Based on interviews, record review, and facility document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) form included all current mental illness diagnoses for one (Resident #26) of one sampled resident reviewed for PASARR requirements. Findings included: A review of a document provided by the facility titled What to submit to COMRU [Central Office Medical Review Unit] for client entering a Skilled Nursing Facility, dated January 2020, revealed that when completing a Level One Nursing Facility Pre-admission Screening for MI/ID [mental illness/intellectual disability], staff should Be sure to complete all blanks and Be sure Section B#2 (Mental Illness Diagnosis) is answered - Refer to client's diagnosis list. A review of Resident #26's admission Record revealed the facility admitted the resident on 04/04/2022. The Diagnosis Information section of the admission Record indicated, No Data Found. A review of Resident #26's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/2022, revealed Resident #26 had an active diagnosis of post-traumatic stress disorder (PTSD). A review of Resident #26's Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability, or Related Condition, completed by the Administrator and signed by the facility's physician, Physician #14, on 04/25/2022, revealed the question for, Does the individual have a current, suspected, or history of a Major Mental Illness as defined by the Diagnostic & Statistical Manual of Mental Disorders (DSM) current edition? was answered no, and the box to indicate a diagnosis of PTSD was not marked. During a phone interview on 10/19/2023 at 10:02 AM, Physician #14 confirmed that he reviewed and signed PASARR forms once the form was completed by the hospital or nursing home staff. Physician #14 stated he was not aware Resident #26 had a diagnosis of PTSD at the time of their admission to the facility but may have missed it. During an interview on 10/19/2023 at 3:17 PM, the Administrator stated she was the one who completed the PASARR screenings with the information received from the hospital, and the facility's physician signed them once they were completed. The Administrator acknowledged the omission of a diagnosis of PTSD on Resident #26's screening and said she missed the diagnosis. The Administrator stated there was no process in place to check the accuracy of the PASARR after she completed the screenings.

Based on observations, interviews, record review, and facility policy review, the facility failed to follow physician orders related to wound care for one (Resident #43) of three residents reviewed for wound care. Findings included: Review of an undated facility policy titled Physician Services revealed, All physician or other health care professional verbal orders, including telephone orders, will be immediately recorded, dated, and signed by the person receiving the order. The policy also noted, All physician orders will be followed as prescribed and if not followed the reason shall be recorded on the resident's medical record during that shift. Review of an undated facility policy titled Clean Dressing Change revealed, It is the policy of the facility to ensure change dressings [sic] in accordance with State and Federal Regulations, and national guidelines. The facility policy indicated Procedure: 1. Verify and review physician's order for procedure. The policy also indicated 19. Apply clean dressing as ordered and ensure the dressing is dated. Review of Resident #43's admission Record indicated the facility admitted the resident on 03/14/2022. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/2023, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The MDS indicated the resident had two unhealed venous and arterial ulcers. The MDS also identified diabetic foot ulcer(s) under a section for other ulcers, wounds, and skin problems. Review of Resident #43's Resident Care Plan, dated 09/28/2023, revealed the resident had diabetic foot ulcers to both feet. The Resident Care Plan directed staff to continue to treat the wounds per physician orders. The Resident Care Plan indicated the resident would see a physician at a wound clinic soon. The Resident Care Plan directed staff to monitor the resident's skin weekly and to pay extra attention to the resident's feet. The Resident Care Plan contained instructions for staff to report any new or worsening areas that were concerning. Review of hospital Progress Note Details, dated 10/04/2023, indicated Resident #43 was seen at the hospital's wound center for two wounds on his/her feet. The document contained right great toe and second left toe wound orders directing staff to cleanse the wounds with normal saline, apply Betadine (antiseptic)-moistened gauze to the wound beds, cover the wounds with gauze, and secure. The order contained a directive to change the dressings daily and as needed. Review of Resident #43's October 2023 Physician's Orders revealed orders for the right great toe and left second toe. Each order directed staff to cleanse the respective wound with wound cleanser, apply Betadine-moistened gauze to the wound bed, and cover with dry gauze daily and as needed until healed. The orders were dated 10/05/2023. Review of Resident #43's Treatment Administration Record [TAR] and Weekly Summary Report revealed a wound treatment order, dated 10/05/2023, directing staff to clean the wounds to the right great toe and the left second toe with wound cleanser, apply Betadine-moistened gauze to the wound