Based on interviews and record review, the facility failed to administer medications for pain management in accordance with the resident's physician orders, which caused unnecessary pain for one Resident (Resident #1) of five sampled residents. The facility census was 63. Review of the facility policy titled, Pain Assessment and Management, revised April 2025, showed: -Establish a treatment regimen specific to the resident based on consideration of the following: a) The resident's medical condition; b) Current medication regimen; c) Nature, severity, and cause of the pain. -The medication regimen is implemented as ordered; -Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications; -Contact the provider immediately if the resident's pain is not adequately controlled. Review of the facility's undated Medication Administration and Scheduled Medication Administration policy showed: -Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency and may be time-critical or non-time critical. 1. Review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 3/14/2025, showed: -Moderately impaired cognition; -Scheduled and PRN (as needed) pain management medications was indicated; - The resident had pain occasionally; -Diagnoses included: Debility, anxiety, depression, lung disease, and pain. Review of the Resident's Physician's Order sheet, active as of 4/30/25., showed: -Pregabalin oral capsule 150 milligrams (mg) given by mouth three times a day for pain. Review of Resident #1's medication administration record (MAR) for the month of April 2025, showed: -Pregabalin doses, during April 2025: 4/11 (evening dose), 4/12 (morning dose), 4/13 (all three doses), 4/14 (evening dose), 4/15 (afternoon dose), 4/16 (evening dose), 4/20 (evening dose, 4/21(afternoon dose), 4/22 (morning and afternoon dose), nursing staff did not document giving the medication to the resident. During an interview on 5/1/2025 at 11:12 A.M., the Resident said: -He/She was supposed to get pregabalin three times a day; -He/She did not get the pregabalin, as prescribed, during the last two weeks of April 2025; -He/She was in pain while waiting for the pregabalin to be administered. During an interview on 5/1/2025 at 2:45 P.M., the ADON., said: -He/She could not explain the gap in the administration of pregabalin; -The facility should have administered the pregabalin as the physician ordered; -The pharmacy was waiting for the physician to sign the order. During an interview on 5/1/2025 at 4:15 P.M., the Administrator said he/she expects medications to be administered as ordered. MO253261

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interviews, and record review, the facility failed to serve meals according to scheduled meal times. This affected one of 17 sampled residents . This had to potential to impact all residents in the community. The facility census was 68. Review of facility policy, food safety requirements, dated 9/1/21, showed: -Foods will be stored, prepared, distributed, and served in accordance with professional standards of food service safety; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of danger zone; -Timely distribution of all meals/snacks. Observation of posted meal times showed: -Dining served in dining room [ROOM NUMBER]:00 A.M., hall trays 9:00 A.M.; -Lunch served in dining room [ROOM NUMBER]:00 P.M., hall trays 1:00 P.M.; -Dinner served in dining room [ROOM NUMBER]:00 P.M., hall trays served 6:00 P.M. 1. Review of Resident #22's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 5/28/24 showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - He/She required set up assistance for meals; - Diagnoses included: Paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). During an interview on 7/7/24 at 2:53 P.M., Resident said his/her food was late quite often. 2. Observation on 7/07/24 at 8:54 A.M. showed Dietary Manager was serving breakfast from steam table to dining room. Observation on 7/7/24 at lunch services showed: -12:24 P.M. first tray served in dining room, 24 minutes after posted meal time; -12:39 P.M. last tray served in dining room, 39 minutes after posted meal time; -12:55 P.M. first cart of hall trays left kitchen; -12:58 P.M. hall trays arrived to 400 hall. Observation on 7/8/24 at lunch showed: -1:16 P.M. first hall tray passed on 300 hall, 16 minutes after posted meal time; Observation of meal service on 7/9/24 showed: -8:22 A.M. First tray served in dining room, 22 minutes after posted meal time; -8:55 A.M. Last tray served to dining room, 55 minutes after posted meal time; -9:00 A.M. First tray added to hot box cart; -9:12 A.M. 200 hall cart loaded and pushed out to dining room, 12 minutes after posted hall tray time; -9:16 A.M. Second food cart for 100 hall trays had first tray added to hot box; -9:28 A.M. Second hall cart loaded with 100 hall trays and wheeled out of dining room; -9:40 A.M. Third hall cart had first food tray added to hot box; -9:51 A.M. Test tray was dished up and added to third hall cart box for 300 hall; -9:58 A.M. Last tray served to resident in room [ROOM NUMBER], 58 minutes after posted hall tray meal service time. During an interview on 7/7/24 at 8:49 A.M., Dietary Manager said: -Meal service times were 8:00 A.M., 12:00 P.M., and 5:00 P.M.; During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -He/She was not aware of meals being served late; -He/She heard meal service was being served late at the evening meal; -Meal service took longer when resident's had a-la-carte orders. During an interview on 7/9/24 at 3:09 A.M., Nurse Aide (NA) D said: -Meals were usually thirty minutes late on day shift. During an interview on 7/10/24 at 6:36 A.M., Certified Nurse Aide (CNA) D said: -Meals were never served on time or early; -It was normal for meals to be served late; -He/She had observed Breakfast, lunch, and supper all being served late; -Meals were usually served late by one hour; -This week supper was served late by two hours; During an interview on 7/10/24 at 9:20 A.M., Dietician said: -He/She expected meal service to take no more than one hour to include room tray delivery. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected meal service to take no more than one hour from first tray to last tray to be served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.Review of Resident #10's Quarterly Minimum Data Set (MDS), dated [DATE]., showed: - The resident was admitted on [DATE]; - A brief interview for mental status (BIMS) score of 14, indicating the resident was not cognitively impaired was completed; - The resident needs partial to moderate assistance required for personal hygiene, Sit to Stand and transfer dependent, and dependent for bathing; - He/She is occasionally incontinent of urine; - He/She uses a wheelchair for mobility; - Diagnoses included: Depression, Stroke, Hypertension (high blood pressure), Hemiplegia (paralysis of one side of the body), Anxiety, and Cardiac arrhythmia (irregular heartbeat). Review of the resident's care plan, dated 6/20/24, showed: - Staff are to monitor the resident for signs of emotional distress with incontinence; - Staff are to assess the resident's fluid intake and hydration status; - Resident requires assistance to the bathroom or a bedside commode and requires one person to physically assist; - Staff are to give verbal cues to the resident to help prompt and transfer to toilet. During an interview on 7/8/24, at 9:53 A.M., the resident stated: - That after finishing his/her meal, he/she must wait a long time (30 min to one hour) for staff to take him/her to the toilet. This results in incontinent accidents which greatly embarrasses him/her. - He/She rarely is checked on by staff during the night for toilet assistance and this is due to lack of staffing during the night. During an interview on 7/8/24 at 1:32 P.M., the resident said: - That nursing staff was unable to help him/her to the bathroom before lunch, and he/she held their bladder until after lunch when staff had more time to assist the resident. -The resident stated he/she often waits for long periods of time for assistance when he/she needs help. During an interview on 7/9/24, at 8:30 A.M., RN B said: - Staff should take residents to the bathroom before meals, staff permitting. - The goal is to take them when they need to go and that residents cannot eat properly if they need to be toileted. - Residents are checked every 2 hours during day time hours if they need assistance for toileting. - The facility policy is to encourage the resident to use the bathroom by using verbal cueing and reminding them that they need to try and use the bathroom. During an interview on 7/9/24, at 9:20 A.M., CNA E said: - Residents should be taken to the bathroom before meals if required. - Every two hours residents are checked on during the day and evening to see if they need bathroom assistance, which is the facility policy. - Staff are to use verbal cueing to remind residents to use the bathroom during the day. During an interview on 7/10/24, at 12:50 P.M., the Administrator said: - She would not want any resident to have an incontinent accident due to staff not getting to them on time. Based on observation, interview, and record review the facility failed to respect resident rights of four residents out of the 17 sampled residents, when the facility failed to provide grooming for one resident (Resident #10), failed to respond to call lights within a timely manner for one resident (Resident #22), and additionally failed to preserve the dignity of two residents, when the staff did not provide mouth care to a dependent resident, and did not keep bedside urinal away from one resident's drinks (Resident #34, and Resident #63) The facility census was 68. Review of the facility's Resident Rights Policy, undated., showed: - Residents have the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. - Receive services and care outlined in the resident's care plan. - Every resident has the right to be treated with dignity and respect. Review of