V was queried to explain the procedure for the Controlled Medication Shift Change Log sheet. LPN V said, the leaving nurse and coming on nurse count medications together verifying the number of medication cards and medication sheets for each shift. LPN V was queried regarding the blank sections on logs sheets. LPN V said that she did not know the reason the sections were blank without count and signatures. Review of the facility policy/procedure titled, Medication Administration, Controlled Medication adopted 07/11/2018, documented in part, . 8. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit. 9. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing Services immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00124750. Based on interview and record review, the facility failed to ensure an evening snack was consistently offered to three residents (#'s 7, 16, 52) of six residents reviewed for meal frequency, resulting in dissatisfaction and the potential for unmet resident care needs. Findings include: It was reported to the State Agency that residents were not being offered a snack at night. On 1/9/2023 beginning at 10:27 AM, Resident #7 (R7), Resident #16 (R16), and Resident #52 (R52) were individually and separately interviewed regarding meal frequency. These interviews yielded the following comments: - R7 stated, I haven't been getting a snack at night. - R16 stated, I get a snack sometimes, when I ask for it. - R52 said he does not get offered a snack at night. During an interview on 1/9/2023 at 4:39 PM, Licensed Practical Nurse (LPN) R stated, There is a snack tray available in the kitchen (in the evening) for residents that want a snack but do not have (a designated) snack with their name on it. We don't go person to person offering snacks. During an interview on 1/10/2023 at 2:23 PM Registered Dietitian (RD) M said it is her opinion that snacks should be offered to everybody. RD M stated, It is better to offer an HS (evening) snack to everybody. A review of the Resident Council meeting minutes of 10/20/2022 documented a concern with evening snack availability as follows: multiple residents report small evening snack portions, lack of options and sometimes not being offered a snack. A review of R7's admission Record documented an initial admission date of 11/21/2014 and readmission date of 12/23/2022. R7's diagnoses included schizoaffective disorder and atherosclerotic heart disease. A Minimum Data Set (MDS) assessment dated [DATE] documented moderate cognitive impairment, upper extremity impairment on one side, and one-person limited assistance for eating. R7 was prescribed a regular diet with mechanical soft texture. A review of R16's admission Record documented an initial admission date of 10/28/2021 and readmission date of 11/20/2022. R16's diagnoses included diabetes mellitus-type 2 and end stage renal disease. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R16 was prescribed a renal 3g potassium, 2g sodium, 80g protein diet with regular texture. A review of R52's admission Record documented an initial admission date of 8/24/2021 and readmission date of 7/16/2022. R52's diagnoses included chronic obstructive pulmonary disease and atrial fibrillation. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R52 was prescribed a regular diet with regular texture. During an interview on 1/11/2023 at 1:33 PM, the Nursing Home Administrator (NHA) indicated an evening snack was important because of the length of time between dinner and breakfast the next day. The NHA stated, If any resident asks for a snack, they should get it. On 1/11/2023 at approximately 5:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to perform proper hand hygiene and glove use during catheter care for one resident (R15) out of one resident reviewed for catheter infection control practices, resulting in the potential for cross contamination during catheter care. Findings include: On 1/10/23 at 1:32 PM, Certified Nursing Assistant (CNA) E and CNA F were observed performing personal care on R15. CNA E and CNA F performed hand hygiene and put on gloves to postion R15 for personal care. CNA F got clean water and wash clothes prepped for care. CNA E and CNA F initiated personal care. CNA F cleaned the catheter site and perineum. CNA F and CNA E finished R15's care and dressed R15 into a new undergarment. CNA E positioned R15 in a comfortable position with the call light in reach. CNA E and CNA F degloved and performed hand hygiene. In an interview with CNA E and CNA F on 1/10/23 at 1:50 PM, CNA Facknowledged that they did not performed hand hygiene and change gloves after they positioned the resident for care, prior to providing care, and after care was provided. CNA E acknowledged that they did not change gloves and perform hand hygiene prior to providing personal care and after providing personal care. In an interview on 1/11/23 at 1:16 PM, the DON said they