beds, cover with dry gauze, and change daily and as needed until healed. Further review of the document revealed initials were present for the date 10/18/2023, indicating staff documented the treatment had been provided as ordered. Observation of wound care completed by Registered Nurse (RN) #1 on 10/18/2023 at 10:31 AM revealed the nurse gathered wound care supplies, including a bottle of povidone iodine (generic Betadine) and a bottle of saline wash. It was observed that the nurse cleaned the wound with saline (wound cleanser) as ordered. Further observation revealed the nurse moistened gauze with povidone iodine solution, wiped the right great toe wound as well as the area around the right great toe, and discarded the gauze. Observation revealed another gauze was moistened with povidone iodine solution, and the nurse wiped the left second toe wound as well as the area around the left second toe, then discarded the gauze. Observation revealed the nurse then applied saline-moistened gauze over the right great toe wound bed and applied another saline moistened gauze over the left second toe wound bed. Observation showed each wound was covered with a dry dressing and secured with tape. During an interview on 10/18/2023 at 11:16 AM, RN #1 stated wound care recommendations were made by a wound nurse, noting a charge nurse transcribed the recommendations to the physician orders and the TAR. During the interview, RN #1 read Resident #43's wound orders and confirmed that the order called for Betadine-moistened gauze, not saline-moistened gauze, to be applied to the wound bed. During an interview on 10/19/2023 at 9:56 AM, Resident #43's primary physician, Physician #14, stated the wound care practitioners' recommendations should be followed. Physician #14 said he did not make any changes to Resident #43's wound care orders from the wound care consultation that occurred on 10/04/2023 at the hospital. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) said she misinterpreted and failed to clarify Resident #43's wound orders. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated staff should follow physician orders for wound care. She said if there was a misunderstanding related to an order, she expected staff to obtain an order clarification.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff maintained infection control practices to prevent the spread of infection during treatments of wounds and administration of medications for one (Resident #43) of two residents observed for wound care and two (Resident #21 and Resident #152) of eight residents observed during medication pass. Findings included: A review of an undated facility policy titled Hand Hygiene Guidelines, revealed, Key times to wash hands included before and after treating a cut or wound. The policy revealed Sanitizers can quickly reduce the number of germs on hands in many situations. A review of an undated facility policy titled Clean Dressing Change, revealed, It is the policy of the facility to ensure change [sic] dressings in accordance with State and Federal Regulations, and national guidelines. The policy revealed Procedure: 1. Verify and review physician ' s order for procedure. 2. Perform hand hygiene and assemble equipment and supplies needed for dressing change. 3. Identify the resident and explain the procedure. 4. Evaluate resident ' s pain and the need for pain medication. 5. Put on gloves. Adjust bedside table to waist level. Clean bedside stand/table with germicidal disposable cloth. Establish a clean field. 6. Place resident ' s trash can within easy reach, 7. Remove gloves and perform hand hygiene. 8. Set up supplies on barrier. 9. Position the resident for comfort. 10. Perform hand hygiene. 11. Put on clean gloves. 12. Remove dressing and place in the resident ' s trash can. 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Cleanse wound with gauze and prescribed cleaning solution using single outwards strokes. 16. Use dry gauze to pat the wound dry. 17. Remove gloves and perform hand hygiene. 18. Put on clean gloves. 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene. A review of a Safety Data Sheet for the hand sanitizer brand used by the facility revealed the product description indicated, A gelled alcohol hand sanitizer with Aloe for hand washing to decrease bacteria on the skin. During an interview via phone on 10/18/2023 at 1:54 PM, the hand sanitizer brand representative stated it was not recommended to apply the hand sanitizer to gloves because the product was a highly flammable liquid and not to be used on latex or any type of gloves. 1. A review of Resident #43's wound care Progress Note Details dated 10/04/2023 revealed the resident had two wounds to the feet. One wound to the right big toe from a partial amputation that did not heal after surgery, and one wound to the left second toe. The provider described each wound as a chronic Wagner Grade 2 Diabetic Ulcer. Further review of the note revealed wound care orders for the left second toe wound, and right great toe wound to cleanse the wounds with normal saline, apply a betadine-moistened gauze to the wound bed, and cover with gauze daily or as needed. Observation of Resident #43's wound care completed by Registered Nurse (RN) #1 on 10/18/2023 at 10:31 AM revealed the nurse gathered wound care supplies, including a bottle of povidone-iodine and a bottle of saline wash, and placed them on a towel that was on the resident's bed. The povidone-iodine and bottle