Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #76) out of 32 sampled residents and one resident (Resident #170) outside the sample. The facility's census was 163. The facility did not provide a policy. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section O0110K1, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions; - Section J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services; - Section A2105: Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. 1. Review of Resident #76's medical record showed: - An admission date of 01/24/23; - Diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), and chronic kidney disease, stage two (the kidneys are damaged and can't filter blood the way they should); - admitted to hospice on 01/12/24; - A quarterly MDS assessment, dated 10/16/24, with Section J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? marked no; - A quarterly MDS assessment, dated 01/30/25, with Section O0110K1 marked no for hospice care. 2. Review of Resident #170's medical record showed: - An admission date of 01/24/25; - Diagnoses of syncope (fainting or sudden temporary loss of consciousness) and collapse (to fall down), orthostatic hypotension (low blood pressure that happens when standing up from a sitting or lying down position) and pulmonary embolism (a blood clot in the lungs causing sudden shortness of breath and chest pain); - Resident was discharged to an assisted living facility/community on 01/29/25; - A discharge MDS assessment, dated 01/29/25, with Section A2105 marked discharge to hospital. During an interview on 03/28/25 at 2:37 P.M., the MDS Coordinator said she would expect the MDS assessments to accurately reflect the condition of the resident and/or the correct discharge/transfer status. If a resident is transferred to an assisted living, the MDS should show discharged to community. During an interview on 03/28/25 at 3:29 P.M., the Administrator and Director of Nursing said they would expect the MDS assessments to accurately reflect the condition and the discharge/transfer location of residents.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices when staff failed to perform hand hygiene during perineal care (peri care - cleaning the genital and anal area) and catheter (a tube that is inserted into the bladder, allowing urine to drain freely) care for one resident (Resident #67) out of 32 sampled residents and one resident (Resident #15) outside the sample. The facility also failed to wear proper Personal Protective Equipment (PPE) for Enhanced Barrier Precaution (EBP) during care for two residents (Resident #100 and #131) out of 32 sampled residents. The facility's census was 163. Review of the facility's policy, Handwashing/Hand Hygiene, undated, showed: - The facility recognizes that handwashing is the most effective measure for the prevention of infection and cross-contamination. All staff is to understand the importance of handwashing, knows when handwashing is indicated and knows how their hands can be washed when limited resources are available; - The purpose of this procedure is to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections; - Good handwashing behavior improves the quality of services. It reduces the chance of infection to staff and residents; - The use of gloves does not replace handwashing; - When to wash hands: When hands are visibly soiled, Before and after entering isolation precaution setting, Before and after assisting a resident with personal care, After handling soiled or used linens, dressings, bedpans, catheters, and urinals, Before and after assisting a resident with toileting, After removing gloves; - Staff may use hand sanitizer or antiseptic towelettes in between washing when not coming in contact with bodily fluids and or between glove changing, then as soon as possible, rewash hands with soap and running water. Review of the facility's policy, Using Gloves, undated, showed: - All employees are to protect the residents and themselves from contamination. Gloves should be worn when it can be reasonably anticipated that the employee may have contact with blood and other body fluids, excretions, secretions, tissues, mucous membranes, and non-intact skin. Gloves do not replace handwashing. Hands must be washed with soap and running water before and after any resident care; - Non-sterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces; - Wash hands after removing gloves (Note: Gloves do not replace handwashing); - Change gloves as often as necessary when grossly contaminated with excretions or when torn; - Gloves should be worn when handling blood specimens, blood soiled items, body fluids, excretions and secretions as well as surfaces, materials and objects exposed to them. Example: Cleansing excrement from residents and when handling or touching contaminated items or surfaces. Review of the facility's policy, Perineal Care, undated, showed: - Perineal care is very important in maintaining the residents' comfort. More frequent care is required for residents who are incontinent or those who have an indwelling catheter. Make every effort to respect the modesty of residents and be gentle when cleansing this