**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to implement care plan intervention related to activities of daily living (ADL) care and hydration for one (1) of four (4) sampled residents, Resident #1. Findings Included: Review of the facility's policy, Care Plans, dated 1/15, revealed, .Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care Record review of the admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD). Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. Further review revealed Resident #1 was dependent upon staff for ADL care. Record review of the Order Summary Report for Resident #1 revealed the resident had physician order listed as Increase water intake by mouth eight ounces three times daily in between meals three times a day with Start Date 8/01/24. Record review of the current Care Plan for Resident #1 revealed the resident had a 'Focus' listed as has the potential for constipation with 'Interventions' listed as 'Encourage adequate fluid intake'; she had a 'Focus' listed as 'has the potential for complications/fluid volume imbalance' with 'Interventions' listed as 'Encourage adequate fluid intake. Fluids with meals/meds, per hydration cart, and at request'; the resident had 'Focus' listed as 'has a self- care deficit due to impaired mobility' with 'Interventions' listed as 'assist with ADLs (activities of daily living) as indicated .nail care to be performed by nursing .one person assistance with eating .hygiene'. On 4/07/25 at 12:15 PM, an observation revealed Resident #1 had no water, water pitcher or water glass in their room. There was an unopened eight (8) ounce bottle of water and a half-filled gallon labeled water on the top of the resident's chest of drawers, out of reach of the resident. Resident #1 had ten (10) fingernails with a thick, grayish brown substance beneath each nail. On 4/07/25 at 12:22 PM, during an observation, the Medical Records Nurse entered the room and offered to assist Resident #1 with lunch and assisted her to drink the water in her glass. The resident's lunch tray was removed, including fluids from the room. There was no water or fluids, or container left for the resident. On 4/07/25 at 1:25 PM, an interview with the Administrator revealed she was aware that Resident #1 had bottled water in her room out of her reach and no water glass or pitcher. On 4/07/25 at 2:05 PM, an observation revealed Resident #1 did not have any water, glass or pitcher in reach. On 4/07/25 at 2:06 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed she said the staff took ice and water to residents. She reported that fluids for oral intake (PO fluids) were provided on meal trays, with medication administration and in Styrofoam cups for all residents unless contraindicated by the resident's condition based on physician orders and resident's care plan. She confirmed that the nurses were responsible for the supervision of care for assigned residents and the implementation of care plan interventions. She stated that Resident #1 received oral (PO) fluids with her breakfast tray, she was not sure how much of those were consumed. She confirmed that the resident received PO fluid with administration of medications and that Resident #1 did not have water provided during the morning of 4/07/25. She stated, We dropped the ball there with the water. She said she believed that ice and water were to be provided at 10:00 AM and 2:00 PM. She confirmed that she had not provided any other PO fluids for Resident #1 on 4/07/25 and she was not sure of the amount of PO fluids consumed by Resident #1 on 4/07/25, she stated, I can't say, I didn't give her any before lunch. On 4/07/25 at 2:30 PM, an observation revealed Resident did not have any water, glass or pitcher in reach and Certified Nurse's Aide (CNA) #1 brought a Styrofoam cup of ice water with straw to Resident #1. On 4/07/25 at 3:00 PM an interview with the Director of Nurses (DON) revealed she said that making sure residents were well hydrated was important and that she expected resident care plans to be followed because it was very important to implement interventions which were in place to address issues the residents had. She said that all nurses had access to resident care plans and all CNAs had access to resident care instructions in each resident's [NAME], which had interventions pulled from the residents' care plans. On 4/07/25 at 4:30 PM an interview with the Administrator revealed she stated that implementation of residents' care plans was very important to ensure appropriate care was provided for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care, specifically nail care, for a dependent resident for one (1) of four (4) sampled residents, Resident #1. Findings Included: Review of the facility's policy titled, A.M. Care, dated 10/09, revealed, .A.M. (Morning) Care will be given to residents daily .Procedure .10. Provide nail care as needed . Record review of the admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD).a Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. Further review revealed Resident #1 was dependent upon staff for ADL care. On 4/07/25 at 12:15 PM, an observation revealed Resident #1 had ten fingernails with thick grayish brown substance beneath each nail. On 4/07/25 at 2:30 PM, during an observation and interview, Licensed Practical Nurse (LPN) #1 reviewed the fingernails of Resident #1 and described them as dirty and removed chunks of a grayish brown substance from beneath each of the resident's fingernails with an orange stick. Resident #1 indicated she preferred her fingernails to be their length, but did not like them to be dirty. On 4/07/25 at 3:00 PM, an interview with the Director of Nurses (DON) revealed she expected staff to perform resident nail care for residents. On 4/07/25 at 4:00 PM an interview with CNA #3 revealed that personal hygiene, including fingernail care and grooming was to be provided to all residents each shift as needed. On 4/07/25 at 4:30 PM an interview with the Administrator revealed it was very important to ensure appropriate care was provided for each resident including grooming, including fingernail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to provide hydration care and services to one (1) of four (4) sampled residents, Resident #1. Findings Included: Policy review of the facility policy titled 'Water Pitchers/Water Glasses' with review date 10/09 revealed the policy stated, Each resident will be provided with ice water/tap water at the bedside .Responsibility Nursing Assistants. Record review of the admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD). Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. Further review revealed Resident #1 was dependent upon staff for ADL care. Record review of the Order Summary Report for Resident #1 revealed the resident had physician order listed as Increase water intake by mouth eight ounces three times daily in between meals three times a day with Start Date 8/01/24. During an observation on 4/07/25 at 12:15 PM, Resident #1 had no water, water pitcher or water glass in their room. There was an unopened eight (8) ounce bottle of water and a half filled gallon labeled water on the top of the resident's chest of drawers, out of reach of the resident. During an observation on 4/07/25 at 12:22 PM, the Medical Records Nurse, entered the room and offered to feed the resident lunch, and assisted the resident to drink the water in her glass. The resident's lunch tray was removed, including fluids from the room, leaving no water or fluids or container left for the resident. The resident consumed all the water in the glass. During an interview on 4/07/25 at 1:20 PM, the Director of Nursing (DON) stated that unless clinically contraindicated, all residents should have fresh water available at all times. During an interview on 4/07/25 at 1:25 PM, the Administrator revealed that she was aware that Resident #1 had bottled water in her room that was out of her reach and had no water glass or pitcher. During an observation on 4/07/25 at 2:05 PM, Resident #1 did not have any water, glass or pitcher in reach. During an interview on 4/07/25 at 2:06 PM, Licensed Practical