the facility's undated Call light policy., showed: To ensure timely response to the resident's requests or needs. Staff are to answer the residents call system immediately. When answering the call light identify yourself and politely respond to the resident's request. Review of the facility's 2018 revised Activities of Daily Living Policy., showed: Residents will be provided with care, treatment and services to ensure that their activities of daily living do not diminish or are unavoidable. Appropriate grooming and hygiene care will be provided to those residents who are unable to provide this independently for their selves to include mouth, lips, and oral care. 1. Review of Resident #34's Annual MDS (Minimum Data Set), A mandated assessment completed by facility staff on 6/10/24., showed: - Severely Impaired Cognition with advanced dementia; - History of Stroke ( paralysis to one or both sides of the body); - In ability to speak, swallow, or make needs known; - Total assist of 2 people for all activities of daily living (ADL); - Staff to anticipate and meet all needs of the resident. Review of the Resident's care plan showed: - End of life with Hospice services care plan with interventions of staff to provide comfort care to the resident throughout the disease process. - Assist with ADLS as needed; No specific interventions listed to specify comfort care. - No care plan to address grooming, or oral care needs. - No care plan to address turning or repositioning of the resident. During an observation on 7/7/24 at 12:47 P.M. the Resident was seen lying in bed, breathing with mouth open, and dry thick crust build up on the tongue and roof of the mouth, lips dry and cracked with no oral care or mouth supplies available at the bedside. During an observation on 7/9/24 at 10:12 A.M., the Resident was seen lying in bed, mouth open and no oral care had been provided. The build up of secretions to mouth and tongue remain. During an interview on 7/9/24 at 9:12 A.M., CNA A said: - He/She would defer oral care to the charge nurse. - Did not know where moisturized oral care swabs were. During an interview on 7/9/24 at 4:21 P.M., NA B said: - He/She personally give's oral care at least once shift, and would report mouth changes to a charge nurse. During an interview on 07/10/24 12:46 PM the Administrator and Director Of Nursing (DON) both said: - Oral and mouth care should be provided to residents with A.M. care or as needed. 2. Review of Resident #63's admission MDS, completed on 5/31/4., showed: - Total care of all ADLS - Behaviors of refusing care. - Not cognitively intact - History of repeated UTI - Chronic Urinary Retention with a Urinary Catheter. -Diagnoses: Depression, Anxiety, Repeated Falls, Muscle weakness and wasting. During an observation on 7/7/24 at 12:47 P.M., the resident was seen lying in bed with overbed table in front of him/her with lunch tray on the overbed table and a dirty urinal collection container sitting next to a class of fresh ice water. During an observation on 7/9/24 at 10:12 A.M., the resident was seen lying in bed with urinal used to empty and measure the amount of urine in the resident's urinary collection bag, was sitting on the residents overbed table next to the residents open Pepsi, while the resident had his/her head resting on the overbed table next to the used urinal. During an interview on 7/9/24 at 9:12 A.M., CNA A said the urinal was used to measure the urinary output from the catheter bag and should be rinsed out and kept in the bathroom. During an interview on 7/9/24 at 4:21 P.M., NA B said residents urinals should not be sitting on overbed tables for residents who don't independently use a urinal to urinate in. During an interview on 7/10/24 at 12:46 P.M., the DON said resident urinals used to empty urinary drainage bags should not be left on resident overbed tables where drinks and food is placed. 4. Review of the resident council minutes, dated 5/22/24 showed: - New business: the staff are turning the call lights off, not doing the task and not returning for over 30 minutes. Review of the resident council minutes, dated 6/12/24 showed: - Old business: the residents are having trouble getting the call lights answered when they turn them on; - No follow up to indicate how it was resolved or if it had improved. During an interview on 7/9/24 at 12:33 P.M., the Activity Director said; - He/she goes over the resolution at the next meeting but did not document it in the resident council minutes. 5. Review of Resident #22's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing and transfers; - Always incontinent of bowel and bladder; - Diagnoses included: Paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and Chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's undated care plan showed: - The resident required maximum assistance of two staff for most of his/her activities of daily living (ADLs). He/she wore braces to his/her feet, legs daily and needed help to put them on. Required the assistance of two staff for bed mobility. The resident had incontinence and will ask for help to clean up; - The resident is always incontinent of bowel and bladder. Assist to the bathroom as needed. Assist with perineal cleaning as needed; - The resident had impaired vision due to glaucoma (a condition in which there is a build-up of fluid in the eye, which presses on the retina and the optic nerve). Place frequently used items in reach. During an interview on 7/7/24 at 2:48 P.M., the resident said: - He/she has waited over an hour and a half for staff to answer the call light; - It seemed the weekends the staff worked short. During an interview on 7/10/24 at 8:25 A.M., CNA B said: - The longest he/she has heard call lights going off is 25 - 30 minutes; - He/she has seen staff go in, shut the call light off and leave the room without taking care of the resident's needs. During an interview on 7/10/24 at 12:50 P.M., the Administrator said the goal was for call lights to be answered within three to five minutes and 15 minutes would be her expectation. The DON said the call lights should be answered within two to four minutes.

Based on observations, interviews, and record review, the facility failed to consider the concerns and recommendations of the resident council members and failed to communicate with the council regarding their concerns as reported by seven of the eight residents who participated in a group meeting. This had the potential to affect all the residents. The facility census was 68. Review of the facility's policy for recording and investigating grievances/complaints, revised April, 2017 showed, in part: - All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances; - Upon receiving a grievance and complaint report, the grievance and complaint report, the grievance officer will begin an investigation into the allegations; - The investigation and report will include: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged incident; the employee's account of the alleged incident, accounts of any other individuals involved and recommendations for corrective action; - The grievance officer will record and maintain all grievances and complaints on the Resident Grievances Complaint Log. The following information will be recorded and maintained in the log: the date the grievance was received; the date alleged incident took place; the name of the person investigating the incident; the date the resident, or interested party, was informed of the findings and the disposition of the grievance; - The Resident Grievance/Complaint Investigation Report Form will be filed with the Administrator within five working days of the incident; - A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed in the business office; Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. Review of the undated Resident Rights Policy, showed, in part: - Federal regulations guarantee residents certain rights and the facility must meet these requirements; - Regular in-services should include education about resident rights; - Resident has the right to voice grievances to facility or other agency that hears grievances without discrimination of reprisal and without fear of discrimination or reprisal; - Resident has the right to and the facility must make prompt efforts by the facility to resolve grievances resident may have, in accordance with this paragraph; - Facility must make information on how to file a grievance or complaint available to the resident; - Facility must establish a grievance policy to ensure prompt resolution of all grievances regarding residents' rights contained in this paragraph; - Upon request, provider must give a copy of grievance policy to resident Grievance policy must include: notifying resident of right to file grievances orally; contact information of grievance official; reasonable expected time frame for completing review of grievance; right to obtain written decision regarding grievance; right to obtain written derision regarding grievance; contact information of independent entities with whom grievances may be filed; - Maintaining evidence demonstrating results of all grievances for a period of no less than three years from issuance of grievance decision. 1. Review of the resident council minutes, dated 4/17/24 showed: - Old business: Ice water still iffy, sometimes not being passed; - Kitchen: some meats are tough and plastic silverware being handed out and can't cut it; cold eggs, burnt toast, burnt bacon, and burnt cookies; - Sometimes the beds are not stripped on shower days; - The notes did not indicate how the old business concerns were addressed or if they were resolved to the residents' satisfaction. 2. Review of the resident council minutes, dated 5/22/24 showed: - Old bushiness: Nursing: Certified Nurse Aide (CNA) being told about resident needing medications and nurse or ladies are not replying for an hour or longer; changing beds on shower days, not happening; resident told staff about bed being wet and CNA gave the resident the pads and left the room; - The notes did not indicate how the old business concerns were addressed or if they were resolved to the residents' satisfaction. 