sensitive area; - The purpose of peri care is to cleanse the peri area for the resident who is unable to or has difficulty with adequately cleaning self; prevents skin breakdown of peri area; prevents itching, burning, and odor; and prevents infection; - For a female resident: wet washcloth and apply soap or use cleansing wipes; wash perineal area, wiping from front to back; separate labia (folds on either side of the vagina) and wash area downward from front to back; continue to wash the perineum moving from the inside outward to and including thighs, alternating from side to side, and using downward strokes; (Note: if the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter); allow the area to dry; instruct or assist the resident to turn on her side with her top leg slightly bent, if able; wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttock; dry area thoroughly; expose peri area. Gently wash the inner legs and outer peri area along the outside of the labia. Note: Wash from front to back to prevent spreading fecal matter from anal area to vagina or urethra (opening to bladder). Always be very gentle when washing the area; - For a male resident: Wet washcloth and apply soap or use cleansing wipes; wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area); wash and rinse urethral area using a circular motion; continue to wash the perineal area including the penis, scrotum (a pouch of skin containing the testicles) and inner thighs; thoroughly rinse perineal area in same order, using fresh water and clean washcloth. (Note: if the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter); gently dry perineum following same sequence; instruct or assist the resident to turn on his side with his upper leg slightly bent, if able; wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks; and dry area thoroughly; - Discard disposable items into designated containers; - Remove gloves and discard into designated container. Wash and dry your hands thoroughly; - Reposition the bed covers. Make the resident comfortable; - Place the call light within easy reach of the resident; - Clean the bedside stand; - Wash and dry your hands thoroughly. Review of the facility's policy, Transmission-Based Precautions, undated, showed: - Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. They are based on the principle that that all blood, body fluids, secretions and excretions may contain transmissible infectious agents; - Enhanced Barrier Precautions (EBP) expand the use of gown and gloves beyond standard precautions and was implemented with the goal of reducing the transfer of multi-drug resistant organisms in the long-term care setting; - Transmission based precautions should only be in place for a duration of time, while EBP can remain in place indefinitely if criteria for use is met; - Proper hand hygiene remains the key preventive measure, regardless of type of transmission-based precautions employed; - The proper use of PPE as a barrier to prevent exposure to any body fluids (whether known to be infected or not); - [NAME] gloves (clean, non-sterile) as outlined: Prior to any contact with body secretions/excretions, performing treatments, personal care; change gloves after providing care and when transitioning from soiled to clean; Remove gloves before leaving the room and perform hand hygiene; After removing gloves and performing hand hygiene, do not touch potentially contaminated environmental surfaces or items in the resident's room. If so, repeat hand hygiene prior to exiting; - It is essential to communicate precautions to all health care personnel, and for personnel to comply with requirements to help minimize the transmission of infections within the facility; - A sign will be used to alert staff and visitors of precautions; - Enhanced Barrier Precautions involve the application of gown and gloves prior to performing high-contact resident care activities for residents known to be colonized or infected with a Multidrug Resistant Organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with chronic wounds defined as three months or longer or indwelling medical devices); - High-contact resident care activities include dressing, bathing/showering, transferring, personal hygiene, changing linens, device care or use (central lines, urinary catheters, feeding tubes, and wound care); - Residents will be not isolated in their rooms. Signage will be placed on the door alerting staff that EBP precautions are in place. PPE will be placed outside of the room or in closet within the unit with hand sanitizer available for staff use. Soiled linen/biohazards bins will be implemented for residents with an active MDRO infection/colonization in an area that involves secretions or excretions. 