expected hand hygiene to be performed before and after catheter care. In an interview on 1/11/23 at 3:00 PM, the Infection Control Nurse said when cleaning the catheter site, nursing staff should perform hand hygiene and change gloves as appropriate. A record review the policy titled Handwashing dated 8/29/2018 documented, Use alcohol-based hand rub .before and after contact with a resident .before and after handling an invasive device .before moving from a contaminated body site to a clean body site during resident care .after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide fresh water at bedside for three residents (R35, R44 and R49) and ensure one resident (R38) maintained a fluid restriction as ordered by the physician, of four residents reviewed for hydration, resulting in the potential for dehydration, abnormal lab values, and/or electroyte imbalances. Findings include: R35 On 1/9/2023 at 9:57 a.m., R35 was observed in the room alert and interviewable. During an interview, R35 stated, A couple of days ago I pressed my button (call light) trying to get some water. I finally got water later about 6 am on that morning on the midnight shift. They didn't give me any cold water until I asked for it, then it took hours. R35 was unable to recall the time cold water was requested or whether fresh water was provided on any prior shift. A foam water cup, labeled 1/9/2023 MN (denoting midnight shift) was observed on the resident's overbed table. The cup was less than 1/4 full and was room temperature to the touch. When R35 was asked about drinking water independently if it were available, R35 demonstrated the ability to reach the water cup to drink water without assistance. During an observation and interview on 1/10/2023 at 12:44 p.m., a water cup observed on the resident's bedside table, dated 1/9/2023 MN, was less than 1/4 full and was room temperature to the touch. R35 stated, No one brought in fresh water yet. According to R35's electronic medical record, R35 was admitted into the facility on [DATE] with diagnoses of muscle weakness and hypertension. R35's quarterly Minimum Data Set (MDS) assessment with a reference date of 12/20/22 indicated R35 was cognitively intact with a BIMS (brief interview for mental status) score of 15. A review of a 12/30/2022 Dehydration care plan revealed, (R35) had dehydration or potential fluid deficit related to poor intake, rectal bleeding . -Goal: (R35) will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor (a decrease in skin turgor is a late sign of dehydration). Review of lab results from a Comprehensive Metabolic Panel Laboratory, dated 12/27/2022, documented the following results: BUN (blood urea nitrogen) level of 73 with a normal reference range of 7 - 22. R38 On 1/9/2023 at 10:15 a.m., R38 was observed lying in bed alert and refused to be interviewed. An undated water cup was observed on the bedside table half filled with dark liquid. No water cup observed in R38's room. According to R38's electronic medical record, R38 was admitted into the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. R38's admission MDS assessment with a reference date of 11/11/22 indicated R38 had moderate cognitive impairement with a BIMS score of 11, was an extensive two-person assist for transfer, and extensive one-person assist for bed mobility. R38 required set up and supervision for meals/eating. Review of an undated Dehydration care plan revealed, (R38) has fluid overload (too much consumption of water can lead to fluid overload) or potential fluid volume overload related to kidney failure. -Goal: (R38) will comply with diet and /or fluid restrictions daily. -Interventions: Fluid restriction as prescribed. Encourage and monitor resident adherence. Report to medical provider as needed. Review of the physician's orders dated 11/11/2022 revealed, 1500 Milliliters (ml) fluid restriction (1200 milliliter from dietary and 300 milliliters from nursing every shift for end stage renal disease with hemodialysis. On 1/10/2023 at 12:44 p.m., a cup with approximately 480 ml of water was observed at R38's bedsided labeled 1/10/2023 MN. On 1/10/2023 at 3:36 p.m., Certified Nursing Assistance (CNA) P and CNA Q were interviewed in the hallway outside of R38's room regarding water pass for the residents. CNA P stated, We passed water in the morning. We get here at 7:00 a.m. and are here until 7:00 p.m. CNA Q stated, Me and (CNA P) were doing the set together technically. room [ROOM NUMBER] (R38) should not have water at bedside because he goes to dialysis. I don't believe he is supposed to have it because of his fluid restriction. I can check to see if he is supposed to have it at bedside. CNA Q walked into R38's room and observed a water cup filled with water within R38's reach and took the water cup away and stated to R38, You are not suppose to have it. R44 On 1/9/2023 at 10:20 a.m., R44 was observed lying in bed alert with a