3. Review of the resident council minutes, dated 6/12/24 showed: - Old business: Nursing: staff turning off lights and not doing task and not coming back for over 30 minutes; beds not being made until late in the day; - Kitchen: did good on sandwich meat for a few meals and now back to one slice of meat on sandwich; not being asked what they want for meals on halls and in the dining room; fried potatoes are burnt on the outside and raw in the middle; food portions too small; - The notes did not indicate how the old business concerns were addressed or if they were resolved to the residents' satisfaction. 4. During a group interview on 7/8/24 at 2:01 P.M., seven of the eight residents in attendance said: - They did not get any follow up from their concerns voiced during the resident council meetings; - All eight residents were unaware of how to fill out a grievance or who to talk to. During an interview on 7/9/24 at 12:33 P.M., the Activity Director said; - He/she goes over the resolution at the next meeting but did not document it in the resident council minutes. During an interview on 7/10/24 at 12:50 P.M., the Director of Nursing (DON) said: - She would expect the resident's concerns to be addressed at the following meeting and documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to hold residents' moneies separate from facility money when they did not reiumburse residents and/or their responsible partiies after the residents were discharged , which affected nine of 17 sampled residents. The facility census was 68. Facility did not provide a policy on refunds; Review of Resident Rights Policy, undated, showed: -Resident has a right to manage their financial affairs, including right to know , in advance, what charges a facility may impose against their personal funds; -If a resident chooses to deposit personal funds with facility, upon written autohrization of a resident, facility must act as a fiduciary of resident's funds and hold, safeguard, manage, and account for all personal funds. -Facility must no timpose a charge aganist personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare; -During course of a covered Medicare or Medicaid stay, facilityies must not charge a resident for folloiwng categories of items or services: nursing services, food and nutrition services, activites program, room/bed maintenance, routine personal hygiene items, medical related social service, hospice services, 1. Review of the facility's Interim Aged Analysis Report, dated 7/9/24, showed: -Resident #219, discharged on 2/27/23, had a negative balance of $-20.00; -Resident #220, dischared on 5/25/23, had a negative balance of $-1,225.00; -Resident #224, discharged on 12/7/23, had a negative balance of $-4,000.00, check was not issued to resident's family until 7/8/24; -Resident #223, discharged [DATE], had a negative balance of $-3,940, check was not issued to resident's family until 7/8/24; -Resident #222 discharged [DATE], had a negative balance of $-57.00; -Resident #223 discharged on 5/28/23, had a negative balance of $-248.10; -Resident #224 discharged on 2/29/24, had a negative balance of $-21,735.00, check was not issued to resident until 7/8/24; -Resident #225 discharged on 2/1/23, had a negative balance of $-1,100.00; -Resident #228 discharged on 12/28/23, had a negative balance of $-636.12. Observation on 7/9/24 at 12:14 P.M. showed: -BOM (Business Office Manager) had checks on his/her desk to be mailed to discharged and deceased residents; -Review of facility copies of checks issued showed check #19187 was issued to Resident #220's family on 7/8/24, #19188 was issued to resident #224's family on 7/8/24, #19190 was issued to Resident #221's family on 7/8/24, and check #19189 was issued on 7/8 to Resident #228's family. During an interview on 7/9/24 at 12:14 P.M., Business Office Manager said: -He/She started position in December 2023; -Facility had 30 days to return resident funds after a resident expired; -If resident was private pay money goes back to resident's family; -If resident was medicaid resident he/she submits a notce to medicaid and family could bring in a receipt for funeral expenses that he/she could authorize payment to; -When he/she determines a refund needed issued he/she would submit a fund request to corporate office to issue a check to resident or resident's family members; -Resident #219 had been trying to obtain resident's spouse information. If he/she could not get a hold of resident's family member the funds would go to unclaimed property. He/She had no record of documentation of letter's sent to resident's spouse. -Resident #220 expired on 5/25/23. Facility issued check #19187 as of 7/8/24, and daughter came to facility to pick up check on 7/9/24. Refund request was sent to corporate on 6/13/24. -Resident #224 had expired 12/7/23. He/She submitted the refund request to corporate office on 3/25/24. Corporate just printed check #19188 on 7/8/24. The previous business office manager had also submitted a prior refund request that had not been issued. -Resident #221 died on [DATE]. Refund request was submitted to corporate by him/her on 6/13/24. Corporate did not issue a check until 7/8/24 with check #19190. He/She was expecting resident's wife to come to facility to pick up check that day. He/She was aware that the last business office manager submitted a refund request in October 2023 for this resident. -Resident #222 discharged [DATE], resident's refund was requested 5/17/2016 in notes that were written by former bookkeeper. Another request was submitted to corporate in February 2023. At that time corporate had not issued a check for resident. -Resident #223 discharged [DATE]. A check request to the estate had not been made; -Resident #224 discharged [DATE]. A refund request was sent to corporate on 6/13/24. A check was just mailed to resident on 7/9/24 in the amount of $21,000. Resident had paid for her stay every month and Medicaid started paying in December on resident. -Resident #225 discharged on 2/1/23. He/She had not submitted a refund request for this resident as he/she had not worked his/her way all the way though the Aging Report yet. -Resident #228's refund was requested 3/5/24. Resident passed away on 12/28/23. He/She just received check #19189 on 7/8/24 in amount of $636.12. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected resident funds to be returned when a resident expired or discharged if they were Medicaid resident within thirty days and if private pay resident within five days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #6's Quarterly MDS, dated [DATE], showed: -He/She had moderately impaired cognition; -He/She had unclear speech; -He/She responded adequately to simple, direct communication only and had clear comprehension of others; -He/She had impairments to both sides of upper extremities; -He/She was dependent on wheelchair; -He/She required substantial/maximal assistance with eating, oral hygiene, personal hygiene, rolling left and right and going from sitting to lying positions; -He/She was dependent on staff for bathing, dressing, toileting, and transfers; -Diagnoses included: Diabetes (too much sugar in the blood), Cerebral palsy (a congenital disorder of movement, muscle tone, or posture), Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), need for assistance with personal care, Gastrostomy (an external opening to the stomach for nutritional support or gastric decompression), repeated falls, and apraxia (cause by brain disease or damage, the brain is unable to make and deliver correct movement instructions to the body). Review of care plan, dated [DATE], showed: -Honor wishes to be a do not resuscitate code status. Review of physician's orders, dated [DATE], showed: -No code status on physician's orders. Review of electronic medical resident on [DATE], showed: -Resident was a do not resuscitate; Review of code status book showed: -Do not resuscitate outside the hospital purple sheet dated [DATE]; 3. Review of Resident #18's, Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a wheelchair; -He/She required set up or clean up assistance with eating, oral care, and personal hygiene; -He/She was dependent for toileting, lower body dressing; -He/She required substantial to maximal assistance with bathing, dressing, position from sitting to lying or lying to sitting, and transfers to toilet, tub, bed, and chairs; -Diagnoses included: Multiple sclerosis (disease in which the immune system eats away at protective covering of nerves), Trigeminal neuralgia (a chronic pain condition affecting the trigeminal nerve in the face), Carpal tunnel syndrome (numbness or tingling in the hand and arm caused by a pinched nerve in the wrist), and lack of coordination. Review of care plan, dated [DATE], showed: -Honor resident's wishes to be a full code status Review of physician's orders, dated [DATE], showed: -No order for a code status. Review of electronic medical record, dated [DATE], showed: -Resident was do not resuscitate; Review of code status book showed; -Do not resuscitate outside the hospital purple sheet dated [DATE] 4. Review of Resident #29's Quarterly MDS, dated [DATE], showed: -He/She was severely cognitively impaired; -He/She had unclear speech, and difficulty communicating some words and understanding some intent of messages; -He/She had impairment to one side of upper and lower extremities; -He/She was dependent for bathing, personal hygiene, dressing, toileting, and oral care; -He/She was dependent for transfers from chair to bed; -He/She required substantial to maximal assistance when rolling left and right; -Diagnoses included: Hemiplegia (muscle weakness or partial paralysis on one side of the body), aphasia (A language disorder that affects a person's ability to communicate), Dementia (impairment of at least two brain functions such as memory loss and judgement), Stroke (damage to the brain from interruption of blood supply), and Seizures (a sudden, uncontrolled burst of electrical activity in the brain). Review of care planned, dated [DATE], showed: -Honor resident's wishes to be a do not resuscitate; Review of physician's orders, dated [DATE], showed: -No order for a code status on the physician's orders. Review of electronic medical record, dated [DATE], showed: -Resident was do not resuscitate; Review of code status book showed; -Do not resuscitate outside the hospital purple sheet dated [DATE]. 