1. Observation of peri care for Resident #15 on 03/28/25 at 1:00 P.M. showed: - The resident lay in bed. Without performing hand hygiene, Certified Nurse Aide (CNA) F and CNA G donned gloves and pulled the resident's pants down; - CNA F held and positioned the resident while CNA G wiped fecal matter from the resident's peri area and buttocks, using a new wipe each time; - Without changing gloves or performing hand hygiene, CNA F and CNA G put a clean brief on and pulled the resident's pants up; - CNA G moved the mechanical lift and the resident's wheelchair with the same soiled gloves; - CNA G handed the remote for the mechanical lift to CNA F, who had removed gloves and did not perform hand hygiene; - CNA F then used the remote to lower the resident while CNA G removed gloves and, without performing hand hygiene, held the mechanical lift sling to position the resident as the resident was lowered into the wheelchair and CNA G put his/her right hand on the resident's forehead for protection from the lift; - CNA F obtained a hairbrush and brushed the resident's hair, smoothing the resident's hair with his/her hand, then touched the privacy curtain to get the resident's call light, and clipped the call light to the resident's shirt. During an interview on 03/28/25 at 1:12 P.M., CNA F said he/she should do hand hygiene before and after care. He/She carries sanitizer in his/her pocket all the time. During an interview on 03/28/25 at 1:24 P.M., CNA G said he/she does hand hygiene before and after care. He/She doesn't really do hand hygiene at any other time during care. 2. Observation of peri care and catheter care for Resident #67 on 03/28/25 at 1:20 P.M. showed: - CNA H and CNA I sanitized hands and donned gowns and gloves in the hall; - CNA H rolled the resident onto his/her left side. CNA I wiped fecal matter from the resident's buttocks using multiple disposable wipes. CNA I wiped visible fecal matter off of his/her right glove with a wipe, then finished cleaning the resident's buttocks; - With the same soiled gloves, CNA I rolled up a new bed pad to put under the resident, rolled the resident, then CNA H pulled the soiled pad out from under resident and unrolled the clean pad under the resident and CNA I positioned the resident on his/her back; - CNA H wiped around the resident's catheter insertion site with a disposable wipe, using a new wipe each time; - CNA H reached into the wipes container and the remaining wipes all came out; - CNA H then laid the wipes he/she had taken out of the container on the resident's bedside table with no barrier, then wiped with them, and folded the last wipe before he/she wiped the resident's catheter insertion site; - CNA H and CNA I removed gloves and washed hands. CNA I rolled the resident to the left to place a clean brief underneath the resident, then rolled the resident back and secured the brief; - CNA H and CNA I washed hands and both left the room with the trash. During an interview on 03/28/25 at 1:40 P.M., CNA H said he/she should wash or sanitize before and after care and when going from dirty to clean. During an interview on 03/28/25 at 1:43 P.M., CNA I said he/she messed up today. He/She should have removed gloves after wiping the resident's bowel movement and washed hands. He/She should wash or sanitize before and after care. 3. Review of Resident #100's medical record showed: - admission date of 03/16/21; - Diagnoses of Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills), congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid in the body), generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things), and seizures (sudden, temporary, bursts of electrical activity in the brain that change or disrupt the way messages are sent between brain cells). Review of the resident's Physician's Order Sheet showed: - An order for wound care to coccyx (tailbone), cleanse with stock wound cleaner, apply collagen pad (encourages the body to heal wounds quickly and effectively) to wound bed, apply skin prep (used to apply a protective film over skin that helps to prepare it for adhesives) to wound area and cover with foam dressing (a dressing that helps maintain a warm, moist wound environment that encourages proper healing) every other day, dated 02/24/25; - An order for wound care to the left heel, cleanse with stock wound cleaner, apply calcium alginate (dressing that promotes healing by preserving moisture in the wound area) cut to fit wound bed, apply skin prep to skin around wound, and cover with foam dressing every day and as need for soiling and dislodgement, dated 03/11/25. Observation on 03/28/25 at 10:45 A.M. of Resident #100's peri and wound care showed: - Registered Nurse (RN) E washed hands and donned gloves; - Without donning a gown, RN E performed wound care to the resident's left heel and coccyx; - Without donning a gown, RN E performed peri care to the resident; - Resident #100 did not have an EBP sign on his/her door or EBP supplies available outside or near his/her door. During an interview on 03/28/25 at 1:15 P.M., RN E said gowns should be worn for residents on EBP. During an interview on 03/28/25 at 1:17 P.M., RN J said he/she is responsible for putting out EBP signage and supplies. RN J said Resident #100 was not on EBP because his/her wound is not infected or draining. 