of saline were observed touching the resident's socks and pants. RN #1 donned gloves and removed the resident's right boot and socks. Continued observation revealed the nurse used hand sanitizer on the gloves and used the same gloves to remove the old dressing from each foot. The nurse again applied hand sanitizer on the gloves and used the same gloves to clean the wound on the left second toe and the wound to the right great toe. When cleaning the wounds, RN #1 used a saline-moistened gauze to clean the wound to the right great toe in a vertical and repeated back-and-forth motion from the wound to the foot, just above the right great toe. RN #1 then used the same saline-moistened gauze to clean around the right great toe, touching the wound several times. Further observation revealed the nurse proceeded to clean the left second toe wound with a saline-moistened gauze in a vertical and repeated back-and-forth motion from the wound to the foot, just above the left second toe. RN #1 then used the same saline-moistened gauze to clean around the left second toe, touching the wound and skin. Further observation revealed RN #1 applied hand sanitizer to the same gloves, and without changing gloves, the nurse took a gauze moistened with povidone-iodine solution and wiped it over the right great toe wound and around the right great toe. With the same gloved hands, RN #1 obtained another gauze moistened with povidone-iodine solution, and the nurse wiped the left second toe wound and around the left second toe. With the same gloved hands, RN #1 then applied a saline-moistened gauze over the right great toe wound bed. Using the same gloves, RN #1 applied another saline-moistened gauze over the left second toe wound bed. Each wound was covered with a dry dressing using tape. It was further observed that RN #1 applied hand sanitizer over the gloves before dating both dressings. RN #1 used the same gloves throughout the entire treatment of both wounds. During an interview on 10/18/2023 at 11:16 AM, RN #1 stated if there was more than one wound, treatments should have been done separately to prevent cross-contamination. RN #1 confirmed wound treatments to Resident #43's left second toe and right great toe were completed together because the treatment orders to both toes were the same. RN #1 confirmed the supplies touched the resident's clothing, and the nurse did not ensure everything was out of the way to prevent contamination. RN #1 stated she used hand sanitizer over the same gloves throughout the treatment process, stating she learned the practice from a physician's office where she worked in the past. 2. Medication pass observation was conducted on 10/17/2023 at 8:52 AM with Registered Nurse (RN) #1. RN #1 applied hand sanitizer, then donned gloves and thumbed through the medication book, picked up a writing pen lying on the cart to write an open date on a new insulin pen, then applied hand sanitizer to the outside of her gloves, touched and closed the medication book, and touched keys to lock a drawer. RN #1 proceeded into Resident #21's room and administered the insulin. Medication pass observation was conducted on 10/17/2023 at 10:07 AM with RN #1. RN #1 applied hand sanitizer, donned gloves, and then touched the cart surface, retrieving an Exelon patch from a bag. She then applied hand sanitizer to the outside of her gloves, touched the medication administration book to close it, and touched a writing pen to write initials and date on the Exelon patch. RN #1 proceeded into Resident #152's room and applied the patch. During an interview on 10/18/2023 at 1:51 PM, RN #1 acknowledged that after performing hand sanitization with alcohol-based hand sanitizer during medication pass observation on 10/17/2023, she had donned gloves and applied hand sanitizer to the gloves then proceeded to touch the medication administration book (MAR), a writing pen to write a date and initials on the Exelon patch to be applied to Resident #152, as well as applying hand sanitizer to gloves before touching a book, a pen, and keys during insulin pen preparation for Resident #21. RN #1 stated, Sometimes I forget and touch stuff. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) stated staff should not use hand sanitizer over the gloves but should take the gloves off and use hand sanitizer on the hands. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated staff should not use hand sanitizer over the gloves. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) stated that when a resident had more than one wound, staff should complete wound care for one wound at a time to prevent cross-contamination. The DON stated that when cleaning a wound, the nurse should clean from the inside center (wound bed) of the wound, working out away from the wound, and then discard the used gauze. The DON stated that cleaning the area outside the wound and then touching the wound with the same gauze contaminated the wound. The DON stated the staff should not use hand sanitizer on gloves but should take the gloves off and use hand sanitizer on the hands. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated when cleaning a wound, staff should clean the wound from inside of the wound toward the outside of the wound. The Administrator stated staff should not use hand sanitizer on gloves and should change gloves between treatment steps. The Administrator stated if the resident had multiple wounds, staff should complete the treatment to one wound at a time.