5. Review of Resident #33's Annual MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She was dependent on a wheelchair; -He/She required supervision or touching assistance for toileting; -He/She required substantial to maximal assistance with bathing; -He/She required set up or clean up assistance with personal hygiene and dressing; -Diagnoses included: Stroke (damage to the brain from interruption of blood supply), Arthritis (joint pain or stiffness), Hemiplegia (muscle weakness on one side of the body that affected arms, legs, and facial muscles), and need for assistance with personal care. Review of care plan, dated [DATE], showed: -Honor wishes to be a full code status; Review of physician's orders, dated [DATE], showed: -No code status on physician's orders. Review of electronic medical record on [DATE], showed: -Attempt cardio pulmonary resuscitation; Review of code status book showed: -No DNR found; Based on interviews and record review, the facility failed to clarify the code status (whether the resident wished to have cardio-pulmonary resuscitation- CPR) of six of the 17 sampled residents, (Resident #22,#63,#6,#18,#29, and #33), and failed to ensure the appropriate code status was listed in the medical record and care planned correctly. The facility census was 68. Review of the facility's Advance Directive Policy dated April, 2013., showed: -Advance Directives will be respected in accordance with state law and facility policy. -The physician will provide an order for Do Not Resuscitate or Full Code. -The care plan will reflect the residents treatment preferences of their Advance Directive. -The Intradisciplinary team will review the Advance Directives ongoing reviews of each residents Advance Directive as needed and yearly. -The Director of Nursing or designee will ensure that appropriate physician orders for Advance directives are obtained and documented in the resident's medical record, and plan of care. 1. Review of Resident #63's admission MDS, completed on [DATE]., showed: - Total care of all ADLS - Behaviors of refusing care. - Not cognitively intact - History of repeated UTI - Chronic Urinary Retention with a Urinary Catheter. -Diagnoses: Depression, Anxiety, Repeated Falls, Muscle weakness and wasting. Review of the residents [DATE] medical record showed: - Resident #63's face sheet did not contain a code status. - There was no physician order for a code status. 6. Review of Resident #22's Outside the Hospital Do Not Resuscitate (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, CPR, if the resident's breathing stops or if a resident's heart stops beating) order, showed: - [DATE]- it was signed by the resident and by the physician. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing and transfers; - Always incontinent of bowel and bladder; - Diagnoses included paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's POS dated July, 2024 showed: - Did not have an order for the resident's code status. Review of the resident's undated care plan, showed: - The code status was a Do Not Resuscitate (DNR). See POS for code status; - Ensure code status is updated yearly or with a significant change in condition. Review of the resident's face sheet showed: - The resident was admitted on [DATE]; - The resident's code status was DNR. During an interview on [DATE] at 12:15 P.M., The Director of Nursing said: - The face sheet should contain the code status of the resident. - There should be a physician order for every resident's code status. During an interview on [DATE] at 12:20 P.M., the Administrator said all resident's should have an order for their code status, it should be on the face sheet, it should be care planned, and it should match in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 7/7/24 at 8:41 A.M. showed staff pulling a chiar over black spot on floor next to wall in seating area by television room between 200 and 400 halls. Observation on 7/7/24 at 8:44 A.M. showed strong odor of urine in 300 hall. Observation on 7/7/24 at 8:49 A.M. showed paint chipping off ceiling in kitchen and spots of drywall have been patched but have not been sanded or painted. Observation on 7/7/24 at 10:29 A.M. of room [ROOM NUMBER] showed floor was sticky, strong odor of urine coming from wheelchair pad in room. Observation on 7/7/24 at 10:31 A.M. of room room [ROOM NUMBER] showed strong potent odor of urine noted in doorway of room. Observation on 7/7/24 at 10:36 A.M. of room [ROOM NUMBER] showed paint was missing at head of bed where wall had been scraped by headboard. Observation on 7/7/24 at 11:08 A.M. of room [ROOM NUMBER] showed paint missing from wall at head of bed and chair in room. Observation on 7/8/24 10:24 A.M. showed spilled milk in hallway outside room [ROOM NUMBER]. Observation on 7/08/24 at 10:53 A.M. showed strong odor of feces in 300 hall outside of room [ROOM NUMBER] and 307. No staff present in area. Observation on 7/8/24 at 1:13 P.M. showed chocolate milk spilled on floor in room [ROOM NUMBER]. Observation on 7/8/24 at 1:40 P.M. showed in room [ROOM NUMBER] there was a 10 inch hole noted in curtain to bathroom door covering, paint missing from wall from furniture gouges at head of bed. Observation on 7/9/24 at 8:05 A.M. showed paint is chipping and coming up around ceiling vents, bubbling from around vents; Observation on 7/9/24 at 8:11 A.M. showed in the living room seating area by nurses station between 200 and 400 halls showed a black circle spot on floor. Observation on 7/9/24 at 2:37 A.M. showed six food trays out on tables in dining room with exposed food. Flies flying around trays. Observation on 7/9/24 at 3:56 A.M. showed feet sticking to floor outside of room [ROOM NUMBER]. Observation on 7/09/24 at 3:57 A.M. showed bathroom curtain was torn in room [ROOM NUMBER]. Observation on 7/10/24 at 9:03 A.M. showed milk spoilled over floor in room [ROOM NUMBER]. Over bed table had sticky substance stuck to it. During an interview on 7/9/24 at 4:53 A.M., Certified Nurse Aide (CNA) D said: -Strong odors of urine were from residents not getting incontinent care frequently enough or staffing not doing regular bed checks; During an interview on 7/9/24 at 12:07 P.M., Maintenance Director said: -The spot on floor between 200 and 400 hall is from a shower leak coming from the wall that he/she thought he/she had fixed, water was coming through the corner of tile in the shower wall in the room on the other side; -Pest control company had been to facility monthly targeting ants in building -Maintenance items are logged on a clip board at each nurses station; -He/She did paint and wall patches in resident rooms, there had been an issue matching wall colors in resident rooms due to the variety of colors but wall colors have been minimized to make repairs easier. Based on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for Resident #23, and common areas on the 200 & 300 halls. The facility census was 68. Review of the facility's undated Resident Rights Policy., included the resident has the right to live in a safe, clean, and homelike enviornment. 1. Review of Resident #23's 5 Day Medicare MDS (Minimum Data Set), a mandatory assessment completed by facility staff, completed on 5/17/24., showed: -The resident was re-admitted from hospital with infected hardware from hip repair; -History of Multi Drug Resistant Organisms; -Impaired Cognition; -Assistance with all Activities of daily living (ADL); -Diagnoses: Anxiety, Delusional Disorders (altered reality), Fracture of left femur bone, Significantly impaired mobility upper and lower extremities, as well as back and spinal disorders, and Depression. Observation on 7/7/24 at 10:05 AM showed: -Resident lying on bed with no blanket, sheet only, and call light lying on the floor. -Resident's floor of room with dirty build up wax on the floor, dull, and sticky with build up of dirt around base trim and wall/door edges. Observation on 7/8/24 at 10:11 A.M showed: -Resident's room unkept with linen on the floor, food on the floor, and call light out of reach lying on the floor under the bed and not attached to the bed. Observation on 7/9/24 at 2:20 P.M. showed: -Resident's room unkept with trash, linen, call light on the floor and resident without any sheet or cover; -The room was cold and resident was shaking asking for a blanket. Observation on 07/09/24 09:00 showed NA A went in to assist Resident #23 with tray delivery, did not ensure call light was in place, did not offer to assist the resident, and did not offer the resident any bed linens or pick up the residents belongings lying on the floor. 2. Observation of the 400 hall showed: - The handrails on each side of the cooridoor walkway missing wood chunks and varnish sealant. - Every resident room door on the 400 hall has missing paint During an interview on 07/10/24 12:36 P.M., the Houskeeping Supervisor said: - She does the stripping and waxing. - She does not currently have a floor tech. - She trys to strip and wax floors when people are out of the rooms, and when the room is empty. - There is no current schedule for stripping and waxing floors. - We have a hard time keeping staff in housekeeping. - Residents have the right to a clean room. -The resident rooms should be cleaned daily. During an interview on 7/10/24 at 12:45 P.M., the Administrator said: - Three rooms a month should be stripped and new waxing done to the floors. - Resident rooms should be cleaned daily.