4. Observation of suprapubic catheter (SPC - a type of urinary catheter inserted through a small incision in lower abdomen, above the pubic bone and directly into the bladder to drain urine) care and wound care for Resident #131 on 03/28/25 at 10:26 A.M. showed: - Registered Nurse (RN) A pushed table with barrier and supplies, including a clean, packaged gown, to Resident #131's bedside; - RN A washed hands, gloved, explained SPC care procedure, removed blanket, and pulled the resident's brief down; - RN A failed to don a gown; - RN A removed gloves, washed hands, donned clean gloves and cleaned the area around SPC with soap and water that had been placed in a small cup; - RN A removed gloves, donned clean gloves and pat-dried the area with a clean cloth; - RN A pulled the brief back up, placed soiled cloths in a plastic bag, removed gloves and washed hands; - RN A explained wound care to Resident #131 and donned clean gloves before wound care on the resident's toe; - RN A realized the gown was still in the package and donned gown; - RN A cleaned the resident's left, second toe with wound cleanser, removed gloves and washed hands; - RN A donned clean gloves, applied skin prep around wound, placed fibracol (a non-adherent, easy to remove type of dressing) dressing and two bandages; - RN A removed gown and gloves and washed hands before leaving the room. During an interview on 03/28/25 at 10:43 A.M., RN A said the EBP gowns were kept in the hall closet with the other EBP supplies because the residents are confused and get into them, if not. RN A tearfully said he/she always wears a gown and had just got ahead of himself/herself. During an interview on 03/28/28 at 3:29 P.M., the Administrator and Director of Nursing said they would expect staff to follow EBP and wear proper PPE when providing care for residents with wounds, foley catheters, suprapubic catheters, and other indwelling devices. They would also expect EBP signage and supplies to be located upon entry to the residents' rooms, and they would expect employees to perform hand hygiene during peri care and catheter care both before and after, between dirty and clean. Staff should not be touching here, there, and everywhere. When staff take gloves off, they should wash or sanitize hands.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 29 opportunities with two errors made, resulting in an error rate of 6.9% for two residents (Resident #49 and #105) out of six sampled residents. The facility's census was 168. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: - Remove cap; - Attach needle; - Prime pen by turning dose selector to two units; - Hold pen with needle pointing up, press and hold button until it stops and the zero is seen in the dose window along with visible insulin at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Review of the facility's policy titled, Administration of Insulin by Subcutaneous Injection, undated, showed it did not address insulin pens. Review of an undated letter, written by Pharmacist D, and received on 02/09/24, showed: - In terms of clinical significance, failure to prime an insulin pen would result in very little, if any, clinical impact on controlling a patient's blood sugar level; - Priming units should be required each and every time a dose is administered from an insulin pen; - Once a small bead of insulin appears at the end of the pen needle, priming should be deemed sufficient; - This instruction may or may not be always be printed on the pharmacy label but should generally be considered a best practice. 1. Review of Resident #49's Physician Order Sheet (POS), dated February 2024, showed: - An order for lispro Solution Pen 100 units per milliliter (ml) subcutaneous (an injection just below the skin) with meals per a sliding scale of blood sugar of 151-200 = 1 unit, 201-250 = 2 units, 251-300 = 3 units, 301-350 = 4 units, 351-400 = 5 units, 401-999 = 6 units and call the medical doctor (MD), dated 02/09/22. Observation of Resident #49 on 02/07/24 at 10:40 A.M., showed: - Registered Nurse (RN) A administered two units of lispro subcutaneously per order of the sliding scale for blood sugar of 201 with the resident's lispro Flex Pen; - RN A failed to prime the lispro Flex Pen per the manufacturer's instructions prior to the administration to the resident. 2. Review of Resident #105's POS, dated February 2024, showed: - An order for lispro 100 units per ml, inject 25 units subcutaneously two times a day, dated 12/14/23; - An order for lispro 100 units per ml with meals per a sliding scale of blood sugar of 151 - 200 = 3 units, 201 - 250 = 6 units, 251 - 300 = 9 units, 301 - 350 = 12 units, 351 - 400 = 14 units, 401 - 999 = call the MD, dated 12/14/23. Observation of Resident #105 on 02/07/24 at 10:48 A.M., showed; - RN A administered 25 units of lispro, with no sliding scale, as blood sugar was below 151, with the resident's lispro Flex Pen; - RN A failed to prime the lispro Flex Pen per the manufacturer's instructions prior to the administration to the resident. During an interview on 02/07/24 at 10:55 A.M., RN A said he/she had been told it was unnecessary to prime the pen unless using a new insulin pen. During an interview on 02/07/24 at 11:00 A.M., Licensed Practical Nurse (LPN) B said she/he did not think it was protocol to prime insulin pens. During an interview on 02/07/24 at 12 :55 P.M., the Director of Nursing (DON) said the first dose from an insulin pen was primed but it wasn't necessary after that. The pharmacy told them it did not matter as the amount was so minimal. During an interview on 02/07/24 at 3:32 P.M., Pharmacist C said she/he would expect a brand new insulin pen to be primed. During an interview on 02/07/24 at 3:35 P.M., Pharmacist D said she/he would expect an insulin pen to be primed the first time, but it would depend on the manufacturer's instructions after that. The problem occurred when insurance did not cover for the primed amount with each pen use and and that could end up costing the resident out of pocket. However, the best practice would be to prime the insulin pen prior to each use to assure the correct dose was received.