Nurse (LPN) #1 revealed she said the staff took ice and water to residents. She reported that fluids for oral intake (PO fluids) were provided on meal trays, with medication administration and in Styrofoam cups for all residents unless contraindicated by the resident's condition based on physician orders. She confirmed that the nurses were responsible for the supervision of care for assigned residents and the implementation of care planned interventions. She stated that Resident #1 received PO fluids with her breakfast tray, she was not sure how much of those were consumed. She confirmed that the resident received PO fluid with administration of medications and that Resident #1 had not had water provided during the morning of 4/07/25. She stated, We dropped the ball there with the water. She said she believed that ice and water was to be provided at 10:00 AM and 2:00 PM. She confirmed that she had not provided any other PO fluids for Resident #1 on 4/07/25 and she was not of the mouth of PO fluids consumed by Resident #1 on 4/07/25, she stated, I can't say, I didn't give her any before lunch. During an interview on 4/07/25 at 3:00 PM, the DON revealed she said that making sure residents were well hydrated was important and that she expected resident care plans to be followed because it was very important to implement interventions which were in place to address issues the residents had. She said that all nurses had access to resident care plans and all CNAs had access to resident care instructions in each resident's [NAME], which had interventions pulled from the residents' care plans. During an interview on 4/07/25 at 4:00 PM, CNA #3 revealed that it was her understanding that fresh water was to be provided to all residents unless contraindicated at least one time each shift. During an interview on 4/07/25 at 4:30 PM, the Administrator revealed she stated that it was very important to ensure appropriate care was provided for each resident. She confirmed that providing and offering water for all residents was very important and that the facility provided ice and Styrofoam cups and straws for the disbursement of water to all residents for which there was no contraindications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to provide the resident or the Resident Representative (RR) with written notification of the bed-hold policy at the time of transfer for one (1) of one (1) sampled residents reviewed for hospitalization. Resident #18. Findings Include: Record review of a typed statement on facility letterhead, dated September 13, 2024, and signed by the Administrator revealed, (Proper name of facility) does not have a policy regarding bed holds. On 09/13/24 at 8:16 AM, during an interview with the RR for Resident #18, he stated that he did not receive a call from the Business Office Manager (BOM) or anyone from the facility regarding his father's bed hold for the hospital transfer that occurred on 09/10/24. The RR explained that no written notification or information was provided about the bed-hold process On 09/13/24 at 8:36 AM, during an interview with the BOM she revealed that she does not send out a bed-hold letter to families when residents are transferred to the hospital. She explained that residents and their families are given the bed-hold information upon admission to the facility. She stated that after each hospital transfer, she typically calls the family to notify them about the bed hold. When the State Agency (SA) requested a copy of the documented bed-hold notification in her system as proof of RR notification for Resident #18, the BOM admitted that she had not placed a note in the system. She also confirmed that she does not document bed-hold notifications in the system for any residents. On 09/13/24 at 11:02 AM, during an interview with the Administrator, she explained that the facility's procedure for notifying families of bed holds occurs upon admission. She stated that she was unaware that the facility was required to provide bed-hold notification at each hospital transfer. The Administrator acknowledged that the facility did not have a policy regarding bed-hold notifications for hospital transfers. A record review of the After Visit Summary revealed that Resident #18 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. A record review of the admission Record revealed that the facility admitted Resident #18 on 01/10/2022 with diagnoses that included Atrial Fibrillation and Heart Failure. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/24 revealed that Resident #18 had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact.

Based on staff interviews, record reviews, and facility policy review, the facility failed to implement the care plan interventions as reflected in the resident's comprehensive Care Plan related to a fall for one (1) of twenty-three (23) sampled residents. Resident #37. Findings Include: A review of the facility's policy titled Comprehensive Person Centered Care Plans, (D.3) dated 3/18, revealed, Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .Definitions .Comprehensive Person Centered Care Plan (CCP) - contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines .Procedure: .4. The Interdisciplinary Team along with the resident and /or Resident Representative will identify resident problems, needs, strengths, life history, preferences, and goals . A record review of Resident #37's care plan with a start date of 5/7/2024 revealed (Proper name of Resident #37) has the potential for falls .Intervention: Dycem to w/c (wheelchair) . A record review of Resident #37's care plan with a start date of 5/7/2024 revealed (Proper name of Resident #37) has a self care deficit .Intervention: Dycem to w/c . During an interview on 09/12/24 at 9:13 AM, Certified Nursing Assistant (CNA) #1 stated that she had not witnessed any falls during the day shift but recalled receiving a report of a fall approximately two weeks ago. She confirmed that there was not a Dycem non-slip mat in the Resident #37's wheelchair. On 09/12/24 at 9:15 AM, during an interview and observation with Licensed Practical Nurse (LPN) #3, she explained that the staff assisted the resident whenever she called and routinely asked if she needed to be repositioned, even when performing other tasks in the room. She emphasized reminding the resident to use the call light and avoid getting up without assistance. LPN #3 confirmed that there was not a Dycem nonslip mat in the resident's wheelchair. During an interview on 09/12/24 at 9:40 AM, with the Speech Therapist (ST), Director of the Therapy Department, she explained that they held weekly Interdisciplinary Team (IDT) fall meetings to review falls, assess previous interventions, and analyze the circumstances leading to each fall. She remarked, You can't stop a fall, but the purpose of these interventions is to minimize the risk and keep residents safe. The ST emphasized that failing to follow recommendations could compromise both resident and staff safety. On 09/13/24 at 9:14 AM, Resident #37 was observed asleep in her bed, with her wheelchair positioned at the bedside. There was not a non-slip mat (Dycem) noted in the resident's wheelchair as indicated as an intervention on the care plan. A record review of Resident #37's Order Summary Report with active orders as of 9/13/24, revealed an order dated 8/20/24 Skilled Physical Therapy four (4) times a week for six (6) weeks, including therapeutic exercise, therapeutic activities, neuromuscular reeducation, gait training, moderate complexity evaluation, electrical stimulation, ultrasound, and short-wave diathermy for diagnoses of Muscle Weakness (M62.81) and Difficulty Walking (R26.2). A record review of Resident #37's admission Record revealed the facility admitted the resident on 5/27/24 with diagnoses that included Unspecified Dementia, with other behavioral disturbance and Other symptoms and signs involving the musculoskeletal system. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/2/24, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Review of Section J revealed that the resident had experienced two (2) or more fall since admission without injury.