Based on interviews and record review, the facility failed to ensure residents knew how to file a grievance. This affected any resident wanting to file a grievance. The facility census was 68. Review of the undated resident rights, showed, in part: - Federal regulations guarantee residents certain rights and the facility must meet these requirements; - Regular in-services should include education about resident rights; - Resident has the right to voice grievances to facility or other agency that hears grievances without discrimination of reprisal and without fear of discrimination or reprisal; - Resident has the right to and the facility must make prompt efforts by the facility to resolve grievances resident may have, in accordance with this paragraph; - Facility must make information on how to file a grievance or complaint available to the resident; - Facility must establish a grievance policy to ensure prompt resolution of all grievances regarding residents' rights contained in this paragraph; - Upon request, provider must give a copy of grievance policy to resident Grievance policy must include: notifying resident of right to file grievances orally; contact information of grievance official; reasonable expected time frame for completing review of grievance; right to obtain written decision regarding grievance; right to obtain written derision regarding grievance; contact information of independent entities with whom grievances may be filed; - Maintaining evidence demonstrating results of all grievances for a period of no less than three years from issuance of grievance decision. 1. Review of the resident council minutes, dated 4/17/24 showed: - Resident rights reviewed: confidentiality. 2. Review of the resident council minutes, dated 5/22/24 showed: - Resident rights reviewed: privacy and respect. 3. Review of the resident council minutes, dated 6/12/24 showed: - Resident rights reviewed: communicate freely. 4. During a group interview on 7/8/24 at 2:01 P.M., all eight residents in attendance said: - They were unaware of how to fill out a grievance or who to talk to. During an interview on 7/9/24 at 12:33 P.M., the Activity Director said; - He/she discussed grievances at th resident council meetings; - Grievance forms are located at both nurse's stations and in front of his/her office. During an interview on 7/10/24 at 12:50 P.M., the Director of Nursing (DON) said the residents should be aware of the location of the grievance forms and how to fill them out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop individualized person centered comprehensive care plans for three of 17 sampled (Resident #18, #43, and #34) when shower preferences (Resident #18), shaving and nail care preferences (Resident #43), comfort care measures (Resident #34), oral care (Resident #34), risk for skin integrity (Resident #34), repositioning of resident (Resident #34) , and therapeutic activities and psychosocial needs (Resident #34) were not care planned. The facility census was 68. Review of facility policy, Care Plans Comprehensive Person-Centered, revised March 2022, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. -Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: -Participate in establishing the expected goals and outcomes of care; -Participate in determining the type, amount, frequency, and duration of care; -Receive the services and/or items included in the plan of care; -The comprehensive, person-centered care plan: -Includes measurable objectives and time frames; -Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Which professional services are responsible for each element of care; -Reflect currently recognized standards of practice for problem areas and conditions; -Services provided for or arranged by the facility and outlined in the comprehensive care plan are: -Provided by qualified persons; -Culturally competent; and -Trauma-informed; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes; -The interdisciplinary team reviews and updates the care plan: -when there has been a significant change in the resident's condition; -when the desired outcome is not met; -when the resident has been readmitted to the facility from a hospital stay, and -at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Review of Resident #18's, Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a wheelchair; -He/She required substantial to maximal assistance with bathing; -Diagnoses included: Multiple sclerosis (disease in which the immune system eats away at protective covering of nerves), Trigeminal neuralgia (a chronic pain condition affecting the trigeminal nerve in the face), Carpal tunnel syndrome (numbness or tingling in the hand and arm caused by a pinched nerve in the wrist), and lack of coordination. Review of care plan, dated 5/10/21, showed: -He/She required bathing assistance of one staff; -He/She had weakness due to multiple sclerosis and needed help with activities of daily living; -He/She required staff assistance with mobility; -Care plan did not show resident's shower preferences to include how often resident preferred to be showered or the time of day. Review of care plan conference summaries, showed: -On 10/10/23 resident complained showers were not completed as often as he/she wanted them to be done and there was too many days between showers; Review of shower schedule showed resident was scheduled to receive showers on Tuesdays and Fridays; During an interview on 7/7/24 at 10:08 A.M., Resident said he/she would like a shower twice a week. His/her last shower was on 7/2/24. He/She did not get showers as often as he/she liked because shower aides got pulled to work the floor when staff members called in. Review of shower logs dated 4/1/24 to 6/30/24, showed: -Showers were received on 4/1, 4/8, 4/16, 4/22, 4/30, 5/7, 5/14, 5/20, 5/27, 6/3, 6/12, 6/21, and 6/26. -He/She received one shower every nine days; -He/She received five showers in April; -He/She received four showers in May; -He/She received four showers in June. 2. Review of Resident #43's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a wheelchair; -He/She required set up or clean up assistance with eating; -He/She was dependent for toileting, bathing, and dressing; -He/She required substantial to maximal assistance with personal hygiene; -Diagnoses included: Heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), Coronary artery disease (damage to heart's major blood vessels), Diabetes (too much sugar in the blood), and Stroke (damage to the brain from interruption of blood supply). Review of care plan, dated 2/21/23, showed: -He/She required assistance from staff with grooming and personal hygiene; -Resident required one person assistance to the sink to perform hygiene and grooming tasks; -He/She was unable to bathe independently; -He/She required one person total assistance with bathing; -He/She required two person assist with hoyer lift for transfer to the shower chair; -He/She needed a full skin evaluation weekly with bath/shower; -Activities of daily living preferences were not care planned to include shaving and nail care. During an interview on 7/7/24 at 2:30 P.M., resident said: -He/She used to shave every day prior to coming to the nursing home; -He/She preferred to be shaved daily; -Staff did not shave him regularly; -Facility sometimes shaved him with an electric razor which irritated his/her skin. -He/She had not had his/her nails cut in awhile and he/she had overgrowth. Observation on 7/7/23 at 2:30 P.M. showed resident had ¼ inch facial hair all over his/her face. Skin was observed to be dry and flaking off and flakes of skin covered his t-shirt. Resident's face was dry and flaking off. Resident's nails were observed needing cut. Observation and interview on 7/10/24 at 8:52 A.M. showed resident had not been shaved. Resident stated he/she had not yet received a shower for the week and wished to be shaved. Review of shower sheets, dated 4/1/24 to 7/1/24, showed: -4/13/24, shower received, no shaving documented, nail care was needed; -4/19/24, shower received, no shaving or nail care was documented; -5/11/24, shower received, no shaving documented, nail care was needed; -5/22/24, shower received, no shaving documented, nail care was needed; -5/28/24, shower received, no shaving documented, nail care was needed; -6/6/24, shower received, no shaving documented, nail care was needed; -6/10/24, shower received, no shaving documented, nail care was needed; -6/14/24, shower received, no shaving documented, nail care was needed; -6/21/24, shower received, no shaving or nail care was documented; -6/22/24, shower received, no shaving documented, nail care was needed; -7/1/24, shower received, no shaving or nail care was documented; Review of shower schedule showed resident was scheduled to receive showers on Tuesdays and Fridays. During an interview on 7/10/24 at 9:06 A.M., Certified Nurse Aide (CNA) B said: -He/She shaved residents when he/she had them in on shower days; -Staff did not shave residents between shower days; -Resident #43 he/she had purchased a special razor for him/her because facility purchased razors cut up his/her face; -He/She cleaned resident nails beds if they had visible gunk, and will trim nails if resident was not a diabetic; -Resident #43 had calcium build up under his/her fingernails and he/she tried to ensure nails were kept trim. During an interview on 7/10/24 at 10:16 A.M., MDS/Care Plan Coordinator said: -Care plans should be updated with resident's change in status for example if they went on hospice or came off hospice, had new orders, had falls; -He/She updated care plans quarterly and with any change in status of resident; -Resident's shower preferences should be care planned for residents who can communicate their preferences; -Shaving should be done with shower cares and he/she would not have included shaving preference in care plan; During an interview on 7/10/24 at 12:50 P.M., Administrator said: -Care plans should be individualized according to a resident's needs; -Shower preferences should be care planned; -Shaving preferences should be care planned; -The time residents chose to get up in the morning should be included in care plan. 3. Review of Resident #34's Annual MDS (Minimum Data Set), A mandated assessment completed by facility staff on 6/10/24., showed: - Severely Impaired Cognition with advanced dementia; - History of Stroke ( paralysis to one or both sides of the body); - In ability to speak, swallow, or make needs known; - Total assist of 2 people for all activities of daily living (ADL); - Staff to anticipate and meet all needs of the resident. Review of the Resident's care plan showed: - End of life with Hospice services care plan with interventions of staff to provide comfort care to the resident throughout the disease process. - No specific interventions listed to specify comfort care. - No care plan to address grooming, or oral care needs. - No care plan to address turning or repositioning of the resident. - No care plan to address risk for skin injury. - No care plan to address theraputic activities or the psychosocial needs of the resident. During an observation on 7/7/24 at 12:47 P.M. the Resident was seen lying in bed on back, breathing with mouth open, and dry thick crust build up on the tongue and roof of the mouth, lips dry and cracked with no oral care or mouth supplies available at the bedside. During an observation on 7/7/24 at 4:30 P.M., the Resident was seen in bed, lying flat on his/her back, face dirty, call light on the floor, no sheet. No change in appearance of mouth care needs since the morning. During an observation on 7/9/24 at 10:12 A.M., the Resident was seen lying in bed, mouth open and no oral care had been provided. The build up of secretions to mouth and tongue remain. During an interview on 7/9/24 at 9:12 A.M., CNA A said: - He/She would defer oral care to the charge nurse. - Did not know where moisturized oral care swabs were. - Did not know where to find a care plan, or what a care plan was. - He/She receives resident information on what residents needs are in report only. During an interview on 7/9/24 at 4:21 P.M., NA B said: - He/She personally give's oral care at least once shift, and would report mouth changes to a charge nurse. - Did not know where to locate a care plan or what a care plan should address. During an interview on 07/10/24 12:46 PM the Administrator and Director Of Nursing (DON) both said: -Care plan should reflect the care needed for each resident and be specific to each resident. -All nursing should be know what a care plan is and how to know what each residents needs are.