Based on observations, interviews, document review, and facility policy review, the facility failed to properly store and secure medications for 2 (Hall 100 medication cart and facility medication/treatment cart) of 3 medication carts observed and failed to ensure proper labeling of eye drops for 1 (Resident #43) of 3 residents observed for eye drop administration during medication pass. Specifically, the facility failed to ensure medications remained in direct line of sight of staff or were in a locked compartment, failed to properly store tramadol under a double lock, and failed to date an eye drop container when opened. Findings included: A review of an undated document titled Medication storage in the facility revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review revealed Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designed for that purpose. Under the section titled Controlled Medication Storage it revealed, Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications. 1. Medication pass observation was conducted on 10/17/2023 at 10:07 AM with Registered Nurse (RN) #1. RN #1 removed an Exelon patch (medication used to treat dementia) from a transparent plastic zip-style bag that contained multiple Exelon patches. RN #1 placed the bag with several Exelon patches remaining in the bag on top of the facility treatment/medication cart. RN #1 left the treatment/medication cart unlocked, left the bag containing Exelon patches on the top of the cart unsecured, and proceeded into Resident #152's room. The resident was in a recliner behind a wall beside the bathroom and adjoining room wall. RN #1 had to lean over the resident behind the bathroom wall to place the patch on the resident's shoulder. The treatment/medication cart was at a 30-to-45-degree angle in the entranceway of Resident #152's room. RN #1 was not within sight of the treatment/medication cart while in the resident's room applying the patch. During an interview on 10/17/2023 at 10:10 AM, RN #1 acknowledged she did not lock the treatment/medication cart, had left the bag containing Exelon patches lying on top of the cart unsecured, and that the cart was not within her line of sight. RN #1 said she should have put the Exelon patches back in the cart and locked it. During an interview on 10/19/2023 at 4:17 PM, the Director of Nurses (DON) stated her expectation was the medication carts should always be locked if left unattended. The DON stated if the medication cart was unlocked, the nurse should be able to see the cart. During an interview on 10/19/2023 at 3:37 PM, the Administrator stated that her expectation was the medication cart should be locked or the nurse should be in the line of vision of the medication cart. The Administrator acknowledged the potential risk was residents could get into the cart or take something off the cart. 2. A review of a document titled Controlled Substances from the Drug Enforcement Agency (DEA) website, www.dea.com, dated 09/18/2023, revealed that tramadol was a Schedule IV-controlled substance (a classification system given to drugs based on the drug ' s acceptable medical use and the drug ' s abuse or dependency potential) under the narcotic category. Observation of the 100-hall medication cart on 10/19/2023 at 11:16 AM with Licensed Practical Nurse (LPN) #6 revealed four cards of tramadol (narcotic medication used to treat moderate to severe pain) in the bottom drawer of the medication cart. The cards of tramadol were not observed to be stored under double lock. During an interview on 10/19/2023 at 11:16 AM, LPN #6 stated the tramadol did not have to be double locked because it was a Schedule I substance and not considered a controlled substance. She stated they received information from the pharmacy on where the medications needed to be stored or placed in the carts. During an interview on 10/19/2023 at 4:17 PM, the DON stated her expectation was for controlled medications to be double-locked. She stated tramadol was okay to be stored under one lock because it was a Schedule I medication. She stated the pharmacy should notify them of the medication classes to be locked, and if there was ever a question, they called the pharmacy. During an interview on 10/19/2023 at 3:42 PM, the Administrator confirmed that controlled substances needed to be stored behind two locks. 3. A review of Resident #43's admission Record indicated the facility admitted the resident on 03/14/2022. A review of Resident #43's Physician's Orders revealed an order dated 03/14/2022 to administer Trusopt (eye drops used to treat glaucoma) 2% one drop to both eyes twice daily. Medication pass observation was conducted on 10/18/2023 at 10:31 AM with Registered Nurse (RN) #1. RN #1 retrieved an open dorzolamide (Trusopt) eye drop container from the medication cart to administer to Resident #43. Observation of the eye drop container revealed no open date. During an interview on 10/18/2023 at 11:16 AM, RN #1 stated eye drops should be dated with an open date when first opening the container. RN #1 confirmed the dorzolamide 2% she administered to Resident #43 did not have an open date. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) stated that when staff opened eye drops, the container should be dated with an open date. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated they did not know about dating eye drops.