Based on observation, interview, record review, and facility policy review, the facility failed to provide timely incontinence care and oral care for one (1) of four (4) residents reviewed for activities of daily living (ADL) care. Resident #73 Findings Include: A review of the facility's policy titled A.M. Care, dated 10/09, revealed: Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants . On 09/09/24 at 11:48 AM, during an interview, the Resident Representative (RR) of Resident #73 stated that the Certified Nursing Assistants (CNAs) did not regularly brush her daughter's teeth or wash her hair. She explained that her daughter was unable to perform personal care independently and could not feed herself. The RR expressed her wish was that staff would more consistently perform these tasks. On 09/09/24 at 11:52 AM, an observation revealed Resident #73's RR brushing and flossing the resident's teeth. The resident's hair appeared short and oily. On 09/12/24 at 2:39 PM, during an interview, CNA #4 stated that ADL care, which includes perineal care, tooth cleaning, and hair care, is performed daily. She explained that if residents refuse care, the refusal is documented in the CNA book, and occasionally the nurse is notified. On 09/13/24 at 9:52 AM, during an observation and interview with Licensed Practical Nurse (LPN) #6, the Unit Manager, he explained that ADL care includes cleaning the face and brushing the teeth and should be completed before breakfast. He noted that Resident #73's hair was oily and could benefit from a wash. He emphasized that he expects CNAs to provide total ADL care. On 09/13/24 at 10:07 AM, during an interview, CNA #1 stated that she washed Resident #73's face before breakfast and would perform peri-care once the resident got up. She initially stated that she had completed all ADL care for Resident #73 but later admitted that she had not brushed the resident's teeth or washed her hair that day or week. She confirmed that both tasks should have been completed. On 09/13/24 at 1:15 PM, during an interview, the Director of Nursing (DON) confirmed that ADL care includes brushing teeth and washing hair as needed. She emphasized that CNAs are responsible for ensuring that residents' nails are clean and that all aspects of ADL care are performed. A record review of Resident #73's admission Record revealed that the facility admitted the resident on 7/28/22 with diagnoses that included Hemiplegia, Unspecified Affecting the Left Non-Dominant Side and Unspecified Intellectual Disabilities. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/29/24 revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 99, indicated the resident could not participate in the interview. Section GG of the MDS revealed that Resident #73 is dependent on staff for oral hygiene, showering, and hair care.

Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to provide urinary catheter care in a manner that prevents possible complications for one (1) of one (1) residents reviewed for urinary catheter care. Resident #18. Findings Include: A review of the facility's policy titled Catheter Care, dated 5/22, revealed, Catheter care is performed to keep the catheter insertion site clean .3. Cleanse around the area where the catheter enters the urethral meatus with an incontinent wipe in a downward motion about 4 inches . Discard soiled incontinent wipes and plastic bag appropriately. On 09/09/24 at 02:38 PM, during an observation and interview, it was noted that Resident #18 had a urinary catheter. The resident was unable to recall how long he had a urinary catheter, however, he stated that it had been for some time. A record review of Order Summary Report, with active orders as of 9/13/24, revealed Resident #18 had a physician order, dated 8/15/24, for urinary catheter and another order, with the same order date, for urinary catheter care every twelve (12) hours as needed. On 09/13/24 at 10:25 AM, during an observation of perineal care, including urinary catheter care provided for Resident #18 by Certified Nursing Assistant (CNA) #2, revealed CNA #2 used the same area of the wipe with each stroke while cleaning the resident's penis. Rather than cleaning the resident's penis with a downward stroke, CNA #2 wiped from bottom to top. CNA #2 then cleaned the urinary catheter tubing, using a back to forth motion, once again using the same area of a single wipe. On 09/13/24 at 10:53 AM, during an interview, CNA #2 admitted that he should have used a clean wipe for each stroke and cleaned from the top to bottom, while providing perineal care to Resident #18. He acknowledged that his care could possibly cause complications. On 09/13/24 at 11:14 AM, during an interview, Licensed Practical Nurse (LPN) #5, the Infection Preventionist, confirmed that CNA #2 should have used downward strokes while cleaning the resident and used clean wipes with each stroke. She emphasized that improper cleaning could lead to complications. On 09/13/24 at 1:07 PM, during an interview, the Director of Nurses (DON) stated that she expected CNA #2 to perform care correctly, as taught during in-service training. She explained that going from a dirty area to a clean area could possibly result in the resident developing a urinary tract infection (UTI) or skin irritation. A record review of Resident #18's admission Record revealed that the facility admitted the resident on 1/10/22, The resident's diagnoses included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Retention of Urine, and Urinary Tract Infection. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/24 revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in a manner to prevent the possibility of complications as evidenced by oxygen tubing that was not dated to indicate weekly oxygen tubing/nasal cannula changes and not cleaning the oxygen concentrator filter as required for one (1) of one (1) resident reviewed for respiratory care. Resident #26 Findings Include: A review of the facility's policy titled Oxygen Therapy, dated 8/14 revealed, Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress .Procedure: . 8. Change tubing weekly. 9. Date tube when changed (weekly). On 9/9/24 at 10:30 AM, during an observation of Resident #26, who was sitting in her wheelchair in her room with a nasal cannula in her nose, it was noted that the oxygen tubing was not dated. On 9/9/24 at 10:35 AM, during an observation and interview with the Director of Nursing (DON), she explained that staff should write the date on a clear plastic bag when the tubing is changed weekly. Upon inspection of the bedside table, the DON pulled out two clear plastic bags, neither of which were dated. She confirmed that the bags should have been dated and that staff are expected to check the tubing and when not in use, store it in a clear plastic bag, which should be changed weekly to maintain infection control. She added that she expects staff to clean the filter when they change the tubing. On 9/9/24 at 10:40 AM, during an interview with Licensed Practical Nurse (LPN) #4, she stated that oxygen tubing is changed weekly for infection control purposes and should be dated when changed. On 9/9/24 at 12:55 PM, during an interview and observation with LPN #4, the oxygen concentrator filter for Resident #26 was found to have a moderate amount of grey lint along the edges and support grid. LPN #4 confirmed that the filter should have been cleaned when the tubing was changed. She acknowledged that the filter had not been cleaned, citing the amount of lint as evidence. She emphasized that cleaning the filter is necessary to ensure the resident receives clean air. On 9/12/24 at 3:39 PM, during an interview with LPN #5, the Infection Preventionist (IP), he stated that the oxygen tubing is supposed to be changed weekly to prevent the buildup of bacteria and reduce the risk of respiratory infections for the resident. On 9/13/24 at 9:56 AM, during an interview with LPN #6, Unit One Nurse Manager, he confirmed that oxygen tubing should be changed every Saturday night and dated to verify it had been changed. He explained that the tubing is replaced to protect the resident from infection and that the oxygen concentrator filter should also be cleaned at the same time, as it filters the air. A record review of Resident #26's admission Record revealed the facility admitted the resident on 2/9/24. The resident's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, and Dependence on Supplemental Oxygen. A record review of the Order Summary report, with active order as of 9/1/24 revealed Resident #26 had a physician order, dated 2/9/24, to change the oxygen tubing and clean the oxygen filter every Saturday night. A record review of Resident #26's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/29/24 revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Section O indicated that the resident was receiving oxygen therapy.