Based on observations, interviews and record review, the facility failed to ensure staff followed professional standards when staff failed to administer eye drops correctly which affected one of the 17 sampled residents, (Resident #26), failed to administer the correct dose of Tylenol (used to treat minor pain) for Resident #, failed to administer Flonase nasal spray (used to treat seasonal allergies) for Resident #21, and failed to allow the fingertip to air dry before obtaining the blood sugar for Resident #4 and #41. Additionally the staff failed to obtain a physician's order to obtain blood sugars for Resident #4. The facility census was 68. The facility did not provide a policy for administration of nasal sprays. Review of the manufacturer's guidelines for Flonase nasal spray, revised March 2016, showed, in part: - Blow your nose to clear your nostrils; - Close one nostril. Tilt your head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose and while breathing in, press firmly and quickly down once on the applicator to release the spray; - Repeat in the other nostril. 1. Review of Resident #21's Physician Order Sheet (POS) dated July, 2024 showed: - Start date: 6/15/24 - Flonase 50 micrograms (mcg.) two sprays in each nostril daily for sick sinus syndrome ( heart rhythm disorder). Review of the resident's Medication Administration Record (MAR), dated July, 2024 showed: - Flonase 50 mcg. two sprays in each nostril daily for sick sinus syndrome. Observation on 7/9/24 at 6:43 A.M., showed: - Certified Medication Technician (CMT) A handed the bottle of Flonase to the resident; - The resident shook the bottle, closed the right side of the nostril and administered one spray in the left nostril, closed the left side of the nostril and gave one spray in the right side of the nostril; - The resident wiped the tip of the applicator with a Kleenex and handed the bottle back to the CMT; - The resident did not give him/herself two sprays in each nostril. During an interview on 7/10/24 at 9:17 A.M., CMT A said: - If the order said two nasal sprays then that is what should have been administered by the resident or the CMT; - He/she should have instructed the resident. During an interview on 7/10/24 at 12:50 P.M., the DON said; - If the order said for two nasal sprays then that's what should be administered; - She would expect the staff to instruct the resident. 2. Review of the facility's policy for instillation of eye drops, revised January, 2014, showed, in part: - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; - Gently pull the lower eye lid down. Instruct the resident to look up; - Drop the medication into the mid lower eye lid. Do not touch the eye or eye lid with the eye dropper; - Instruct the resident to slowly close his/her eye lid to allow for even distribution of the drops. Instruct the resident not to blink or squeeze the eye lids shut, which forces the medicine out of the eye. - The policy did not indicate how long lacrimal pressure (press your fingertip against the inside corner of the eye) should be applied. Review of Resident #26's POS, dated July, 2024 showed: - Start date: 11/2/23 - Timolol maleate 0.5% eye drops, give one drop in both eyes twice daily to treat high pressure inside the eye. Review of the resident's MAR, dated July, 2024 showed: - Timolol maleate 0.5% eye drops, give one drop in both eyes twice daily to treat high pressure inside the eye. Observation on 7/9/24 at 6:53 A.M., showed: - CMT A instilled one drop in the resident's right eye and the tip of the eye dropper touched the resident's eye lashes. The resident applied lacrimal pressure for eight seconds; - CMT A instilled one drop in the resident's left eye and the tip of the eye dropper touched the resident's eye lashes. The resident applied lacrimal pressure for eight seconds. During an interview on 7/10/24 at 9:17 A.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lashes or eye lids. During an interview on 7/10/24 at 12:50 P.M., the DON and Administrator said; - The tip of the eye dropper should not touch the eye lashes or eye lids; - The policy states staff are supposed to apply lacrimal pressure for one minute. 3. Review of the facility's policy for obtaining a fingerstick glucose level, dated October, 2011, showed, in part: - The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level; - Wash the selected fingertip , especially the side of the finger with warm water and soap. If alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the reading. Review of Resident #4's POS, dated July, 2024 showed: - Did not have a physician's order to obtain the blood sugar. Review of the resident's MAR, dated July, 2024 showed: - Did not have a physician's order to obtain the blood sugar. Observation and interview on 7/9/24 at 8:00 A.M., showed: - Licensed Practical Nurse (LPN) A cleaned the resident's fingertip with an alcohol wipe, let it air dry for four seconds and obtained the resident's blood sugar; - LPN A said the resident's blood sugar was 113 and the resident would not get any sliding scale insulin. 4. Review of Resident #41's POS, dated July, 2024 showed: - Start date: 4/19/23 - Accucheck as needed for signs and symptoms of low blood sugar. Notify primary care physician if blood sugar is greater than 400 or less than 60; - Start date: - Fiasp (Novolog), fast acting insulin per sliding scale before meals and at bedtime for diabetes mellitus. Per sliding scale (150-199- give one unit). Blood sugar 160, give one unit of Novolog inuslin. Review of the resident's MAR, dated July, 2024 showed: - Fiasp (Novolog), fast acting insulin per sliding scale before meals and at bedtime for diabetes mellitus. Per sliding scale (150-199- give one unit). Blood sugar 160, give one unit of Novolog inuslin. Observation on 7/9/24 at 8:05 A.M., showed: - LPN A cleaned the resident's fingertip with an alcohol wipe, let it air dry for three seconds and obtained the resident's blood sugar; - LPN A said the resident's blood sugar was 160 and the resident would get one unit of insulin per sliding scale. During an interview on 7/10/24 at 10:37 A.M., LPN A said: - He/she should let the resident's fingertip air dry for about two or three seconds before obtaining the blood sugar; - Should have an order to check the resident's blood sugar. During an interview on 7/10/24 at 12:50 P.M., the DON said: - The fingertip should not be visibly wet, it should be air dried; - There should be an order to check the blood sugars. 5. Review of Resident #2's POS dated, July 2024 showed: - Start date: 5/13/24 - Tylenol 325 milligrams (mg.) one tab three times a day for minor pain. Review of the resident's MAR, dated July, 2024 showed: - Tylenol 325 mg. one tab three times a day for minor pain. Observation on 7/9/24 at 7:10 A.M., showed: - CMT C placed two Tylenol tabs in the medicine cup and administered to the resident. During an interview on 7/10/24 at 9:09 A.M., CMT C said; - If the order said for one Tylenol, then that's what should be administered; - He/she should follow the physician's orders. During an interview on 7/10/24 at 12:50 P.M., the DON said: - If the order said for one tab of Tylenol, then staff should only administer one tab.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #10's Quarterly Minimum Data Set (MDS), dated , 6/26/24, showed: - Resident was admitted on [DATE]; - Brief interview for mental status (BIMS) score of 14, indicating the resident was not cognitively impaired; - Two person partial/moderate assistance required for personal hygiene, dependent with Sit to Stand mechanical lift for transfers, and for bathing; - Occasionally incontinent of urine; - Uses a wheelchair for mobility; - Diagnoses included: Depression, Stroke, Hypertension (high blood pressure), Hemiplegia (paralysis of one side of the body), Anxiety disorder, and Cardiac arrhythmia (irregular heartbeat). Review of the resident's care plan, dated 6/20/24, showed: - The resident is monitored for signs of emotional distress with incontinence; - Assessments of fluid intake and hydration status are required; - Resident requires assist to bathroom or commode and requires one person assistance; - Staff to give verbal cues to help prompt and transfer to toilet. Observation and interview on 7/8/24, at 9:53 A.M., showed: - The resident had oily hair; - The resident said he/she felt embarrassed because he/she is only getting one shower a week. - The resident said he/she does not like hair being oily and would like to feel clean. - Resident stated that showers are scheduled for Tuesday and Saturday weekly but rarely happen. Review of shower sheets on 7/9/24 at 7:14 A.M., showed: - In 30 day period in June 2024 resident received 5 showers and should have had 8 showers; - In 31 day period in May 2024 resident received 3 showers and should have had 9 showers; - In 30 day period in April 2024 resident received 5 showers and should have had 9 showers; During an interview on 7/10/24, at 12:50 P.M.: The Director of Nursing., said: - Residents getting showers twice a week has been a struggle. - The expectations is that residents receive showers twice a week. - Shower aides get pulled to the floor sometimes instead of administering showers. During an interview on 7/10/24 at 12:55 P.M., the Administrator said: -The expectation is that residents get showers twice a week. MO237626 3. Review of Resident #18's, Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a wheelchair; -He/She required substantial to maximal assistance with bathing; -Diagnoses included: Multiple sclerosis (disease in which the immune system eats away at protective covering of nerves), Trigeminal neuralgia (a chronic pain condition affecting the trigeminal nerve in the face), Carpal tunnel syndrome (numbness or tingling in the hand and arm caused by a pinched nerve in the wrist), and lack of coordination. Review of care plan, dated 5/10/21, showed: -He/She required bathing assistance of one staff; -He/She had weakness due to multiple sclerosis and needed help with activities of daily living; -He/She required staff assistance with mobility; -Care plan did not show resident's shower preferences to include how often resident preferred to be showered and time of day. Review of care plan conference summaries, showed: -On 10/10/23 resident complained showers were not completed as often as he/she wanted them to be done and there was too many days between