Based on interviews and document review, the facility failed to ensure three (Certified Nursing Assistant (CNA) #7, #8, and #11) of five CNAs had at least 12 hours of in-service training per year. Findings included: During an interview on 10/19/2023 at 4:56 PM, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Health Information Manager (HIM) stated the facility had no policy related to required training for CNAs. A review of a Centers for Medicare and Medicaid Services (CMS) memorandum dated 04/07/2022 regarding the Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers revealed In response to the COVID-19 PHE [Public Health Emergency] and under the Secretary's authority set out at section 1135 of the Social Security Act, CMS enacted several temporary emergency declaration blanket waivers which were intended to provide health care providers with extra flexibilities required to respond to the COVID-19 pandemic. The memorandum indicated, CMS is ending the specific emergency declaration blanket waivers for SNFs/NFs [Skilled Nursing Facilities/Nursing Facilities], Additionally, Providers are expected to take immediate steps so that they may return to compliance with the reinstated requirements according to the timeframes listed below. Further review revealed Emergency Declaration Blanket Waivers for Various Provider-Types Ending 60 days from Publication of this Memorandum: included In-service Training for LTC [long-term care] facilities - 42 CFR [code of federal regulations] 483.95 (g)(1) [F947]. CMS modified the nurse aide training requirements for SNFs and NFs which required the nursing assistant to receive at least 12 hours of in-service training annually. A review of CNA #7's Inservice Training Record for 2022 revealed she completed 11.5 hours of in-service training. A review of CNA #8's Inservice Training Record for 2022 revealed she had completed 5 hours of in-service training. A review of CNA #11's Inservice Training Record for 2022 revealed she had completed 8.75 hours of in-service training. During a telephone interview on 10/19/2023 at 3:21 PM, CNA #7 stated she had worked at the facility for seven years as a CNA. She stated she had decreased to part-time status to accommodate schooling and had missed several in-service trainings. During a telephone interview on 10/19/2023 at 3:52 PM, CNA #8 stated she had worked at the facility for five years. She stated she worked nights, and a lot of the training meetings were scheduled for 2:00 PM, but she only attended the 7:00 AM training meetings. During an interview on 10/19/2023 at 4:53 PM, the DON stated she was in charge of the CNA training program and made sure there were plenty of in-services scheduled throughout the year. She stated training was completed via in-services, videos, and handouts. The DON stated she could only schedule the training and could not force staff to attend. According to the DON, she was unaware the CMS training waiver ended in June 2022. The DON stated she thought the CNA training waiver was lifted in May 2023. During an interview on 10/19/2023 at 5:22 PM, the Administrator stated she was aware facility CNAs had to have 12 hours of in-service training per year. She stated the training year restarted every January. The Administrator stated there was no reason the CNAs should not have received their mandated training hours. The interview with the Administrator revealed she also believed the CMS training waiver was lifted in the spring of 2023 and was unaware it was lifted in June 2022.