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure proper hand hygiene and enhanced barrier precautions were followed prior to providing care for a resident with an indwelling catheter, for one (1) of one (1) resident observed for urinary catheter care. Resident #18. Findings Include: A review of the facility's policy titled Enhanced Barrier Precautions (EBP), dated 4/24, revealed . Definition: 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in Nursing Homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g. residents with wounds or indwelling medical devices) A review of the facility's policy titled Catheter Care, dated 5/22 revealed, Catheter care is performed to keep the catheter insertion site clean .Procedure: 1. Complete perineal care. 2. Wash hands and apply gloves . A review of the facility's Hand Washing policy, dated 9/19, revealed Staff are expected to use proper handwashing techniques to prevent the spread of infection . On 9/9/24 at 2:38 PM, prior to entering the room on Resident #18, signage of resident's door was observed. The sign indicated that the resident was on Enhanced Barrier Precautions and stated that everyone entering the resident's room must clean their hands when entering and leaving the room. Further information intended for staff directed staff performing high-contact resident care activities to wear gloves and a gown. Upon entering the room, it was noted that Resident #18 had an indwelling urinary catheter. On 09/13/24 at 10:25 AM, during an observation of care provided by Certified Nursing Aide(CNA) #2, entered Resident #18's room without performing hand hygiene. Prior to beginning perineal care, CNA #2 applied gloves, however, CNA#2 did not put on a gown. During the procedure, CNA #2 did not remove his soiled gloves to open the drawer to the bedside table to retrieve additional supplies. At one point, CNA #3, who was assisting CNA #2, reminded CNA #2 to remove his gloves prior to opening the resident's closet door to retrieve a clean brief for the resident. CNA #2 removed his gloves, but failed to perform hand hygiene prior to applying clean gloves. On 09/13/24 at 10:53 AM, during an interview, CNA #2 admitted that he forgot to wear a gown and should have washed his hands prior to beginning care and after each glove change. He acknowledged that failing to wash his hands could increase the risk of infection to the resident. On 09/13/24 at 11:14 AM, during an interview, Licensed Practical Nurse (LPN) #5, the Infection Preventionist, confirmed CNA #2 failed to follow proper hand hygiene protocols. She emphasized that the CNA's failure to wear a gown and perform hand hygiene increased the risk of infection for Resident #18. On 09/13/24 at 1:07 PM, during an interview, the DON, also reiterated that by CNA #2 not wearing a gown and his lack of hand hygiene could increase the risk of infection for Resident #18, as well other residents receiving care provided by the CNA. A record review of Resident #18's admission Record revealed that the facility admitted the resident on 1/10/22, The resident's diagnoses included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Retention of Urine, and Urinary Tract Infection. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/24 revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy review, the facility failed to ensure staff washed or sanitized hands during wound care for one (1) of four (4) residents reviewed with wounds. Resident #4 Findings include: A record review of the facility's policy, Pressure Ulcer/Injury and Skin Conditions Guide for Wound Evaluation Documentation, undated, revealed, It is the practice of this facility to ensure residents with pressure ulcers receive necessary evaluation and treatment to promote healing, prevent infection . During the wound care observation, on 05/31/23 at 2:30 PM, for Resident #4, Licensed Practical Nurse (LPN) #1 removed his gloves after removing the soiled dressing but did not perform hand hygiene prior to applying clean gloves and cleaning the wound. After cleaning the wound, he did not remove the soiled gloves and perform hand hygiene prior to applying the clean dressing. On 05/31/23 at 2:55 PM, in an interview with LPN #1, he acknowledged that he did not wash his hands after removing the soiled dressing and should have washed his hands and changed gloves after cleaning the wound, before applying the clean dressing to the wound. On 05/31/23 at 3:29 PM in an interview with the Director of Nursing (DON), she confirmed LPN #1 should have washed his hands after removing the soiled dressing and applying clean gloves and should have removed his gloves and performed hand hygiene prior to applying the clean dressing. The DON acknowledged that LPN #1's actions were an infection control issue. A record review of Resident #4's Face Sheet, revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Pressure ulcer left buttock,stage 2 and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the Physician Orders, dated 05/23/23, for Resident #4 revealed, Clean stage two to left buttock with normal saline apply skin prep and cover with dry dressing daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Resident [NAME] of Rights review and staff interviews the facility failed to ensure residents had readily available and reasonable access to their personal funds on weekends. This had the potential to affect 55 of 112 residents who had funds managed by the facility. Findings Include: Record review of the facility's policy, Resident [NAME] Of Rights, with a revision date of 11/2017, revealed, .A. Facility residents shall have the right to . 22. Manage his or her financial affairs. The resident must authorize the facility in writing to manage any personal funds and the facility must ensure the resident has reasonable and ready access to those funds . On 12/05/22 at 11:16 AM, in an interview with Resident # 29, he stated that he has a trust fund at the facility, but he is not able to get money on the weekends. He stated that if he wanted money for the weekends, it would have to be requested on Friday, as the lady that disperses the money does not work on weekends. On 12/7/22 at 3:40 PM, in an interview with the Manager of Payroll and Resident Trust Accounts, she confirmed residents cannot get money on weekends. She revealed that she checks with residents on Friday before she leaves, as she would be unavailable to assist residents with their monetary requests on weekends. On 12/7/22 at 4:38 PM, in an interview with Administrator, she confirmed staff are not available on weekends to assist residents with access to their personal funds, as she was unaware that residents wanted to get money on weekends. Record review of the Statement Register for the month of December 2022 revealed Resident #29 has an active account with the facility. Record review of the Resident #29's Face Sheet, revealed the facility admitted the resident to the facility on [DATE], with medical diagnoses including Type 2 Diabetes Mellitus and Hypothyroidism. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/27/2022, revealed a Brief Interview of Mental Status (BIMS) of 09, which indicated the resident had moderate cognitive impairment. Record review of the facility's Active Patient Trust Accounts, revealed Resident #29, along with 54 other residents currently have a trust account with the facility.