Based on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pest out and/or to keep the garbage contained in the dumpster. The facility census was 168. The facility did not provide a policy regarding the dumpsters. Observations on 02/06/24 at 10:30 A.M., and 02/06/24 at 3:01 P.M., of the outside 200 Hall kitchen showed a two-lid dumpster with both lids opened with visible trash bags and other miscellaneous items. Observations on 02/06/24 at 10:54 A.M., and 02/06/24 at 3:18 P.M., of the outside 300 Hall kitchen, showed a two-lid dumpster with both lids opened with visible trash bags and other miscellaneous items. Observation on 02/07/24 at 10:01 A.M., of the outside 300 Hall kitchen showed a two-lid dumpster with one lid opened with visible trash bags and several broken down cardboard boxes. During an interview on 02/06/24 at 9:41 A.M., Dietary Aide A said dumpster lids should be closed after trash was placed inside for pest control purposes. During an interview on 02/06/24 at 10:34 A.M., the Food Services Director said trash dumpster lids should be closed after staff discards trash and other miscellaneous items. During an interview on 02/07/24 at 9:25 A.M., Certified Nursing Assistant (CNA) B said nursing placed the bags of trash in a designated location and the maintenance supervisor disposed the trash for them. During an interview on 02/07/24 at 9:27 A.M., Housekeeper C said the housekeeping department places the bags of trash in a designated location and the maintenance department disposed the bags of trash for them. During an interview on 02/08/24 at 9:49 A.M., the Maintenance Supervisor (MS) said there were staff designated daily to take out the trash for the facility. The dumpster lids should be closed after staff throw away trash and other discarded items. During an interview on 02/09/24 at 11:02 A.M., the Administrator said she would expect the dumpster lids to be closed at all times and after staff discarded trash and other miscellaneous items for disposal purposes.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 168. Review of the facility's policy titled, Cleaning and Sanitation of Dining and Food Service Areas, dated 11/14/23, showed: - The dining service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule; - The Certified Dietary Manager (CDM)/dining service director/kitchen manager/designee will record all cleaning and sanitation tasks for the department; - All staff will be trained on the frequency of cleaning necessary; - A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed; - Staff will be held accountable for cleaning assignments. Review of the kitchen's cleaning schedule, undated, showed: - After each use: all small equipment, utensils and appliances; - Daily: exterior of dishwashers, kitchen sinks and other appliances; - Weekly: garbage containers; - Twice per month: ice machines, ovens, cabinets and drawers; - Monthly: clean behind and under major appliances. Observations on 02/06/24 at 9:52 A.M., 02/07/24 at 9:59 A.M., and 02/08/24 at 2:27 P.M., of the 200 Hall kitchen area showed: - A buildup of a dried white residue on the outside lid, inside lid, crevices and surface area of the ice machine; - A buildup of a dried white grime on the upper part of the left and right-side corner crevices of the ice dispenser machine located in the steam table serving area; - A buildup of a dried white residue on the bottom area and side surfaces of the ice dispenser machine located in the steam table serving area. Observations on 02/06/24 at 10:14 A.M., 02/07/24 at 9:53 A.M., and 02/08/24 at 2:38 P.M., of the 300 Hall kitchen showed: - A buildup of grime on the front surface sliding doors located by the two-compartment sink; - A buildup of grime, debris and residue on the tops and side surfaces of the dishwasher machine; - Three metal-like panels connected to the ceiling above the chemical machine with dried residue; - A white trash can with a flip lid overflowed with paper towels on the floor located under the handwashing sink; - A large gray trash can and lid with buildup of dirt and grime on the top, sides and wheels located near the handwashing sink; - A trash can with no lid with visible trash and other miscellaneous items located under the far right-side three-compartment sink counter; - A deep fryer with a buildup of dirt, debris and grime; - The robo-coup (mixer) with dirt, debris and loose French fries on the surface area under the plastic covering; - A buildup of grime and dried residue on the surface areas and backsplash of the three-compartment