showers; Review of shower schedule showed resident was scheduled to receive showers on Tuesdays and Fridays; During an interview on 7/7/24 at 10:08 A.M., Resident said he/she would like a shower twice a week. His/her last shower was on 7/2/24. He/She did not get showers as often as he/she liked because shower aides got pulled to work the floor when staff members called in. Review of shower logs dated 4/1/24 to 6/30/24, showed: -Showers were received on 4/1, 4/8, 4/16, 4/22, 4/30, 5/7, 5/14, 5/20, 5/27, 6/3, 6/12, 6/21, and 6/26. -He/She received one shower every nine days; -He/She received five showers in April; -He/She received four showers in May; -He/She received four showers in June. 4. Review of Resident #43's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a wheelchair; -He/She required set up or clean up assistance with eating; -He/She was dependent for toileting, bathing, and dressing; -He/She required substantial to maximal assistance with personal hygiene; -Diagnoses included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), coronary artery disease (damage to heart's major blood vessels), diabetes (too much sugar in the blood), and stroke (damage to the brain from interruption of blood supply). Review of care plan, dated 2/21/23, showed: -He/She required assistance from staff with grooming and personal hygiene; -Assist him/her to the sink to perform hygiene and grooming tasks; -He/She was unable to bathe independently; -He/She required one person total assistance with bathing; -He/She required two person assist with hoyer lift for transfer to the shower chair; -He/She needed a full skin evaluation weekly with bath/shower; -Activities of daily living preferences were not care planned to include shaving and nail care. During an interview on 7/7/24 at 2:30 P.M., resident said: -He/She used to shave every day prior to coming to the nursing home; -He/She preferred to be shaved daily; -Staff did not shave him regularly; -Facility sometimes shaved him with an electric razor which irritated his/her skin; -He/She had not had his/her nails cut in awhile and he/she had overgrowth. Observation on 7/7/23 at 2:30 P.M. showed resident had ¼ inch facial hair all over his/her face. Skin was observed to be dry and flaking off and flakes of skin covered his t-shirt. Resident's face was dry and flaking off. Resident's nails were observed needing cut. Observation and interview on 7/10/24 at 8:52 A.M. showed resident had not been shaved. Resident stated he/she had not yet received a shower for the week and wished to be shaved. Review of shower schedule showed resident was scheduled to receive showers on Tuesdays and Fridays. Review of shower sheets, dated 4/1/24 to 7/1/24, showed: -2 showers received in April; -3 showers received in May; -5 showers received in June; -4/13/24, shower received, no shaving documented, nail care was needed; -4/19/24, shower received, no shaving or nail care was documented; -5/11/24, shower received, no shaving documented, nail care was needed; -5/22/24, shower received, no shaving documented, nail care was needed; -5/28/24, shower received, no shaving documented, nail care was needed; -6/6/24, shower received, no shaving documented, nail care was needed; -6/10/24, shower received, no shaving documented, nail care was needed; -6/14/24, shower received, no shaving documented, nail care was needed; -6/21/24, shower received, no shaving or nail care was documented; -6/22/24, shower received, no shaving documented, nail care was needed; -7/1/24, shower received, no shaving or nail care was documented; During an interview on 7/10/24 at 9:06 A.M., Certified Nurse Aide (CNA) B said: -He/She shaved residents when he/she had them in on shower days; -Staff did not shave residents between shower days; -Resident #43 he/she had purchased a special razor for him/her because facility purchased razors cut up his/her face; -He/She cleaned resident nails beds if they had visible gunk, and will trim nails if resident was not a diabetic; -Resident #43 had calcium build up under his/her fingernails and he/she tried to ensure nails were kept trim. 5. Review of Resident #29's Quarterly MDS, dated [DATE], showed: -He/She was severely cognitively impaired; -He/She had unclear speech, and difficulty communicating some words and understanding some intent of messages; -He/She had impairment to one side of upper and lower extremities; -He/She was dependent for bathing, personal hygiene, dressing, toileting, and oral care; -He/She was dependent for transfers from chair to bed; -He/She required substantial to maximal assistance when rolling left and right; -Diagnoses included hemiplegia (muscle weakness or partial paralysis on one side of the body), aphasia (A language disorder that affects a person's ability to communicate), dementia (impairment of at least two brain functions such as memory loss and judgement), stroke (damage to the brain from interruption of blood supply), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). Review of care plan, undated, showed: -Allow resident opportunities to make choices and participate in cares as is safe for him/her; -He/She needed help with clothing adjustment, sometimes he/she could help with good arm; -Unable to complete self cares due to stroke; -Full assist needed with dressing, personal hygiene, bathing, and oral care; -He/She needed assistance of one for personal hygiene, shaving, oral care, face washing, and hair grooming. -He/She had history of aggressive behaviors with activities of daily livings; -If he/she refused cares, wait and return in fifteen minutes or have another staff ask me. Observation on 7/7/24 at 3:03 P.M. showed resident wearing hospital gown, hair unkempt, resident was unshaved with quarter inch of facial hair growth on face. Observation on 7/8/24 at 1:13 P.M. showed resident in bed wearing hospital gown, hair unkempt, and unshaved. Review of shower schedule showed resident was scheduled to receive showers on Tuesdays and Fridays. Review of shower sheets, dated 4/1/24 to 6/30/24, showed: -2 showers received in April on 4/8 and 4/26; -5 showers received in May on 5/3, 5/9, 5/16, 5/22, and 5/28; -4 showers received in June on 6/5, 6/10, 6/20, and 6/27; -No shaving documented on shower sheets. During an interview on 7/10/24 at 9:06 A.M., CNA B said: -He/She shaved resident when he/she came to receive showers on shower days; -He/She did not know why resident was only wearing hospital gown, resident had clothes; During an interview on 7/8/24 at 1:44 P.M., Certified Nurse Aide (CNA) A said: -Shower aide is pulled from doing showers to work the floor so showers do not get done; During an interview on 7/9/24 at 3:09 A.M., Nurse Aide (NA) A said: -There was not enough staff to accomodate residents receiving two showers per week; -Shower aide was pulled from doing showers to help work on the floor. During an interview on 7/9/24 at 4:53 A.M., CNA D said: -Residents will usually get one shower a week but not two showers weekly due to staffing shortages; During an interview on 7/9/24 at 6:36 A.M., CNA D said: -He/She had residents complain about not getting enough showers; -He/She did not do showers on evening shift or at night unless a nurse specifically asked them to complete a shower; -There was one specific staff assigned to showers. During an interview on 7/9/24 at 9:06 A.M., CNA B said: -He/She was pulled form doing showers on 7/8/24; -He/She had lost count how many times he/she was pulled to work floor and unable to give showers; -There had been times residents did not get showers at all in a week; -There is one other staff person that will do showers; -He/She shaved residents when he/she had them in the shower; -He/She filled out shower sheets when he/she completed showers; -He/She cleaned nailbeds of residents with visible garb and will trim resident nails if they are not a diabetic resident; -No staff member shaves residents between shower days; -He/She did not document shaving or nail care on shower sheets. Based ob observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of the 17 sampled residents, (Resident #18, #22 and #25), failed to provide AM care for Resident #25, and failed to ensure showers were completed for for Resident #10, #18, #29 and #43. Additionally, the facility failed to ensure shaving was completed for Resident #29 and #43. The facility census was 68. Review of the facility's policy for shower/tub bath, revised February, 2018, showed, in part: - The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; - Documentation included: the date and time other shower/tub bath was performed; then name and title of the individual who assisted the resident with the shower/tub bath; all assessment data (e.g. any reddened areas, sores, etc. on the resident's skin) obtained during the shower/tub bath; how the resident tolerated the shower/tub bath; if the residetn refused the shower/tub bath, the reasons why and the intervention taken; the signature and title of the person recording the data. Review of the skin monitoring: comprehensive Certified Nurse Aide (CNA) shower review showed it also indicated if the resident needed toenails cut, nail care provided, bed stripped, wiped, down and made with clean linen and if the resident was shaved. Review of the facility's policy for supporting activities of daily living (ADLs), revised March 2018, showed in part: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; - Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; - Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing ADLs are unavoidable; - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing grooming and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks) and communication (speech, language, and any functional communication systems); - The resident's response to interventions will be monitored, evaluated and revised as appropriate. Review of the facility's policy for care of fingernails/toenails, revised February, 2018, showed in part: - The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections; - Documentation: the following information should be recorded in the resident's medical record: the date and time that nail care was given; the name and title of the individuals who administered the nail care; the condition of the resident's nails and nail bed, including: redness or irritation of skin of hands and feed; breaks or cracks in skin, especially between