Based on interviews and facility document review, the facility failed to ensure the designated Dietary Manager (DM) had the required education, certification, or experience to qualify her for the position. This had the potential to affect 52 of 52 residents who received meals from the dietary department. Findings included: During an interview on 10/18/2023 at 2:09 PM, the Administrator stated the facility had no policy or procedure addressing the requirements to serve in the dietary management position. A review of the DM's employee file revealed the facility initially hired the DM in August 2022 as a housekeeper and laundry aide. No documentation of training was found within the DM's employee file regarding her move from housekeeping and laundry to the position of DM, nor was there any information regarding any food service certifications. An Employee 60 Day Review, dated 01/16/2023, indicated the DM was learning new role, including ordering, cooking, and supervising, and an Employee 90 Day Review, dated 03/27/2023, indicated the DM continues to learn. The DM's employee file also revealed she had experience at two local gas station convenience stores where kitchen, scheduling, inventory, ordering, and workplace improvement were listed as job duties between April 2006 and April 2022. During an interview on 10/18/2023 at 12:05 PM, the DM stated the Contracted Certified Dietary Manager (CCDM) provided her training, which included food safety. She stated she had no formal training, and her experience came from previous employment at a couple of convenience stores in town. During an interview on 10/18/2023 at 2:09 PM, the Administrator stated the facility had no training record for the DM. She stated the DM started with the facility in August 2022 and then moved into the role of DM in October 2022. She stated the facility had no certificate of completion for any food service or managerial program. The Administrator stated training had been arranged in a nearby town, but the DM was unable to make the scheduled training. During a follow-up interview on 10/18/2023 at 2:29 PM, the DM stated this was the first skilled nursing home kitchen she had worked in. She stated her previous kitchen experience was at a gas station convenience store in town. The DM stated she had discussed attending the ServSafe training (a training program developed to maintain standards and safety in the food service industry) with the Contracted Registered Dietitian (CRD) and the CCDM, but the training had already started, and she was unable to join that training. The DM stated she had no education as a dietary manager, dietitian, or any other professional food industry training. During a follow-up interview on 10/18/2023 at 3:08 PM, the Administrator stated the DM oversaw the day-to-day activities of the kitchen. She stated she had spoken with the CRD several times throughout the year about getting the DM into formal training, but it was unable to be arranged. She stated the DM received training from the former supervisor, Dietary [NAME] #13, who was still employed and supported the DM. During a follow-up interview on 10/19/2023 at 9:40 AM, the DM stated the CCDM spent two days in the facility training her when she accepted the position in October 2022. During an interview on 10/19/2023 at 9:58 AM, the CRD stated the CCDM worked for her and finished the training that she started in the facilities she contracted with and was in the facilities daily during the training period. She stated the CCDM also completed kitchen audits and provided training to dietary staff. The CRD stated the CCDM completed the DM ' s training and completed mock inspections of the kitchen with the DM, going over any concerns and issues identified. She stated the former supervisor, Dietary [NAME] #13, also assisted with training the DM and was still employed, providing managerial support. The CRD stated she reviewed the training book kept in the kitchen and could not find all of the training that had been provided to the DM and confirmed training information was missing. During a follow-up interview on 10/19/2023 at 5:22 PM, the Administrator stated she knew the DM required some classes or two years of experience. She stated that due to the rural nature of the area, it was hard to find anyone with the right qualifications, and the DM was the closest match they could find.

Based on observations, interviews, facility document and policy review, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure staff maintained meal temperature monitoring records for each meal service; failed to ensure staff maintained monitoring records of the sanitizer concentrations for the three-compartment sink to ensure items were properly sanitized; and failed to ensure staff thawed a roll of ground beef in accordance with professional standards. These failures had the potential to affect 52 of 52 residents who received meals from the dietary department. Findings included: 1. A review of an undated facility policy titled Department Meal Service: Meal Service Temperatures revealed, Purpose To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service. The policy also indicated, Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis. The procedural section of the policy indicated, Temperatures shall be recorded on the Temperature Report Form at each meal. During initial kitchen observation and interview on 10/16/2023 at 10:24 AM, a review of the Food Temperatures log for the timeframe from 07/30/2023 through 10/15/2023 revealed no meal temperature data had been logged for the following meals: -Breakfast meals: 08/05/2023, 08/24/2023, 09/07/2023, 10/01/2023, 10/04/2023, 10/05/2023, or 10/14/2023. -Lunch