Based on observation, resident and staff interviews, record review and facility policy review the facility failed to remove facial hair on a female resident who required assistance with Activities of Daily Living (ADLs) for one (1) of 78 residents observed on initial tour. Resident #44. Findings Include: Record review of the facility policy titled, Resident Hygiene revised 06/2022 revealed .Standard It is the practice of this facility to assist residents with bathing/showering to maintain proper hygiene and help prevent skin infections. Bathing includes washing the entire body, in addition, resident's fingernails and toenails will be trimmed when needed, facial hair shaved when needed and hair washed as needed Staff Responsibilities .7. Staff providing assistance will provide nail care (unless medically contraindicated), shampoo, and shave each resident on every bath/shower day . On 4/30/24 at 9:39 AM, an observation of Resident #44 lying in her bed revealed six (6) to eight (8) scattered facial hairs approximately three (3) inches long on her chin and some facial hair above her upper lip that was approximately one-half to one inch long. On 4/30/24 at 9:42 AM, an interview with Resident #44 revealed that no one had removed the hair from her face, and she would like the hair to be gone. She stated, That would be wonderful if someone would. On 4/30/24 at 4:55 PM, an observation revealed scattered facial hair to Resident #44's chin and upper lip. On 4/30/24 at 5:00 PM, an interview with Licensed Practical Nurse (LPN) #1, confirmed that Resident #44 had long facial hair to her chin and hair above her top lip. She stated, I can see it plainly. LPN #1 revealed the Certified Nursing Assistants (CNAs) were supposed to look at the residents while they gave them their baths and take care of facial hair if it was needed during that time. On 5/01/24 at 9:00 AM, an interview with CNA #1 revealed that Resident #44 was assigned to her yesterday, 4/30/2024, and she gave her a bath but did not shave her facial hair. She revealed that it was a hectic day, and she was focused on getting Resident #44 cleaned up and didn't look at or notice the facial hair. CNA #1 revealed that trimming facial hair was part of their job. She stated this was supposed to be done when they were doing resident baths and she failed to do this. CNA #1 confirmed she should have taken care of this. On 5/01/24 at 10:39 AM, an interview with LPN #2 revealed Resident #44 was confused and may not always know what was asked of her. She revealed that Resident #44 had worsening confusion and needed help with her bathing and personal hygiene. LPN #2 revealed that Resident #44 was not able to shave herself or pluck her own facial hairs. Record review of Resident #44's admission Record revealed an admission date of 1/24/2024 and that she had diagnoses that included Osteoarthritis of Knee, Muscle Weakness, Unsteadiness on Feet and Unspecified Lack of Coordination. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/02/2024 revealed under Section C, a Brief Interview for Mental Status (BIMS) Score of 11 which indicated that she had moderate cognitive deficits.

Based on record review, facility policy review and staff interviews, the facility failed to develop a Care Plan for catheter care for one (1) of four (4) residents with catheters, Resident #41. Findings include: Review of the facility's Comprehensive Care Plan policy, dated 03/2019, revealed:, Standard: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 6. The comprehensive care plan will describe at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. 9. The comprehensive care plan will include measurable objectives and timeframes to meet the needs identified in the resident's comprehensive assessment. the objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of Resident #41's care plan revealed the Focus: Resident #41 has an indwelling catheter (cath) related to (r/t) stage 3 sacral wound. Resident has a stage 4 (wound) to the left elbow. Date initiated: 10/23/19. The Desired Outcome was Resident #41 will remain free from catheter-related trauma through review dated of 01/30/2020. Further review of the Interventions/Tasks revealed there was no intervention/tasks to provide catheter care. The Interventions/Tasks only spoke to the presence of the 16 fr (french) indwelling Foley catheter with a 10 cc (cubic centimeter) bulb, keep the catheter bag and tubing below the bladder level and away from the entrance room door, monitor and document intake and output, monitor for pain/discomfort due to the catheter, monitor/record/report signs and symptoms (s/s) for Urinary Tract Infection (UTI) to the MD (Medical Doctor), and observe for s/s of discomfort on urination and frequency. On 12/11/19, at 11:00 AM, an observation during Resident #41's catheter care provided by Certified Nursing Assistant (CNA) #1 revealed CNA #1 wiped back to front along the left labia major, back to front along the right labia major and back to front between the labia minor with each step of the cleaning process to include cleansing, rinsing and drying. CNA #1 grasped the Foley Catheter at the connection to the drainage bag tubing, instead of at the catheter insertion site at the meatus, and wiped downward from the catheter insertion site three (3) times to include