sink; - An opened bag of brussel sprouts in a zip lock with no date located in the left-side walk-in freezer; - An opened bag of chicken strips in a zip lock with no date or label in the left side walk-in freezer; - An opened bag of broccoli in a zip lock bag with no date located in the left-side walk-in freezer; - A buildup of a dried white residue on the outside lid, inside lid, crevices and surface area of the ice machine; - A buildup of a dried white residue on the left and right-side corner crevices of the upper area of the ice dispenser machine located in the steam table serving area; - A buildup of a dried white residue on the bottom area and side surfaces of the ice dispenser machine located in the steam table serving area. Observations on 02/07/2024 at 1:18 P.M., 02/08/2024 at 10:39 A.M., and 02/09/2024 at 9:20 A.M., of the 600 Hall dining room showed: - A buildup of dried liquid and food on the steam lid covers and surface areas located on the portable steam table; - Dirt and food debris on the floor located behind the portable steam table; - A buildup of dried liquid and food inside the microwave located near the portable steam table; - A quart-size measuring cup containing white sugar with no date, label, and uncovered located on a counter behind the kitchenette. During an interview on 02/06/24 at 9:41 A.M., Dietary Aide A said the kitchen equipment should be free of grime, dirt, debris build up and dried visible residue. Dried smears just did not look sanitary and should be wiped off better. There was a daily cleaning checklist that was completed and initialed after a kitchen task was done. Not everybody cleaned the same way and it should be consistent. The ice machine and lids should be free of dried residue and grime buildup because it could make the ice taste funny. During an interview on 02/06/24 at 3:11 P.M., the Food Services Director said he/she would expect kitchen equipment to be free of buildup of grime, dirt, debris and dried residue. He/She would expect staff to label and date frozen foods after it was opened for consumption purposes. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed. Both kitchens in the facility should meet the same standard requirement. There shouldn't be a difference in cleaning techniques. During an interview on 02/06/24 at 3:14 P.M., the CDM said he/she would expect kitchen equipment to be free of buildup of grime, dirt, debris and dried residue. Opened foods should be labeled and dated. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed. Both kitchens in the facility should meet the same standard requirement. The staff that worked in the 200 Hall kitchen may clean differently than the staff that worked in the 300 Hall kitchen and there shouldn't be a difference. During an interview on 02/06/24 at 3:25 P.M., the Registered Dietician (RD) said he/she would expect the kitchen equipment be free of buildup of grime, dirt, debris and dried residue. Opened foods should be labeled and have a date for consumption purposes. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed and monitored by the CDM. Both kitchens in the facility should meet the same standard requirement. The RD said recommendations were made during weekly/monthly inspections. Any concerns were brought to the attention of the CDM and the Food Services Director to be addressed. The RD said the kitchen equipment could be cleaner. During an interview on 02/09/24 at 11:02 A.M., the Administrator said she would expect the kitchen equipment to be free of buildup of grime, dirt, debris and dried residue. Opened foods should be labeled and dated. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed and monitored by the kitchen supervisor. Both kitchens in the facility should meet the same standard requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accuracy of the advance directive (a written statement of a person's wishes pertaining to medical treatment) regarding the cardiopulmonary resuscitation (CPR) (a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped) status for one resident (Resident #105) out of 35 sampled residents. The facility's census was 178. Record review of the facility's Advanced Directive policy, undated, showed: - Do Not Resuscitate (DNR) - in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative directed no CPR or other life-saving methods to be used; - The Social Service staff will review annually with the resident their advance directives to ensure that such directives continue to be the wishes of the resident; - Changes or revocations of a directive must be submitted in writing to the facility and the facility may require new documents with any extensive changes. 