**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that dietary staff supported the nutritional well-being of residents while respecting an individual's right to make choices about their diet for one (1) of thirteen (13) sampled residents reviewed for food preferences. (Resident #169) Findings included: On 11/12/2024 at 10:50 AM, during an interview, Resident #169 stated his primary concern about the facility was the type of food he was being served. He reported that his doctor instructed him to follow a high-protein and low-carbohydrate diet. However, he stated that since being in the facility, he was served more carbohydrates than protein. He indicated that he had complained to the Dietary Manager, leading to a temporary change, but the facility reverted to serving high-carbohydrate meals. He expressed concern that this could negatively impact his health. On 11/13/2024 at 12:10 PM, during a follow-up interview and an observation, Resident #169 described his meals for the day. He reported having pancakes, eggs, and grits for breakfast and stated that he would not eat both buns of the hamburgers served for lunch and did not want the banana pudding because he is diabetic, and it would raise his blood sugar levels. An observation of the lunch meal on 11/13/2024 revealed that Resident #169 was served two hamburgers, French fries, and banana pudding. On 11/13/2024 at 1:11 PM, during an interview, the Dietary Manager confirmed that Resident #169 had expressed his preference for high-protein and low-carbohydrate meals, which she understood to be part of the doctor's orders due to surgical incisions. She admitted that the resident's breakfast and lunch meals did not align with his meal ticket and acknowledged that her staff did not consistently follow the preferences listed for Resident #169. She attributed this inconsistency to staff not understanding high-protein diets. On 11/14/2024 at 8:20 AM, during an interview, the Administrator confirmed the facility had failed to honor Resident #169's food preferences but stated it was the facility's goal to meet his and all residents' preferences. A record review of the admission Record revealed that the facility admitted Resident #169 on 10/31/2024 with diagnoses that included Fusion of Cervical Spine, Essential Hypertension, and Type 2 Diabetes Mellitus. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/24 revealed Resident #169 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. A record review of the Registered Dietitian (RD) assessment dated [DATE] for Resident #169 revealed, Nutrition Diagnosis: 1.) Increased energy needs R/T (related to) surgical wounds .2.) Inadequate energy/protein intake .Interventions: Recommend 1.) Increase protein portions to large at meals TID (three times a day). 2.) 30 mL (milliliters) Liquid protein daily for 30 days. Record review of Resident #169's tray card dated 11/13/24 revealed Diet Order: CCD/NAS (Consistent Carbohydrate Diet/No Added Salt) High Protein .

Based on observations, staff interviews, record reviews, and facility policy reviews, the facility failed to ensure food items were stored in accordance with professional standards for food safety, as related to food items not being labeled and dated for one (1) of two (2) kitchen observations. Findings included: A review of the facility's policy titled, Food Storage Labeling with a revision date of 5/18, revealed The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the Food .Date of storage . 3. Rotation a. First In, First Out method is used to rotate food in all storage areas .Identify the food item's use by date or expiration date. Store items with the earliest use-by or expiration date in front of items with later dates . On 11/12/2024 at 10:10 AM, during an observation of the initial tour of the kitchen with the Dietary Manager, several items in the stockroom and kitchen were noted to lack open dates. These items included a six (6) pound container of rainbow sprinkles, a 16-ounce container of red shade pure food color, a 48-ounce container of Real Lemon 100% juice, a one-half (1/2) gallon of buttermilk labeled Wholesome, a clear container of seasoning salt without a date or item description, and a 32-ounce container of imitation vanilla flavor. All items were open with no open dates on the packages or containers. On 11/13/2024 at 11:47 AM, during an interview, the Dietary Manager explained that staff are required to date all open items in the kitchen. She stated that dating items indicates their shelf life and helps prevent potential outbreaks. She further stated that it is her responsibility to ensure staff adhere to this practice and that she has conducted in-service training on the importance of dating open items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and facility policy reviews, the facility failed to follow infection control practices by not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for multidrug-resistant organisms (MDRO) (Resident #3) and failed to practice hand hygiene during care for five (5) of thirteen (13) sampled residents (Residents #3, #11, #68, #70 and #216). Findings included: A review of the facility's policy titled, Suprapubic Catheter Site Care, revised 01/2024, revealed, Purpose * To maintain catheter patency. * To keep area clean and prevent infection . Procedure . 4. Perform hand hygiene and apply clean gloves . A review of the facility's policy titled, Hand Hygiene, dated 08/21, revealed, Purpose *To cleanse hands to prevent transmission of infection or other conditions. *To provide clean, health environment for residents, staff and visitors . Procedure . Indications for Hand Washing . 3. Before and after procedures. 