cleansing, rinsing, and drying the Foley Catheter tubing. On 12/11/19 at 11:10 AM, in an interview with CNA #1, CNA #1 stated she was taught to wipe back to front on females during catheter care. CNA #1 stated the catheter should be held by the connector to the drainage tubing to prevent the catheter from being pulled out during care. Record review of the Medication Review Report dated 12/11/19, revealed Resident #41 had an order for an indwelling catheter for wound/skin protection due to a stage 3 sacral wound. The start date for the order was 10/23/19. On 12/11/19 at 4:00 PM, an interview with the Assistant Director of Nursing (ADON), revealed Registered Nurse (RN) #1 was responsible for care plans, so the ADON could not speak to care plans. On 12/11/19 at 4:07 PM, an interview with Registered Nurse #1, (RN) confirmed there was no catheter care intervention for cleaning Resident #41's Foley catheter included on the care plan and the catheter care should be care planned. Review of the admission Record for Resident #41 revealed the resident was admitted by the facility, on 10/22/19, with a primary diagnosis of Encounter for Orthopedic Aftercare Following Surgical Amputation, and secondary diagnoses to include but not limited to Acquired Absence of Left Leg Above Knee, Unspecified Severe Protein Calorie Malnutrition, Pressure Ulcer of Sacral Region Stage 3, and Urinary Tract Infection. Record review of the Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 10/29/10, revealed a Brief Interview for Mental Status Score of 99, and the Cognitive Skills for Daily Decision Making was coded a 3, which indicated severe cognitive impairment, never or rarely made decisions. The MDS also revealed Resident #41 was coded for the presence of an indwelling catheter (which included a suprapubic catheter and/or nephrostomy tube) .

Based on observation, record review, staff interview and facility policy review the facility failed to provide catheter care in a manner to prevent the possibility for a Urinary Tract Infection (UTI) for one (1) of four (4) residents reviewed with catheters, Resident #41. Findings include: Review of the facility's statement on letterhead, dated 12/11/19, revealed, The Perineal Care standard dated May 2014 is the Policy and Procedure for Perineal Care. Review of the Perineal Care Standard, revised May 2014, revealed: Perineal Care, for a female resident: a. Using washcloth/personal wipes, clean in a downward motion (front to back) and from center to thighs (center to side to side). b. Separate labia with non-dominant hand to expose urethral and vaginal openings; and wash area downward from front to back using clean surface of washcloth for each swipe. Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three (3) inches. On 12/11/19 at 11:00 AM, an observation revealed Resident #41's catheter care was provided by Certified Nursing Assistant (CNA) #1. CNA #1 wiped back to front along the left labia major, back to front along the right labia major and back to front between the labia minor with each step of the cleaning process to include cleansing, rinsing and drying. CNA #1 grasped the Foley Catheter at the connection to the drainage bag tubing, instead of at the catheter insertion site at the meatus and wiped downward from the direction of the catheter insertion site three (3) times to include cleansing, rinsing, and drying the Foley Catheter tubing. On 12/11/19 at 11:10 AM, an interview with CNA #1 revealed she was taught to wipe back to front on females during catheter care. CNA #1 stated the catheter should be held by the connector to the drainage tubing to prevent the catheter from being pulled out during care. An interview with Registered Nurse (RN) #3/Staff Education Nurse, on 12/11/19, at 12:00 PM, revealed RN #3 stated females should be wiped from front to back during catheter care and the catheter should be secured at the meatus to prevent pulling it out with the bulb inflated, which could cause stretching of the urethra and increased risk of infection. Review of the Perineal Care: Performance Checklist Female revealed,CNA #1 had completed a performance check off with an Acceptable grade conducted by RN #3 on 5/7/19. The performance evaluation included female catheter care per agency policy. Review of the Medication Review Report, dated 12/11/19, revealed Resident #41 had an indwelling catheter, for wound/shin protection due to a stage 3 sacral wound, with a start date of 10/23/19. Review of the admission Record for Resident #41 revealed the resident was admitted by the facility, on 10/22/19, with a primary diagnosis of Encounter for Orthopedic Aftercare Following Surgical Amputation, and secondary diagnoses to include but not limited to Acquired Absence of Left Leg Above Knee, Unspecified Severe Protein Calorie Malnutrition, Pressure Ulcer of Sacral Region Stage 3, and Urinary Tract Infection. Review of the Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 10/29/10, revealed a Brief Interview for Mental Status Score of 99, and the Cognitive Skills for Daily Decision Making was coded a 3, which indicated severe cognitive impairment, never or rarely made decisions. The MDS also revealed Resident #41 was coded for the presence of an indwelling catheter ( which included a suprapubic catheter and/or nephrostomy tube) .