Based on observation, record review, and facility and staff interviews, the facility failed to ensure a resident received services included in the plan of care related to a condom catheter for one (1) of 23 sampled residents. Resident #68 Findings include: On 12/05/22 at 11:50 AM, the State Agency (SA) observed Resident #68 lying in bed. There was a urinary catheter privacy bag attached to the bed with no urine observed in the bag. Record review of the Face Sheet revealed the facility admitted Resident #68 on 06/05/19 with diagnoses including Anoxic Brain Damage and Persistent Vegetative State. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/22 revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 3 which indicates severe cognitive impairment. Record review of Resident #68's December 2022 Physician Orders, revealed an order dated 11/14/22, Freedom (Name brand of condom catheter) Cath (catheter), leg strap and privacy bag in place each shift. On 12/05/22 at 03:34 PM, during a phone interview with the Resident Representative (RR), she explained Resident #68 previously had an indwelling catheter, but it was removed. She stated that he had a Physician's Order to wear a condom catheter, but she was told by the facility that it was on order and had not been received. Every time she has visited, she has not seen Resident #68 wearing the condom catheter.She commented that he voids frequently, and she requested a condom catheter because she felt like it would help to prevent skin breakdown. On 12/06/22 at 3:00 PM, during an interview with Certified Nurse Aide (CNA) #2, she explained Resident #68 has not worn a condom catheter for several weeks because the nurses said there were no condom catheters for him. On 12/06/22 at 3:30 PM, during an interview with the Director of Nursing (DON), she stated that it was decided to place a condom catheter on Resident #68 to keep him dry and to prevent skin break. She explained the last she heard the resident was using the condom catheter. She confirmed that Resident #68 does have a Physician's Order to wear a condom catheter. On 12/06/22 at 3:40 PM, during an observation of Resident #68 with the DON, she confirmed the resident was not wearing a condom catheter, and she had no clue that a condom catheter was not being placed on the resident. She explained she expected staff to follow the physician orders and the care plan. On 12/07/22 at 1:40 PM, during an interview with Licensed Practical Nurse (LPN) #1/Unit Manager, she explained that the purpose of the condom catheter was to keep Resident #68 dry. She stated that Resident #68 has not worn the condom catheter. On 12/07/22 at 3:00 PM, during an interview with the Administrator, she explained she was aware that Resident #68 had a Physician's Order to wear a condom catheter and there had been an issue with receiving the catheters. She stated she was not aware that the Physician's Order was not discontinued when the condom catheters were not available. She expected staff to carry out physician orders and to follow the plan of care.

Based on interview, record review, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic drugs were discontinued or documented as necessary after 14 days for one (1) of five (5) residents reviewed for unnecessary medications. Resident # 57. Findings include: A record review of the facility's policy, Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, updated 3/18, revealed . Procedure: . 3. PRN (as needed) psychotropic drugs should be limited to 14 days unless the primary physician has documentation supporting the rational in the medical record and has indicated the duration for the PRN order. 4. PRN antipsychotic drugs are limited to 14 days and cannot be renewed unless the primary physician or prescribing practitioner evaluates the resident. Record review of the December 2022 Physician Orders, for Resident #57 revealed, .Diazepam (Valium) 5 MG (milligrams) tablet give one tablet by mouth every six hours as needed .Order date 9/16/11 and Start Date 9/16/22 . The diagnosis related to the order was written as, Anxiety Disorder, unspecified, but did not include a specific duration of time for administration of the medication. Record review of Note to Attending Physician/Prescriber, dated 09/21/22, written by the Consultant Pharmacist (CP) for Resident #57 revealed, .RE: PRN Valium . Recommend discontinue PRN use of the above medication per the following federal guideline: .Orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then he/she should document the rationale in the resident's medical record and indication the duration for the PRN order On Physician/Prescriber Response section of the form, the Disagree box was checked, and the signed notation, dated 9/27/22, revealed, Pt takes medication for anxiety PRN - When scheduled routine Pt is too drowsy. Anxiety is an approved diagnosis for this med. The additional comments made by the CP revealed, - Not PRN - dx (diagnosis) irrelevant. Record review of the Face Sheet, revealed the facility admitted Resident #57 on 07/19/21. The resident's current diagnoses included with diagnoses of Major Depressive Disorder and Anxiety. Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/22, revealed that Resident #57 had a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impairment. The Medication Section of the MDS revealed that the resident had received five (5) days of an antianxiety medication during the last seven (7) days. Record Review of the December 2022, EMAR (Electronic Medication Administration Record), revealed nurse initials indicating Resident #57 had been administered Diazepam (Valium) 5 mg by mouth five (5) times in the first eight (8) days. On 12/08/22 at 1:50 PM, during a telephone interview with the CP, she confirmed that on 9/21/22, she had sent a note to the facility for the Physician/Prescriber regarding the PRN (as needed) use of Valium for Resident #57. She revealed that although the information reviewed the CMS (Centers for Medicare & Medicaid Services) regulations regarding the use of PRN psychotropic medications, she cannot make the physicians write the orders per regulations, all she can do is keep asking for their review and document her recommendations. On 12/08/22 at 2:10 PM, during a telephone interview with the Nurse Practitioner (NP), she revealed she had been unaware of the PRN regulations for psychotropic medications. She