meals: 08/05/2023, 08/08/2023, 08/20/2023, 08/23/2023, 08/24/2023, 09/05/2023, 09/07/2023, 10/01/2023, 10/04/2023, 10/05/2023, 10/11/2023, or 10/14/2023. -Dinner meals: 08/01/2023, 08/02/2023, 08/04/2023, 08/05/2023, 08/08/2023, 08/09/2023, 08/11/2023, 08/12/2023, 08/15/2023, 08/16/2023, 08/18/2023, 08/19/2023, 08/22/2023, 08/23/2023, 08/25/2023, 08/26/2023, 08/29/2023, 08/30/2023, 09/01/2023, 09/02/2023, 09/05/2023, 09/06/2023, 09/08/2023, 09/09/2023, 10/01/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/06/2023, 10/07/2023, 10/10/2023, 10/11/2023, 10/13/2023, or 10/14/2023. No food temperature logs were provided for the timeframe from 09/10/2023 through 09/30/2023. The Contracted Certified Dietary Manager (CCDM) stated the meal temperature logs should be filled out each day at every meal. During an interview on 10/16/2023 at 10:36 AM, Dietary [NAME] #13 stated meal temperature logs should be documented for each meal every day. She stated logging meal temperatures was important for food safety. During an interview on 10/18/2023 at 2:29 PM, the Dietary Manager (DM) stated the CCDM had provided training about documenting the hot and cold meal temperatures on the log for food safety. She stated temperatures needed to be logged every day for every meal. The DM stated the dietary department recently hired new staff and they must have forgotten to log the meal temperatures. During an interview on 10/19/2023 at 3:08 PM, the Administrator stated meal temperatures should be taken correctly and logged for each meal. 2. A review of the United States FDA 2022 Food Code, dated 01/18/2023, revealed, Chapter 2. Management and Personnel, 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are used, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH [power of hydrogen], temperature, and exposure time for chemical SANITIZING. During initial kitchen observations on 10/16/2023 at 10:36 AM, the three-compartment sink was observed, in which the facility utilized a quaternary ammonium sanitizing solution. At this time, a review of the Three Compartment Sink Sanitizing Solution PPM [parts per million; a measurement of concentration] Log, for the timeframe from 09/01/2023 through 10/16/2023 revealed no documented sanitizer PPM data on 09/02/2023, 09/03/2023, 09/06/2023, 09/07/2023, 09/11/2023, 09/13/2023, 09/17/2023, 09/18/2023, 09/20/2023, 09/21/2023, 09/25/2023, 09/27/2023, 09/30/2023, 10/04/2023, 10/05/2023, 10/11/2023, 10/14/2023, or 10/15/2023. During an interview on 10/16/2023 at 10:36 AM, Dietary [NAME] #13 stated the sanitizer sinks were filled at 10:00 AM and then refilled every couple of hours to make sure the sanitizer stayed effective. She stated the PPM should be logged every time the sink was filled. Dietary [NAME] #13 stated logging the PPM was important to make sure the machine was functioning properly and getting the ratio right. During an interview on 10/18/2023 at 2:29 PM, the DM stated the sanitizer PPM log should be filled out every time the sink was refilled, which was three times a day. She stated the dietary department recently hired new staff and they must have forgotten to log the PPM data. 3. A review of the United States FDA 2022 Food Code, dated 01/18/2023, revealed, Chapter 3. Food, 3-501.13 Thawing. Except as specified in [paragraph] (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 [degrees] C [Celsius] [41 degrees Fahrenheit] or less; or (B) Completely submerged under running water: (1) At a water temperature of 21 [degrees] C [70 degrees Fahrenheit] or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 [degrees] C [41 degrees Fahrenheit], or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under [paragraph] 3-401.11(A) or (B) to be above 5 [degrees] C [41 degrees Fahrenheit], for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5 [degrees] C [41 degrees Fahrenheit]. During lunch meal observations in the kitchen on 10/18/2023 at 11:54 AM, a roll of ground beef was observed sitting in a pan on the counter next to the three-compartment sink. The ground beef was still frozen but was not placed under running water to thaw outside the refrigerator. During an interview on 10/18/2023 at 11:56 AM, the DM stated when staff had to thaw something, they put it in a pan, labeled it with the date, and put it in the refrigerator for the next day. The DM said the meat thawing on the counter was planned for the evening meal on 10/18/2023. During lunch meal observations in the kitchen on 10/18/2023 at 1:01 PM, the roll of ground beef was observed sitting in a pan on the counter. The ground beef was still frozen, was still not under running water to thaw outside the refrigerator, was starting to thaw with visibly melted frost dripping into the pan and was starting to get soft on the outside of the roll. During a return visit to the kitchen on 10/18/2023 at 2:26 PM, the roll of ground beef had been cut in half. One section remained on the counter in a plastic bag, while the other was labeled and dated and put in the refrigerator. During a follow-up interview on 10/18/2023 at 2:29 PM, the DM stated the ground beef was an 8-pound roll thawing on the counter for use at the dinner meal. She stated that when dietary staff needed meat for a meal, they would put it into its own pan and let it thaw. She stated she would also thaw bags of ready-made scrambled eggs on the counter if they were not taken out the night before. She stated food should be stored at 36 degrees F or below to prevent foodborne illness and bacteria growth. During an interview on 10/18/2023 at 3:08 PM, the Administrator stated meat should be thawed in the bottom of the refrigerator but was unfamiliar with other methods to thaw raw meat safely.