Based on observation, staff interview, and facility policy review, the facility failed to discard out of date foods, provide proper sanitation during food handling, and properly clean cooking utensils as evidenced by expired food items in the refrigerator, prepping foods with contaminated gloves and the presence cookware with heavy grease buildup for two (2) of two (2) kitchen tours. Findings include: Review of the facility's Food Storage Labeling policy, revised 10/2019, revealed the facility will ensure the safety and quality of food by following good storage labeling procedures. Procedure 3b. revealed foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by-date or expiration date. Review of the facility's Dining Service Operational Standards for Purchasing, Cooking, and Storage policy, revised 10/2019, revealed the facility stores, prepares, distributes, and serves food under sanitary conditions to prevent the spread of food borne illness and reduce those practices that result in food contamination and comprised food safety. Procedure 6d. revealed to wash hands before handling food, after handling raw food, and after any interruption that may contaminate hands. Review of the facility's Manual Warewashing policy, revised 10/2019, revealed dining service pots and pans that cannot fit in a dish machine are cleaned and sanitized in the three-compartment sink. Procedure #2 revealed to rinse, scrape, and soak all items before washing. Procedure #3 revealed to use a brush, cloth, or nylon scrub pad to loosen remaining soil. An observation, of the kitchen on 12/9/19 at 11:20 AM, and a revisit on 12/11/19 at 11:15 AM, revealed the following out of date foods in the walk in refrigerator: One (1) five (5) pound opened Ricotta cheese container with a pinkish -orange film over the top of the cheese, expiration date 9/19 ; two (2) five (5) pound containers of Ricotta cheese with an expiration date of 11/13/19; one third of a quart of buttermilk, expiration date 12/8/19; one (1) five (5) pound container of cottage cheese, expired on 10/8/19 ; and two (2) five (5) pound containers of Pimento cheese, expired on 10-26-19. An interview, on 12/11/19 at 11:15 AM, with the Dietary Manager (DM), revealed it is everyone's responsibility to check dates, but ultimately it was her responsibility because she is the manager. The DM stated they need to be checking food expiration dates closer every day. She stated this could cause people to get sick. An observation, on 12/11/19 at 11:45 AM, with the Dietary Manager (DM) during the tray line prep, revealed the Dietary Aide (DA) prepping parsley in a large bowl that was to be placed on the lunch trays. The parsley was being stemmed. The DA stemmed several pieces of parsley with gloves on then moved to another table and picked up the tray cards and a box of plastic wrap taking them back to prep table and started prepping the parsley again. He then assisted with the tray line by placing the parsley and tray cards on the plates and picking up the plate covers. The dietary aide did not change gloves and wash his hands at any time during this process. An interview, on 12/11/19 at 11:50 AM, with the dietary aide (DA),. confirmed his gloves were not clean when he touched the parsley. He stated this could cause illness or infection. An interview, on 12/11/19 at 11:55 AM, with the DM, revealed the DA should have changed his gloves and washed his hands before touching the parsley. The DM confirmed the DA's gloves were contaminated by touching the plastic wrap and the tray cards .She stated the only thing the DA should have been doing was putting the parsley on the trays. The DM stated she felt he was just nervous. An observation, on 12/11/19 at 12:05 PM, revealed a large skillet sitting on the stove with an approximate two (2) inch ring of dark brownish black build-up around the inside of the top of the skillet and the outer sides and bottom were thickly coated with a rough black build-up. The observation also revealed five (5) large and two (2) small baking pans coated on the outside and bottom with a dark brownish build-up. An interview, on 12/11/19 with the DM, revealed the skillet and the pans should be scrubbed to remove the burned-on grease. The DM stated it is possible that some of the black buildup on the skillet could come off in the food. She also stated the build up on the skillet and pans could cause a fire during cooking.