water cup at bedside labeled 1/9/2023 MN. R44 did not want to be interviewed. According to R44's electronic medical record, R44 was admitted into the facility on [DATE] with diagnoses of cerebral infarction and dysphagia. R44's quarterly MDS assessment with a reference date of 10/5/22 indicated R44 had no documented BIMS score. R44 required set up and supervision for meals/eating. Review of an undated Dehydration care plan revealed, (R44) has dehydration or potential fluid deficit related to diuretic use. -Goal: (R44) will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. -Interventions: Educate the resident/family/caregivers on importance of fluid intake. -Invite the resident to activities that promote additional fluid intake. Offer drinks during one-to-one visits. On 1/10/2023 at 12:44 p.m., a water cup was observed at R44's bedside labeled 1/9/2023 MN. On 1/10/2023 at 3:36 p.m., CNA Q was interviewed in the hallway outside of R44's room regarding water pass for the resident. CNA Q verified that there was no fresh water passed to R44 and the water cup was not from the day shift. R49 On 1/9/2023 at 10:25 a.m., R49 was observed standing over the bed folding clothes. R49 appeared to be pleasantly confused and unable to be interviewed. No water was observed at R49's bedside or in R49's room. According to R49's electronic medical record, R49 was admitted into the facility on 1/27/2022 with diagnoses of anxiety disorder, dysphagia, bipolar disorder, and epilepsy. R49's quarterly MDS assessment with a reference date of 11/28/22 indicated R49 had severe cognition impairment with a BIMS score of 6. Required supervision and one person set up for Activities Daily Living (ADL). Review of an undated Dehydration care plan revealed, (R49) has a potential fluid deficit related to fluid shift (associated with profound changes in vascular permeability and water electrolyte imbalance). -Goal: R49 will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. -Interventions: Monitor/document/report as needed any signs and symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. -R49 has tremors and is unable to safely hold regular cup, ensure drinks are in cup with handle and lid. -R49 requires Nectar thick fluids. On 1/10/2023 at 12:44 p.m., no water cup was observed on R49's bedside table or in the room. On 1/10/2023 at 3:36 p.m., CNA P and CNA Q were interviewed in R49's room regarding water for the resident. CNA P and CNA Q verified that there was no water cup in the room, and they had not passed water to R49 for the shift. During an interview on 1/10/2023 at approximately 4:53 p.m., the Director of Nursing (DON) was asked about water pass every shift. The DON stated, Water should be passed every twelve-hour shift and as needed. Water should be at the bedside unless the resident is on a fluid restriction and I believe thicken liquid but, I would have to look at the policy. The DON said R38 is on dialysis, has a fluid restriction, and should not have water at bedside. A review of the facility's policy titled, Hydration, dated 7/11/2018, revealed the following:: It is the policy of the facility to encourage fluid intake to maintain the resident's hydration in compliance with physician orders. Purpose: - To ensure that each resident is encouraged to consume adequate fluids in order to maintain proper hydration for optimum functioning of various body systems. Procedure: -3. Fluids will be offered at a minimum of every two hours for the dependent resident, unless contraindicated. -5. Additional beverages will be distributed throughout the day, depending on physician orders and resident preference. Residents may request additional fluids and receive them, if not contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure palatability of meatloaf served to four residents (#'s 7, 16, 23, 52) of six residents reviewed for meal acceptance, resulting in dissatisfaction with the meal experience. Findings include: On 1/9/2023 at 8:56 AM, during the initial tour of the kitchen, an opened 30-pound bag of ground beef mixed with textured vegetable protein (TVP - soy meat extender) was observed in the walk-in cooler. When asked what was made from this product, Dietary Manager (DM) J said it was recently used to make a meatloaf. On 1/9/2023 beginning at 10:27 AM, Resident #7 (R7), Resident #16 (R16), Resident #23 (R23), and Resident #52 (R52) were individually and separately interviewed regarding the palatability of the meatloaf recently served in the facility. These interviews yielded the following comments: - R7 stated, I don't like it. It tastes funny. - R16 stated, The meatloaf was nasty. It was dry and crumbly. It tasted like cardboard. - R23 stated, It wasn't that good. It didn't taste right. - R52 stated, The meatloaf was terrible. It was more bread in there than meat. It didn't taste like meatloaf. During an interview and record review on 1/10/2023 at 10:49 AM, the recipe for