1. Record review of Resident #105's face sheet showed: - An admission date of [DATE]; - A code status of full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Record review of the resident's physician's order sheet (POS), dated [DATE], showed: - A code status of DNR. Record review of the resident's Request Concerning Life-Prolonging Procedures, dated [DATE], showed: - No CPR. Record review of the resident's Code Status form, dated [DATE], showed: - Code status to be DNR and signed by a physician. Record review of the resident's care plan, revised on [DATE], showed: - On the top and bottom of page one, DNR hand-written and undated; - On the middle of page one, code status: full code - DNR hand-written and undated, full code - DNR marked through with error/staff initials hand-written and undated, full code hand-written again under the marked through code statuses and undated; - A code status of full code addressed under the Activities of Daily Living (ADL) self-care focus section with a revision date of [DATE]. Observation of the resident's hard chart at the nurse's station showed: - A blue sticker on the spine of the binder. During an interview on [DATE] at 2:02 P.M., Registered Nurse (RN) A said staff look at the the sticker on the binder or if the computer is unlocked, then the face sheet of a resident, to quickly see if the resident is a full code or a DNR. All documentation for the code status should match each other. The blue sticker on the binder means the resident is a full code. The profile page in the computer shows the resident to be a DNR. The care plan shows both a full code and a DNR. During an interview on [DATE] at 1:05 P.M., the Director of Nursing and the Administrator said they would expect code status orders to be documented on the resident's face sheet, POS, and the care plan. All documentation should match. The facility policy does not include using stickers to indicate a resident's code status. They would expect the wishes of the resident and/or the responsible party to be what is ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, for three residents (Residents #116 and #125) out of 35 sampled residents. The facility's census was 178. 1. Record review of Resident #116's medical record showed: - An admission date of 7/24/20; - Diagnoses of atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow) and cerebral infarction (damage of tissues in the brain due to a loss of oxygen). Record review of the resident's Physician Order Sheet (POS), dated April 2022, showed: - An order for aspirin (an antiplatelet) 81 milligrams (mg) by mouth every morning for prophylaxis (action taken to prevent disease), dated 5/8/21; - No orders for an anticoagulant (medications to help prevent blood clots) medication. Record review of the resident's significant change MDS, dated [DATE], showed: - Resident received anticoagulant medication. During an interview on 4/21/22 at 9:00 AM, the MDS Coordinator said aspirin is used as a preventive. During an interview on 4/21/22 at 1:00 P.M., the DON said the MDS Coordinator is responsible for the completion and accuracy of the resident's MDS and aspirin should not be coded as an anticoagulant. 2. Record review of Resident #125's medical record showed: -An admission date of 7/1/21; -Diagnosis of Alzheimer's disease (progressive mental deterioration). Record review of the resident's POS, dated dated March and April 2022, showed: - No order for dialysis (process of purifying the blood of a person whose kidneys do not work normally); - Hospice care services. Record review of the resident's quarterly MDS, dated [DATE], showed: - Received dialysis treatments; - Did not receive hospice services. During an interview on 4/19/22 at 2:00 P.M., the Director of Nurses (DON) said the resident never received dialysis treatments, only hospice care services. The DON said the MDS Coordinator must have coded dialysis by mistake. The facility follows the Resident Assessment Instrument (RAI) manual, therefore, did not provide a policy.

Based on observation, interview, and record review, the facility failed to accurately assess for the risks and benefits for the use of side rails for one resident (Resident #142) out of 35 sampled residents. The facility's census was 178. 1. Record review of Resident #142's face sheet showed: - An admission date of 4/16/21; - Diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning) and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Record review of the resident's Side Rail Evaluation, dated 4/16/21, showed: - The resident did not wish to have side rails at that time; - The facility failed to assess the resident for the use of side rails. Observations of the resident showed: - On 4/18/22 at 11:30 A.M., the resident lay in bed with both upper half side rails up; - On 4/19/22 at 10:25 A.M., the resident lay in bed with both upper half side rails up; - On 4/20/22 at 2:06 P.M., the resident grabbed onto a half side rail when assisted by the staff to turn onto his/her side; - On 4/21/22 at 8:55 A.M., the resident sat up in bed with both upper half side rails up. During an interview on 4/21/22 at 12:58 P.M., the Director of Nursing (DON) said she would expect a resident with side rails to have an assessment. Record review of the facility's Proper Use of Side Rails policy, undated, showed: - Will use side rails to treat the resident's medical symptoms and assist the resident to attain or maintain his/her highest practical physical and psychosocial well-being as requested by the resident; - Side rails will only be permissible if used to treat a resident's medical symptoms, or to assist with the mobility and transfers of a resident per the resident's request.