confirmed that she had received the pharmacy review regarding Resident #57 and the PRN use of Valium. The NP acknowledged the Valium order written for Resident #57 did not have an indication for continued use or duration of time for administration. On 12/08/22 at 2:30 PM, during an interview with the Director of Nurses (DON), she confirmed the Note to Attending Physician/Prescriber, revealed the specific CMS regulations for the use of PRN psychotropic medications. However, the DON acknowledged Resident #57 had an order for Valium PRN and there was no documentation regarding the indication for continued use with a specific duration of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) to include Activities of Daily Living, Pre-admission Screening Assessment Resident Review (PASARR), anticoagulant, and tube feedings for four (4) of 30 MDS assessments reviewed. Resident #84, #87, #96, and #129. Findings include: A review of the facility policy's titled MDS Assessment, dated 11/17, revealed the team member's signatures will attest to the completion/accuracy of the assessments. A review of the Resident Assessment Instrument (RAI) manual revealed the process has multiple regulatory requirements that require that the assessment accurately reflect the resident's status. Resident #84 Record review revealed Resident #84's Pre-admission Screening and Resident Review (PASARR), Level II was completed on 05/13/16, with recommendations. Review of the Annual Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 02/02/19, revealed Resident #84 was not coded to have a Serious Mental Illness in section A1500, but had a diagnosis which included Schizophrenia. Interview with Registered Nurse (RN) #1, on 07/01/19 at 10:13 AM, confirmed the Annual MDS with the ARD of 02/02/19, noted in section A1500, that Resident #84 was not evaluated by PASARR, and section A1510A was left blank for Serious Mental Illness. RN #1 confirmed the resident did have a diagnosis, which included Schizophrenia, and was checked in section 16000. RN #1 confirmed the assessment was not accurate, and that this assessment should have been coded for Serious Mental Illness. Resident #87 A review of the Physician Orders revealed an order, dated of 06/05/19, for Jevity 1.5 by Percutaneous Endoscopic Gastrostomy (PEG) tube at 45 milliliter/hour (ML/HR) continuous with 20 ML of free water flush every hour for 24 hours and total 24 hour tube intake. The physician orders also indicated nothing by mouth (NPO) and flush PEG tube with 180 cubic centimeters (CCs) of water every six (6) hours. Check residual every six (6) hours, hold if greater than 60 CCs and notify the physician. Check placement of PEG prior to medication, feedings, and flushes. Flush with 15 CCs of water prior to medications, mix each medication with five (5) CCs of water, administer one at a time flushing with 15 CCs of water between each medication. Flush with 15 CCs of water after last medication. Clean site with normal saline (NS) and cover with sponge daily. Review of the comprehensive Admission/Discharge MDS assessment, with an Assessment Reference Date (ARD) of 05/06/19, revealed the MDS was not coded to include tube feeding. The Comprehensive Care Plan, with and onset date of 05/16/19, included interventions for tube feedings. Review of the resident's Diagnosis and Allergy List indicated the resident had a diagnosis of Dysphagia following Cerebral Infarction and Encounter for Attention to Gastrostomy. On 06/30/19 at 11:00 AM, an observation revealed Resident #87 was lying in bed, awake, with the head of bed (HOB) up at least 45 degrees. He had a tube feeding of Jevity 1.5 at 45 cubic centimeter/hour (CC/HR) by a feeding pump. On 07/01/19 at 4:39 PM, an interview with Registered Nurse (RN) #4, revealed the Admission/Discharge MDS assessment, with an ARD of 05/06/19, was not coded correctly to include tube feeding, and that was an inaccurate MDS assessment. Resident #96 Record review of the MDS, with an ARD of 03/17/2019, revealed Resident #96 was limited assist with Activities of Daily Living (ADLs) with set up help only. Record review of the MDS, with an ARD of 06/4/2019, revealed Resident #96 required extensive assist with ADLs, with staff providing weight bearing assist. This assessment revealed Resident #96 had a decline in the ADLs. Record review of the Restorative Notes revealed the resident had been receiving Restorative care starting, on 02/11/2019 until present. Restorative Notes, dated 06/17/2019, revealed Resident #96 was tolerating the restorative program well without difficulty. Resident #96 was still participating in therapeutic exercises, and showing fair progress, but refused restorative care some days. Resident #96's excuse for refusing the restorative care was pain to the left leg. Pain was reported to the floor nurse each time the resident refused. Resident #96 was able to perform three (3) sets/three (3) reps of Active Range of Motion (AROM) to bilateral lower extremities with one (1) rest period after each set. Resident #96 was able to ambulate 50 feet with two (2) rest periods. Resident #96 ambulated with one (1) person assist with a rolling walker and gait belt for safety. Unsteady gait was noted. Restorative Certified Nursing Assistant (RCNA) will continue to encourage resident and focus on building stamina slowly and safely. Restorative will continue therapeutic regimen to help prevent functional decline and foster independence in self-care skills. An observation, on 07/01/19 at 9:57 AM, revealed Resident #96 was sitting in a wheelchair watching television, speech was slurred, but was able to make simple needs known. Certified Nursing Assistant (CNA) assisted Resident #96 up out of the wheelchair. The CNA assisted Resident #96 to the bathroom. Resident #96 was able to transfer to the toilet without assistance. During an interview, on 07/01/19 at 10:06 AM, the Speech Therapy (ST) Manager revealed Resident #96 was discharged from Occupational Therapy, on 05/01/2019, due to no longer requiring the skills for occupational therapy, however Resident #96 required restorative therapy. The ST Manager stated the CNAs and Resident #96 was trained on proper use of wheel chair brakes and grab bars for toilet transfers with return demonstration performed and observed by the therapist. The ST Manager also said Resident #96 was stand by assist at the time of discharge. The ST