the meat loaf was reviewed with DM J. The recipe specified the use of Ground beef 80/20 (80 percent lean beef to 20 percent fat). DM J said she was unsure if the meatloaf recipe needed to be altered based upon the meat product used. The Nutrition Facts label from the ground beef/TVP mixture documented that a four ounce serving size provided 28g (grams) of fat of which 11g were saturated fat. According to the website: https://www.nutritionvalue.org, a four ounce serving size of 80/20 ground beef provided 23g of fat of which 8.6g were saturated fat. During an interview on 1/10/2023 at 2:23 PM Registered Dietitian (RD) M said she had no knowledge of the facility using a ground beef/TVP product for the facility residents. RD M stated, I wouldn't care for that if she went to a restaurant and ordered meatloaf but found out the kitchen used ground beef/TVP product instead of 100% ground beef. In terms of the kitchen preparation, RD M stated, I would want them to use what the recipe called for. I support doing better with the meatloaf and meat products. A review of R7's admission Record documented an initial admission date of 11/21/2014 and readmission date of 12/23/2022. R7's diagnoses included schizoaffective disorder and atherosclerotic heart disease. A Minimum Data Set (MDS) assessment dated [DATE] documented moderate cognitive impairment, upper extremity impairment on one side, and one-person limited assistance for eating. R7 was prescribed a regular diet with mechanical soft texture. A review of R16's admission Record documented an initial admission date of 10/28/2021 and readmission date of 11/20/2022. R16's diagnoses included diabetes mellitus-type 2 and end stage renal disease. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R16 was prescribed a renal 3g potassium, 2g sodium, 80g protein diet with regular texture. A review of R23's admission Record documented an admission date of 12/6/2021. R23's diagnoses included diabetes mellitus-type 2 and schizophrenia. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R23 was prescribed a regular diet with regular texture. A review of R52's admission Record documented an initial admission date of 8/24/2021 and readmission date of 7/16/2022. R52's diagnoses included chronic obstructive pulmonary disease and atrial fibrillation. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R52 was prescribed a regular diet with regular texture. A review of Resident Council meeting minutes documented concerns with food palatability on 10/20/2022 as follows: lack of seasoning on meals; the vegetables are sometimes undercooked and that the French fries are soggy. During an interview on 1/11/2023 at 1:33 PM, the Nursing Home Administrator (NHA) stated, Maybe the (meatloaf) recipe should have been tweaked after the way people responded to it. On 1/11/2023 at approximately 5:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/10/23 at 9:41 AM, the cover for the radiant heater was observed hanging off the heater exposing the radiant heater piping. During an interview on 1/10/23 at 9:42 AM, Maintenance Director I from a sister facility said that the radiant cover should be on the radiant heater. Also, Maintenance Director I explained that hot water travels through the piping of the radiant heater, allowing heat to come out of the vent. The exposed piping could cause harm to residents. During an interview on 1/11/23 at 9:44 AM, the facility's Maintenance Director G said that it was not okay for the cover to be off the heater. It could have caused too many safety hazards (cuts and burns) for the resident residing in the room. Based on observation, interview, and record review, the facility failed to 1.) maintain clean and sanitary bathroom flooring; 2.) ensure that there were no chipped paint and scuff marks on the bathroom doors and walls; 3.) ensure there were no missing bathroom floor tiles in resident's rooms (214, 215, 216, 217, 219, 220, and 221) on Unit B, and 4.) ensure the vent cover was placed securely over the heating/cooling unit in room [ROOM NUMBER], of 23 rooms reviewed for the enviroment, resulting in an unsafe, unsanitary, and uncomfortable environment for the residents. Findings include: On 1/9/2023 at 11:00 a.m. and on 1/10/2023 at 2:34 PM during a tour of the facility on Unit B, the bathroom of resident's rooms 214, 215, 216, 217, 219, 220, and 221 were observed with sticky substances and dark dirty areas on the floor. The bathrooms also had chipped paint and scuff marks on the doors and walls. In the bathroom of room [ROOM NUMBER] a white high raised toilet seat leaning against the wall was observed with dust and yellow stains resembling urine and missing floor tiles. On 1/10/2023 at 2:44 p.m., during an interview Housekeeper C stated, I am a regular on this unit and the bathroom floors have been like this for years. The high raised toilet seat, we housekeepers don't clean, the CNA (Certified Nursing