4. Before and after applying gloves . A review of the facility's titled, Enhanced Barrier Precautions, revised 03/24, revealed, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions may involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . Resident #3 An observation of sacral wound care on 11/13/2024 at 10:31 AM, revealed that during care by Registered Nurse (RN) #1 and the Physical Therapist Assistant (PTA), neither RN #1 nor the PTA donned (put on) a gown prior to providing care. On 11/13/24 at 10:41 AM, during an interview, Registered Nurse (RN) #1 confirmed that neither she nor her assistant wore gowns while providing care. When asked if Resident #3 required EBP, RN #1 stated, No, we don't have anyone in the facility on that. On 11/13/2024 at 11:20 AM, during an interview, Licensed Practical Nurse (LPN) #2, the Infection Prevention (IP), explained residents are usually placed on contact or isolation precautions for infections, but she had just been informed by RN #1 that EBP included residents with catheters, Percutaneous Endoscopic Gastrostomy (PEG) tubes, and chronic wounds. She was unable to recall if staff had received training regarding EBPs. On 11/13/2024 at 12:15 PM, during an interview, the Director of Nursing (DON) stated that Resident #3 required the use of EBP, which the facility had not instituted. She explained that anyone performing close contact care with Resident #3 should wear a gown and gloves in accordance with EBP guidelines. She stated that an in-service was conducted by the facility in March when the Centers for Medicare and Medicaid Services (CMS) recommended the use of EBP, and it was her expectation that staff would follow these guidelines. She emphasized that not following them placed residents at increased risk for MDROs. A record review of the admission Record for Resident #3 revealed that the facility admitted the resident on 09/19/24. The resident had admission diagnoses that included Pressure Ulcer of Sacral Region, Stage 2 and Pressure Ulcer of Other Site, Unstageable. Resident #11: On 11/13/24 at 2:48 PM, during an observation of PEG tube site care provided by LPN #1, revealed LPN #1 removed the soiled dressing and proceeded to clean the site. LPN#1 did not remove her soiled gloves, perform hand hygiene, and apply clean gloves before cleaning the site. During an interview on 11/13/24 at 2:55 PM, LPN #1 confirmed that she did not remove her gloves, wash her hands, or apply clean gloves before cleaning the site. She acknowledged her actions could potentially cause the resident to develop an infection. A record review of Resident #11's admission Record revealed the facility admitted the resident on 09/23/24. The resident had diagnoses that included Parkinsonism, Dementia, and Dysphagia. Resident #68: During an observation of perineal care on 11/12/24 at 11:12 AM, with Certified Nursing Assistant (CNA) #1 revealed CNA #1 entered the room holding one pair of gloves. She did not perform hand hygiene before donning gloves, closing the privacy curtain, adjusting the bed with the remote control, and retrieving a pack of wipes from the dresser. She then proceeded with care without washing her hands. During an interview on 11/12/24 at 11:18 AM, CNA #1 admitted she did not think about washing her hands upon entering the room. She stated she performed hand hygiene in the hallway before entering but confirmed that she did not perform hand hygiene after touching the door, privacy curtains, and bed remote. CNA #1 acknowledged that her actions could result in cross-contamination, potentially causing an infection. A record review of Resident #68's admission Record revealed an admission date of 11/07/24 with diagnoses that included a Urinary Tract Infection (UTI), Nausea and Vomiting, and Encounter for Palliative Care. Resident #70: During an observation of perineal care on 11/13/24 at 11:03 AM, with CNA #1 revealed CNA #1 entered the room, washed her hands, and donned a pair of gloves. During the care, she retrieved pre-moistened wipes from a container four times, touching the container with soiled gloves. She then placed the container on the resident's bedside table. After cleaning the resident, CNA #1 applied barrier cream to the resident's perineal area and buttocks while wearing the same soiled gloves. She later changed her gloves but did not perform hand hygiene before applying clean gloves. During an interview on 11/13/24 at 11:15 AM, CNA #1 confirmed she had received training and understood that she should not touch objects with dirty gloves and should wash her hands before applying clean gloves. Record review of the admission Record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses that included Urinary tract infection and Type 2 Diabetes Mellitus. Resident #216 On 11/13/2024 at 1:21 PM, during an observation, LPN #3 was observed providing suprapubic catheter care for Resident #216. LPN #3 failed to remove or change her gloves during the entire procedure. She removed the soiled dressing, placed it in the biohazard container, cleaned the site, and applied a new dressing while wearing the same gloves. On 11/13/2024 at 1:25 PM, during an interview, LPN #3 confirmed that she did not remove or change her gloves during the procedure. She acknowledged placing the soiled dressing in the biohazard trashcan in Resident #216's room and then touching the suprapubic catheter site with the same gloves. She agreed this was a break in infection prevention protocol. A record review of the admission Record, revealed the facility admitted Resident #216 on 10/30/24. The resident had diagnoses that included Sepsis due to Methicillin-Resistant Staphylococcus Aureus (MRSA). with diagnoses including Sepsis due to methicillin-resistant Staphylococcus aureus (MRSA). On 11/13/2024 at 2:10 PM, during an interview LPN #2/Infection Preventionist (IP) verified staff are expected to follow infection prevention guidelines by changing gloves each time they are soiled and performing hand hygiene before applying new gloves. She stated that failing to do so could increase infection rates in the facility. On 11/13/2024 at 2:21 PM during an interview, the Director of Nursing (DON) stated that her expectation was for staff to clean their hands and change gloves after removing soiled dressings. She further explained that not doing so could increase the risk of infections such as UTIs and other complications due to cross-contamination.