Based on observation, interview, and record review, the facility failed to follow the spreadsheet menu when preparing and serving the lunch meal on 3/4/19 to residents on pureed and mechanical soft diets. The facility failed to add bread to the pureed entrée and pureed vegetable, failed to serve gravy with the meal, and failed to ensure staff served the correct portion of food items as directed by the spreadsheet menu. The facility census was 55. 1. Review of the facility dietary listing, dated 2/21/19, showed two residents with a physician's order for a pureed diet. Review of the spreadsheet menu for lunch on 3/4/19, showed residents on a pureed diets should receive the following items: -1/2 cup pureed Salisbury steak with pureed bread; -1/2 cup whipped potatoes; -1/4 cup gravy; -1/2 cup pureed vegetable blend with pureed bread. Observation on 3/04/19 at 11:54 A.M. showed Dietary Staff A placed two pieces of Salisbury steak into the food processor, added a small amount of brown gravy, blended the mixture to a pureed consistency, and placed it into a pan. Dietary Staff A did not add bread to the pureed Salisbury steak. Observation on 3/04/19 at 12:02 P.M. showed Dietary Staff A added two servings of vegetables to the food processor with some liquid, blended the mixture to a pureed consistency, and placed it into a pan. Dietary Staff A did not add bread to the pureed vegetables. Observation on 3/04/19 at 12:05 P.M. showed Dietary Staff A began the lunch service in the main dining room. A small silver ice cream scoop (no measurement visible on the utensil) was located in the pan of pureed Salisbury steak, and a 2-ounce (1/4 cup) dipper was located in the pan of pureed vegetables. Observation on 3/04/19 between 12:43 P.M. and 1:07 P.M. showed staff served the two residents on pureed diets a 1/4 cup portion of pureed Salisbury steak without gravy, whipped potatoes without gravy, and the unmeasured portion of pureed vegetable blend. During an interview on 3/5/19 at 10:30 A.M., the dietary manager said dietary staff used the silver ice cream scoop on a regular basis to serve residents. She thought the scoop was 1/2 cup but the scoop was not actually labeled to indicate the serving size. During an interview on 3/04/19 at 3:35 P.M., the dietary manager said staff know how to make pureed items by referring to the dietary spreadsheet menu. If the food item on the spreadsheet showed bread should be pureed with the item, then staff should add 1/2 slice of bread to the food item and then blend. Staff should use the correct serving utensils when serving food. Staff should have served gravy over the pureed entrée and mashed potatoes for lunch, but they ran out of gravy. 2. Review of the facility Dietary Listing, dated 2/21/19, showed nine residents with a physician's order for a mechanical soft diet. Review of the spreadsheet menu for lunch on 3/4/19, showed residents on a mechanical soft diet should receive the following items: -1/2 cup ground Salisbury steak; -1/2 cup whipped potatoes; -1/4 cup gravy. Observation on 3/04/19 between 12:05 P.M. and 1:07 P.M. showed staff served all residents on a mechanical soft diet ¼ cup of ground Salisbury steak instead of ½ cup as directed on the diet spreadsheet. Staff did not serve gravy on top of the ground meat. During an interview on 3/04/19 at 1:08 P.M., Dietary Staff A said staff should put gravy on top of mechanical meat, but they ran out of gravy very early in the meal service. During an interview on 3/04/19 at 3:35 P.M., the dietary manager said staff know how to make mechanical (ground) items by referring to the dietary spreadsheet menu. Staff should use the correct serving utensils when serving food. Staff should have served gravy over the ground entrée for lunch, but they ran out of gravy. 3. Review of facility policy, Meal Production, revised January 2016, showed the following: -Menus shall be followed which have been written and approved by a registered, licensed dietician in compliance with the Federal and State regulations and consistent with standards of practice on nutritional care; -Purpose: To ensure proper nutritional care of the residents and to comply with nutritional standards and regulations governing menus and nutritional care. Review of the facility policy, Meal Service, revised January 2016, showed meals shall be prepared according to the facility approved menu.