Manager said she has not seen a decline in Resident #96's status. Record review of the Care Plan revealed Resident #96 had a self-care deficit, and the potential for falls and skin breakdown related to (r/t) impaired mobility with right sided hemiplegia/ Cardiovascular Accident (CVA), Anemia, Bowel and Bladder Incontinency. Interventions included: One (1) person assist for transferring, bathing, dressing and toileting. However according to the MDS, dated [DATE], upon admission, revealed the resident was independent for transfers and required only staff supervision or touching for assistance for toileting, and the resident needed some help with dressing. During an interview, on 07/02/19 at 11:04 AM, revealed the Director of Nursing (DON) said she was not aware of this resident having a decline in the ADLs. The DON said she thought it was because the resident had a Urinary Tract Infection (UTI). The DON also said she thought the resident was getting Restorative care. The DON said the MDS was not correct. The resident is still stand by assist with ADLs. During an interview, on 07/02/19 at 12:38 PM, Registered Nurse (RN) #4/Care Plan Nurse confirmed she made a mistake on the June MDS. RN #4 said she coded the MDS according to the nurse's notes on her look back period. RN #4 said the resident is limited assist with ADLs. A review of the facility's Face Sheet revealed the facility admitted Resident #96, on 10/03/2018, with diagnoses, which included Vascular Dementia , Hemiplegia and Overactive Bladder . A review of Resident #96 Quarterly MDS, with an ARD of 6/04/2019, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitively intact. Resident #129 A review of Resident #129's MDS, with an ARD of 06/17/19, revealed documentation for an anticoagulant medication for seven (7) days under section N0410E. A review of Resident #129's Physician's Orders revealed the resident was currently on Plavix (a medication to prevent the blood platelets from sticking together and/or form a blood clot), with a start date of 01/12/18. A review of Resident #129's Medication Administration Record (MAR) revealed the resident was administered Plavix for the month of June 2019. An interview, on 07/02/19 at 9:36 AM, with Licensed Practical Nurse (LPN) #2/MDS Nurse, revealed Resident #129's MDS, with an ARD date of 06/17/19, was inaccurately coded for an anticoagulant. LPN #2 stated Resident #129 was only on Plavix, and that was an antiplatelet. LPN #2 also said the MDS was completed by a nurse that was not currently working at the facility. LPN #2 stated the policy they use was the RAI manual to guide the staff to document on the MDS.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide Resident #87's tube feeding site care in a manner to prevent the possibility of cross contamination/spread of infection. Licensed Practical Nurse (LPN) #1 failed to wipe and/or clean the feeding tube site in the appropriate direction and rotate the Normal Saline soaked gauze with each wipe, or change to a new gauze. This concern was identified for one (1) of four (4) tube feeding site care observations. Findings include: Review of the facility's policy titled, Daily Cleaning of G/J (Gastrostomy/Jejunostomy) Tube Site, dated 08/11, revealed a resident with a Gastrostomy or Jejunostomy tube will have the tube site cleaned daily. Further review of the policy revealed the Procedures did not include steps for the actual cleaning procedure related to direction of wipes and rotation of gauze to prevent contamination of the cleaned areas. Step 3. Cleanse with soap and water and dry during routine morning care or at other designated time. Step 4. If site appears red, inflamed, has drainage or the resident complains of pain at site, notify the nurse. Step 5. The nurse will notify the physician if indicated for further orders. A review of the Physician Orders revealed an order, dated 06/05/19, for Jevity 1.5 per Percutaneous Endoscopic Gastrostomy (PEG) tube at 45 milliliter (ML)/HR continuous with 20 ML of free water flush every hour for 24 hours and total 24 hour tube intake. The physician orders also indicated, nothing by mouth (NPO), and flush PEG tube with 180 cubic centimeters (CCs) of water every six hours. Check residual every six hours, hold if greater than 60 cc and notify the physician. Check placement of PEG prior to medications, feedings, and flushes. Flush with 15 CCs of water prior to medications, mix each medication with 5 CC of water, and administer one at a time flushing with 15 CCs of water between each medication. Flush with 15 CCs of water after last medication. Clean site with normal saline (NS), and cover with sponge daily. Review of the Comprehensive Care Plan, with an onset date of 05/16/19, revealed the Approaches included enteral feedings as ordered/recommended, weights per facility policy, Registered Dietician (RD) as needed, and flushes as ordered/recommended. On 6/30/19 at 11:00 AM, an observation revealed Resident #87 lying in bed awake. On 7/01/19 at 3:19 PM, an observation of Licensed Practical Nurse (LPN) #4 revealed she performed gastric tube site care. LPN #4 explained she had washed her hands and set up her supplies and barrier prior to the observation of care. Using clean gloved hands, LPN #4 removed the resident's soiled 4x4 gauze dressing, removed her soiled gloves, and applied clean gloves without washing her hands or using Alcohol Based Hand Gel (ABHG). She poured normal saline (NS) into a plastic cup that had 4x4 gauzes in it. LPN #4 took one (1) of the NS moistened 4x4 gauzes and wiped half way around the resident's gastric tube site on the left side of the tubing in a downward motion once, LPN #4 rotated the gauze, and wiped three (3) more times, without rotating the gauze, and then discarded the gauze dressing. She then retrieved another NS moistened gauze from the plastic cup and wiped the resident's gastric tube site in an upward motion on the right side of the tubing once, rotated the gauze dressing, wiped completely around the tubing, then in a back forth motion twice on the right side of the tubing. LPN #4 placed a clean dry dressing to the resident's gastric tube site, taped it in place, disposed of the soiled items, and washed her hands. On 7/01/19 at 4:23 PM, an interview with the Director of Nursing (DON) revealed the nurse should not have wiped in a back and forth motion to prevent the spread of infection.