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to revise a care plan related to hospice for one (1) of 13 resident care plans reviewed, Resident #5. Findings include: A review of the facility's Care Plan Process policy, revised 08/2017, revealed, the care plan must be reviewed and revised on an ongoing basis to reflect the services provided or arranged. A review of Resident #5's comprehensive care plan, revealed a problem that addressed hospice services, with an onset date 06/03/2016, and a goal/target date of 03/05/2020. Review of Resident #5's electronic record, revealed the physician's order for hospice services was discontinued on 01/22/2020. During an interview, on 01/28/2020 at 2:16 PM, Resident # 5 stated she was no longer on hospice services. An interview on 1/28/2020 at 3:05 PM, with the Administrator, revealed Resident #5 had to be discharged from hospice related to long term admission, and she was no longer a candidate for hospice services. An interview on 01/30/2020 at 11:13 AM, with Licensed Practical Nurse (LPN) #1/Minimum Data Nurse (MDS)/Care Plan Nurse, revealed, she was aware of Resident # 5's discharge from hospice because she had consulted with the Hospice Nurse on the day of discharge. LPN #1 confirmed Resident #5's care plan had not been updated or removed related to hospice services, but she was working on that today. LPN #1 stated the policy of the facility was to update the care plan as soon as possible by entering the changes in the computer and printing out a copy for the chart. LPN #1 also stated it was important to keep the care plans updated because that was what the staff used to care for the residents.

Based on observation, staff interview, record review, and facility policy review, the failed to ensure an expired medication was removed from the medication stock, for one (1) of three (3) medication storage areas observed. Findings include: Review of the facility's Destruction of Unused, Expired or Discontinued Medications policy, dated 10/2019, revealed: All outdated, discontinued and/or recalled drugs, and all containers with illegible or no labels will be given to the Director of Nursing (DON) for proper disposition. These will be removed during monthly inspections or any other time as such are found, and will be disposed of according to policy, at least quarterly. On 01/29/2020 at 10:00 AM, during an interview and observation of the medication storage room, Licensed Practical Nurse (LPN) #3 revealed a bottle of Calcium 600 milligrams (mg)/Vitamin D, 400 tablets, with an expiration date of 07/2019. LPN #3 stated the medication should have been pulled and destroyed. The LPN #3 revealed the expired medication could cause harm to the resident, if it was given. During an interview, on 01/30/2020 at 12:58 PM, the Director of Nursing (DON) revealed the expired medications should have been pulled, destroyed, and reordered. The DON stated the expired medication may not work effectively if it is out of date. The DON revealed she checks the medication stock rooms monthly or bi-monthly. The DON stated, I missed it.

Based on observation, record review, staff interview and facility policy review the facility failed to ensure the milk and ice cream cooler were kept in a clean and sanitary condition, for two (2) of four (4) kitchen observations. Findings include: A review of the facility's Sanitation Check List policy, dated 09/2004, revealed: The sanitation checklist shall be used as a part of an ongoing program designed to ensure sanitary conditions and to correct an sanitation deficiencies found in the food service department. The sanitation check of the food service department of the storage areas would be done at least monthly by the Dietary Manager or Dietician which would included the refrigerators and freezers. Review of the facility's Cleaning Instructions Milk Cooler policy, dated 09/2004, revealed: POLICY: Equipment shall be maintained in a clean and sanitary condition. A review of the facility's Sanitary Conditions of the Food Service Department policy, dated 09/2004, revealed, the dietary manager would develop a master cleaning schedule to include what, when, who, and how the equipment in the kitchen would be cleaned. An observation, on 01/28/2020 at 10:30 AM, during the initial tour of the kitchen, revealed,. the ice cream freezer had frost and ice inside on all four (4) walls with a temperature of 32 degrees Fahrenheit (F). The ice cream freezer also had water accumulated on the plexi-glass doors. The milk cooler's thermometer was at a temperature 32 degrees (F), with several of the milk cartons frozen. The milk cooler had accumulated ice and frost on all four (4) walls inside the cooler. The top inside of the cooler had clear water droplets that had frozen. During an observation of the kitchen, on 01/29/2020 at 11:31 AM, the milk cooler temperature measured at 28 degrees (F). The milk cooler still had ice and frost accumulation on all four sides, and the top noted with frozen water droplets hanging down. Ice and frost accumulation was also still present in the ice cream freezer, and present on several ice cream cartons. The ice cream freezer temperature measured at 28 degrees (F). During an interview with the Dietary Manager (DM), on 01/29/2020 at 11:25 AM, DM revealed there were schedules in place for monthly defrosting of ice and frost build up in coolers/freezers. The DM revealed there was the ice and frost build up in the ice cream and milk coolers, and frozen water droplets hanging in the milk cooler. The DM could not produce any documentation to indicate when the milk cooler and ice cream freezer had been defrosted or cleaned.