Assistance) are supposed to clean the toilet seats because it's been sitting there for a long time. Housekeeper C verified the bathrooms had been cleaned already for the shift. Housekeeper C demonstrated mopping the bathroom floor of room [ROOM NUMBER]. Housekeeper C was asked to demonstrate her technique used to mop the floors. Housekeeper C prepared the water with cleaning solution and attached a light grey mop pad onto the mop handle. During Housekeeper C's mopping demonstration, the dark and sticky substances on the floor were being removed with each stroke. Housekeeper C was asked to mop the silver colored floor transition strip at the entrance of the bathroom. The dark and sticky areas on the transition strip were removed after Housekeeper C completed the demonstration. Housekeeper C was asked to confirm the color of the mop pad after completing the demonstration and said it was black. On 1/10/2023 at approximately 4:55 p.m., during an interview, Housekeeping Director (HKD) D stated, Mopping is to be done daily in every resident's room and as needed. I haven't been here long, about two months or so. I do walking rounds every day on every unit. I did notice the bathroom floors have been neglected. Some of the cleaning products are not working. I am trying to find a good cleaning product to clean properly and train staff on stripping and waxing. On 1/10/2023 at approximately 5:55 p.m., the Director of Nursing (DON) stated during an interview, Housekeepers clean the toilet seats, but I will have to check to see who cleans the high raised toilet seats. For the bathroom floors, my expectation for housekeeping is to mop the bathroom floors daily. On 1/10/2023 at approximately 6:05 p.m., a HKD D was asked to provide a deep cleaning environmental schedule. On 1/11/2023 at 2:30 p.m., HKD D presented a B unit housekeeping daily work area schedule and stated, This is what we are using now. Review of facility document titled, B Unit Housekeeping Daily Work Area schedule documented the following: -Start of Shift: All resident rooms .bathroom, toilet, sink, mirror, sweep and mop . A review of the facility's policy, Environmental Services, dated 3/8/2021, revealed the following: Environment Cleaning: -Thorough scrubbing/disinfecting shall be done for all environmental surfaces that are being cleaned in-patient care areas. -In patient care areas, cleaning of non-carpeted floors and other horizontal surfaces (e.g., bedside tables), shall be done daily. -Cleaning schedules and procedures for all patient rooms, corridors, nursing stations and other areas shall be maintained in the Department of Environmental Services.

Based on observation, interview, and record review, the facility failed to: 1. Ensure food items past the use-by-date were not stored with active food stock; 2. Ensure proper storage, sealing, and date-labeling of perishable food; 3. Ensure the walk-in cooler floor and walls were properly cleaned; 4. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, cooked chicken and tomato soup; 5. Ensure wire storage racks were in good condition and cleanable; 6. Ensure a screen was installed in an opened window; 7. Ensure pans and lids were clean and allowed to air dry before stacking and storage; and 8. Maintain kitchen steam tables and dish tank areas in a clean and sanitary condition. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 1/9/2023 at 8:56 AM, during the initial tour of the kitchen the following was observed: An opened 44-ounce container of prune juice with a use-by-date of 12/11/2022 was observed in the cook's cooler. Dietary Manager (DM) J stated, It should have been thrown away. The following was observed in the walk-in cooler: - A 30-pound bag of ground beef mixed with textured vegetable protein (TVP) was opened and not date labeled with an opened date and discard date. The ground beef/TVP was observed unsealed and exposed to the refrigerator air. - A plastic storage bag of approximately 2 1/2 pounds of shredded cheese was not date labeled with an opened date and discard date. - A wall in the walk-in cooler was stained with multiple streams of a black colored substance. DM J described the substance as some type of mold and stated, It needs to be cleaned. Something dripped down and was never cleaned up. - The perimeter of the walk-in cooler floor and the area where wall baseboards might be installed were covered with food debris, dirt, and what appeared to be mold. - A third size pan of sweet and sour chicken and a third size pan of tomato soup were cooked on 1/8/2023. DM J said there should be cooling logs for the chicken and tomato soup but was unable to provide documentation that these items were cooled properly. - The protective covering on multiple storage racks was missing in several areas and the exposed metal was rusted. The following was observed in the walk-in freezer: - A 3 ½ quart container of chicken and dumplings was labeled