Based on observation, record review, facility policy review, and staff interview, the facility failed to assess and evaluate Resident #61's need for assistive devices to assist with eating. This concern was identified for one (1) of eleven (11) residents assessed for nutrition. Findings include: Review of a untitled document written on the facility's letterhead, dated July 2, 2019, provided and signed by the Administrator, revealed that in this facility, through nursing observations, residents can be referred to Restorative Nursing and/or Therapy services to accommodate resident's needs. When a policy on the accommodation of needs was requested, the facility provided this document. Review of Resident #61's medical record document titled, Physician Orders, dated June 2019, revealed that an order for a Regular Puree diet with a divided plate had been in place since 01/14/13. Review of Resident #61's medical record document titled, Departmental Notes, dated 06/12/19, revealed the Registered Dietitian (RD) entered a note where she documented Resident #61 had a significant weight loss. The note indicated the RD recommended no changes to the Plan of Care (POC) be made at this time. Review of Resident #61's medical record document titled, Weight Change History, dated 06/10/19, revealed there was a 10 pound (lb.) change in the weights between 05/08/19 and 06/10/19. The document indicated that on 05/08/19, Resident #61's weight was 157 lbs, and on 06/10/19 Resident #61's weight was 148 lbs. During a dining observation of the lunch meal, on 06/30/19 at 11:45 AM, Resident #61 was spilling her food on her clothes and the table where she was seated. Resident #61 had difficulty guiding the standard sized spoon from her plate to her mouth successfully. Resident #61 was drinking from a regular glass of tea, and spilled her tea on herself. Staff members from the Dietary Department were present in the dining room, but Resident #61 did not receive any assistance from anyone with her meal. Resident#61 had four separate episodes of harsh coughing during the meal observation. During a lunch meal dining observation, on 07/01/19 at 11:23 AM, Resident #61 was present in the main dining room. A staff member from the Dietary Department, applied a protective garment around Resident #61's neck, also set up Resident #61's dining tray, opened her milk, and served her the lunch meal. Resident #61 was now using a larger sized spoon utensil to eat her meal. Resident #61 consumed about 90 percent (%) of the food on her plate, and the remaining 10% of the food on Resident #61's plate was now on the table and on her clothes. Resident #61 continued to have difficulty guiding the larger spoon utensil into her mouth, causing the food to spill. It was observed that the food spilled, because Resident #61 was attempting to scoop the food on her spoon from the side of her plate. During an interview, on 07/02/19 at 9:00 AM, the Speech Therapist (ST)/Therapy Team Leader revealed that according to Resident #61's medical records, there was no documentation the resident was spilling her food while eating. The ST stated she was unaware of Resident #61's recent weight loss. The ST stated she would see to it that Resident #61 was observed at meal times and see if there is a need for adaptive utensils to aid the resident while eating. An observation and interview, on 07/02/19 at 11:45 AM, revealed Resident #61's Occupational (OT) and Speech Therapist (ST) were present to assess the resident during the meal. Resident #61 continued to spill her food on herself. The ST and OT stated a recommendation would be made for the use of a larger and thicker divided plate, and a smaller spoon to be used by Resident #61 for better control and success with the resident's meal. During an interview on, 07/02/19 at 11:15 AM, Licensed Practical Nurse (LPN) #3/Restorative Nurse, revealed Resident #61's breakfast and lunch meals are monitored. LPN #3 stated Resident #61 had been gradually spilling more of her food for a while now. LPN #3 stated she had not reported or documented Residents #61 has had a decline in being able to coordinate her utensils and her food. LPN# 3 also stated she had not been at work for the last two (2) days. During an interview, on 07/02/19 at 11:20 AM, Registered Nurse (RN) #2 revealed she had been in the dining room for the past two (2) days to supervise and watch the residents while eating. RN #2 stated she was familiar with Resident #61, and was aware the resident often spilled her food. RN #2 stated Resident #61 had good days and bad days. RN #2 also stated someone from the Therapy Department had taken Resident #61 to the therapy gym and observed her during the lunch meal. Review of the Face Sheet revealed Resident #61 was admitted by the facility on 05/26/06, with diagnoses to include Unspecified Intellectual Disabilities and Aphasia.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to store, prepare and serve food under a safe and sanitary manner; as evidenced by failure to document freezer and refrigerator temperature checks for two (2) of three (3) days of the survey, pork chops cooked and served to the residents after being thawed in the sink without room temperature running water, and failure to maintain a 200 parts per million (ppm) sanitizer level for the 3-compartment sink for two (2) of three (3) staff observed to check the sanitizer lever. These identified concerns placed all residents who received food/nourishment from the kitchen at risk for food borne illnesses. Findings include: Review of the facility's policy titled, Guidelines for Staff Preparing Food Fundamentals to Prevent Food Borne Illness, dated 2011, noted foods should never be thawed on a counter or at room temperature. This policy noted foods are thawed in the refrigerator, under freely flowing, room temperature water or in the microwave and immediately cooked and served. Review of the facility's policy titled, EPA (Environmental Protection Agency) registered no rinse Quat sanitizer manufacturer's instructions noted the acceptable range for testing should be 150, 200, or 400 parts per million (ppm). Observations and interview during the initial tour of the kitchen, with Dietary Department [NAME] #1, on 06/30/19 at 9:10 AM, revealed pork chops thawing in the sink with no running water. The pork chops were not in any type of container, just lying in the sink. The 3-compartment sink sanitizer sink, tested zero (0) ppm on the test strip after submersion for 10 seconds. There was no documentation for the 3-compartment sink sanitizer level since the 06/28/29, morning check on the check sheet. The main freezer had no thermometer inside the freezer, only on the outside. The Equipment Temperature Log was last documented, on 06/28/19, for the morning and noon checks for the Cooler and Freezer temperatures. The Milk Coolers had no documentation for temperatures on the June 2019 Temperature Log for 06/29/19, and the AM shift for 06/30/19. Dietary Department [NAME] #1 was observed filling the 3-compartment sink with plain water, and pushing the button on the sanitizer a couple of times. Again the 3-compartment sink sanitizer tested zero (0) ppm when the strip was held for ten (10) seconds in the water solution. An interview during this time with [NAME] #1 revealed she stated when you are unable to sanitize dishes in the 3-compartment sink it could cause germs, infections and food disease for the residents. [NAME] #1 confirmed there was not any running water through the sanitizer for the 3-compartment sink, and did she did not know to do that. She stated she had been working at this facility in the kitchen for 13 years and did not know to do that until today. On 06/30/19 at 2:40 PM, an observation revealed [NAME] #1 retested the 3-compartment sink's sanitizer compartment and obtained a reading of 200 ppm. [NAME] #1 was asked about the pork chops thawing in the sink earlier in the day, and she confirmed they were in the sink and thawing. She confirmed they were baked and barbequed, and later served to the residents. [NAME] #1 stated the pork chops should have been in a strainer with water running over them, and not directly in the sink. [NAME] #1 stated she did clean the sink prior to placing the pork chops directly in the sink.