with a use-by-date of 11/13/2022. Near the mechanical dishwasher area, an exterior unscreened kitchen window was opened approximately four to five inches. DM J said there should be a screen at the window if it is open. The shelves and floor underneath the mechanical dishwasher were covered with a chalky white substance. The following was observed in the clean pot and pan area: - Two 1/2-size pans were wet and nestled with clean pans. - Two full-size pans contained food debris and were nestled with clean pans. - Three solid steam table lids of varying sizes, a full size, 1/2 size, and 1/3 size, contained food debris and were nestled with clean lids. On a return visit to the kitchen on 1/9/2023 at 10:40 AM the following was observed regarding the kitchen's two sets of steam tables: - The shelf underneath one steam table was stained with what DM J described as lime scale. - The shelf underneath the other steam table was stained with grease and food debris. DM J stated, They should be cleaned. During an observation and interview on 1/10/2023 at 4:03 PM, areas of the exhaust vent of the kitchen dish machine were noted to be sealed using foil tape. (A product used for taping joints and seams in duct work for ventilation systems.) However multiple areas of the foil tape were peeled back from the surface of the vents rendering the surfaces not smooth and easily cleanable. Maintenance Director G said the foil tape observed on the exhaust vents of the kitchen dish machine needed to be replaced. During an interview on 1/11/2023 at 1:01 PM DM J stated, When I arrived here two weeks ago, there was no cleaning schedule. (Kitchen staff) were not completing end of the day (cleaning) tasks. DM J said her expectations for date-labeling were to label and date every time something is opened. Regarding the floor in the walk-in cooler, DM J stated, There is a half tile missing and the rest is dirt and mold. DM J said the whole dish room needs to be wiped down and scrubbed. It needs a thorough deep cleaning. (The shelving underneath the mechanical dishwasher) is calcified water that has accumulated from not being wiped down. During an interview on 1/11/23 at 1:33 PM Nursing Home Administrator (NHA) said she was unaware of the condition of the kitchen storage racks and that foil tape was being used on the exhaust vents of the dish machine. A review of the 2013 FDA Food Code documented the following: - Section 3-101.11: Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. - Section 3-501.14: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135ºF (Fahrenheit) to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. - Section 4-601.11: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. - Section 4-903.11: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. - Section 6-201.11: Except as specified under § 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. - Section 6-202.15: Except as specified in (B) and (E) of this section, if the windows or doors of a food establishment, or of a larger structure within which a food establishment is located, are kept open for ventilation or other purposes or a temporary food establishment is not provided with windows and doors as specified under (A) of this section, the openings shall be protected against the entry of insects and rodents by: (1) 16 mesh to 25.4 mm (16 mesh to 1 inch) screens; (2) Properly designed and installed air curtains to control flying insects; or (3) Other effective means. On 1/11/2023 at approximately 5:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to ensure proper working order of a walk-in freezer and the outlet pipe for an ice machine was protected against contamination from sewage or other sources of contamination, potentially effecting all residents in the facility. Findings include: On 1/9/2023 at 8:56 AM, during the initial tour of the kitchen, a mound of ice was observed on a box of puff pastry in the walk-in freezer. Mounds and pieces of ice were observed on the three shelves underneath the box of puff pastry. On 1/10/2023 at 9:00 AM during an observation and interview regarding the ice machine with Maintenance Director G, the drain line from the ice machine was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). Maintenance Director G said, I will rectify that ASAP. During an interview on 1/11/2023 at 1:01 PM, Dietary Manager J described the sizes of the ice formed on the box of puff pastry as the size of a football, the ice formed on the lower shelves were of varying sizes similar to the size of a softball, baseball, with several smaller broken off pieces of ice. During an interview on 1/11/2023 at 1:18 PM Maintenance Director G said there was a leak of the condensate line in the walk-in freezer. According to the 2013 FDA Food Code, Section 5-202.13: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. On 1/11/2023 at approximately 5:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.