toes; pale, bluish, or gray discoloration of feet; bluish or dark color of nail beds; corns or calluses; ingrown nails; bleeding ; and /or pain and any difficulty in cutting the resident's nails. Review of the facility's policy for shaving the resident, revised February, 2018 showed, in part: - The purpose of this procedure is to promote cleanliness and to provide skin care; - Review the resident's care plan to assess for any special needs of the resident; - Documentation: the following information should be recorded in the resident's medical record: the date and time that the procedure was performed; the name and title of the individual who performed the procedure; in and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure; any problems or complaints made by the resident related to the procedure; if the resident refuse the treatment, the reasons why and the intervention taken; the signature and title of the person recoding the data; - Notify the supervisor if the resident refuses the procedure. Review of the facility's policy for urinary catheter care (sterile tube inserted into the bladder to drain urine), revised August, 2022 showed, in part: - The purpose of this procedure is to prevent urinary catheter - associated complications, including urinary tract infections; - Ensure the catheter drainage bag is placed in a dignity bag for privacy and dignity; - Routine perineal hygiene: Separate the skin folds, use a wash cloth with warm water or wipe, to cleanse the skin folds. Use one area of the wash cloth or wipe for each downward, cleansing stroke; do not allow the wash cloth or wipe to drag on the resident's skin or bed linen; - For the male resident: Use a wash cloth with warm water or wipe to cleanse around the skin folds; separate the skin folds using circular strokes from the inside outward; change the position of the wash cloth or wipe with each cleansing stroke; return the skin folds to the normal position. Review of the facility's policy for perineal care, revised March, 2022 showed, in part: - The purpose of the's procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; - For female residents: wash the perineal area, wiping from front to back. Separate the skin folds and wash area downward from front to back. Continue to wash the perineum moving form inside outward to the thighs. Wash the rectal area thoroughly, wiping from the base of the skin folds towards and extending over the buttocks; - For the male resident:Wash perineal area starting with the skin fold and working outward. Retract the skin fold of the uncircumcised male. Wash and rinse the skin folds using a circular motion. Continue to wash the perineal area including all the skin folds and inner thighs. Reposition the skin fold of the uncircumcised male. Was the rectal area thoroughly, including the area under the skin fold, the anus and the buttocks. 1. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/28/24 showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing and transfers; - Always incontinent of bowel and bladder; - Diagnoses included paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's undated care plan showed: - The resident required maximum assistance of two staff for most of his/her activities of daily living (ADLs). He/she wore braces to his/her feet, legs daily and needed help to put them on. Required the assistance of two staff for bed mobility. The resident had incontinence and will ask for help to clean up; - The resident is always incontinent of bowel and bladder. Assist to the bathroom as needed. Assist with perineal cleaning as needed Observation on 7/9/24 at 2:56 A.M., showed: - Nurse Aide (NA) D and Certified Nurse Aide (CNA) D unfastened the resident's wet, soiled brief; - CNA D turned the resident on his/her side and wiped front to back multiple times with fecal material on each new wipe; - CNA D used a new wipe and used the same area of the wipe to clean a smear of fecal material on the buttocks then wiped the rectal area; - CNA D removed the soiled, wet brief and placed a clean incontinent brief under the resident; - CNA D and NA D turned the resident side to side in bed and fastened the clean incontinent brief; - CNA D did not provide peri care to the front perineal folds. During an interview on 7/10/24 at 6:35 A.M., CNA D said: - He/she should not use the same area of the wipe to clean different areas of the skin; - He/she should separate and clean all areas of the skin where urine or feces had touched; - Should not fold the wipe; - He/she should have cleaned the front skin folds. 2. Review of Resident #25's Quarterly MDS, dated [DATE] showed: - Long and short term memory problems; - Upper and lower extremities impaired on both sides; - Dependent on the staff for eating, oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included Alzheimer's disease ( a progressive disease that destroys memory and other important mental functions), dementia (inability to think), anxiety, depression and COPD. Review of the resident's undated care plan showed: - The resident was dependent on staff for ADLs. Staff have to brush the resident's hair, wash face and hands. Required full staff assistance of one staff for bathing, all personal cares, and oral care for the resident's own teeth. Required full staff assistance of two staff for dressing; - The resident was incontinent of bowel and bladder. Check the resident every two hours in bed for incontinence. Required full assistance of two staff for incontinent care. Check the resident before and after meal and at bedtime for incontinent care needed. Observation on 7/9/24 at 4:21 A.M., showed: - NA D uncovered the resident, unfastened the wet and soiled incontinent brief; - NA D wiped down one side of the resident's groin and used the same area of the wipe and wiped down the other side of the groin then turned the resident on his/her side; - NA D wiped down one side of the buttocks and with same area of the wipe, cleaned the rectal area with fecal material noted. Used a new wipe and wiped front to back with fecal material on the wipe, folded the same wipe and wiped the rectal area. Used a new wipe and with the same area of the wipe, wiped down each side of the buttocks and then wiped front to back; - NA D placed a clean incontinent brief on the resident; - NA D dressed the resident in pants and shirt and placed the lift pad under the res and covered him/her with blankets and left the room at 4:33 A.M. During an interview on 7/17/24 at 2:30 P.M., NA D said: - He/she should wipe front to back; - Should separate and clean all areas of the skin where urine or feces had touched; - Should not fold the wipe; - Should not use the same area of the wipe to clean different areas of the skin; - He/she was told by management when the staff pre-dress a resident in the mornings to place the lift pad under the resident; - Before the staff get the resident up in the morning, they should check the resident to see if they are wet or soiled. Observation and interview on 7/9/24 at 6:25 A.M., showed: - CNA A and CNA C entered the resident's room with the mechanical lift; - CNA A and CNA C uncovered the resident and used the mechanical lift and transferred the resident from his/her bed to the Broda chair (a type of reclining geri chair); - CNA C made the resident's bed and moved the resident close to the bed and placed the call light in reach; - CNA A bagged the trash and wiped the lift down with a disinfectant wipe; - CNA A said the resident will go to the dining room about 7:45 A.M. to 8:00 A.M.; - CNA A and CNA C did not check the resident prior to getting him or her up in the broda chair and did not wash the resident's face or hands, did not brush the resident's hair or provide oral care; - CNA A and CNA C left the resident's room at 6:40 A.M. During an interview on 7/17/24 at 12:55 P.M., CNA C said: - They start getting residents up at 5:00 A.M. for breakfast; - Breakfast is served at 8:00 A.M., - The residents should not be laying on the lift pads for two to three hours; - Should make sure to check the resident to see if they are wet or soiled before taking them to breakfast; - When we got the resident up we should have washed his/her face and hands, brushed the resident's hair and provided oral care. 3. Review of Resident #18's care plan for ADL needs/toileting preferences, dated 5/14/21 showed: - Assistance of two staff for use with the mechanical lift; - Peri care as needed. Review of the resident's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Dependent on the assistance of staff for toilet use; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Diagnoses included high blood pressure and multiple sclerosis (MS, a disorder of the Central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech and bladder control). Observation on 7/9/24 at 4:35 A.M., showed: - NA D uncovered the resident, unfastened the wet incontinent brief; - NA D wiped down one side of the groin, folded the wipe and wiped down the other side of the groin, folded the wipe again and wiped down the middle skin folds; - NA D turned the resident on his/her side, removed the wet incontinent brief and used a new wipe and wiped from front to back then placed a clean incontinent brief on the resident; - NA D did not separate and clean all the skin folds and did not clean the buttocks. During an interview on 7/17/24 at 2:30 P.M., NA D said: - He/she should wipe front to back; - Should separate and clean all areas of the skin where urine or feces had touched; - Should not fold the wipe; - Should not use the same area of the wipe to clean different areas of the skin. During an interview on 7/10/24 at 12:50 P.M., the Director of Nursing (DON) said: - She thought it was okay to pre-dress some residents; - Staff should not put the lift pad under the resident if they pre-dress the resident; - She expected staff to check the resident to see if they were wet or soiled before getting the resident up for meals; - When staff get the residents up for the day she would expect the staff to provide oral care, wash the resident's face and hands, comb their hair and make sure clothes are clean and dry; - When staff provide peril care, she expects staff to wipe from the inside skin folds outward and wipe from front to back. Staff should not fold the wipe and cannot fold the wash cloth. Staff should not use the same area of the wipe to clean different areas of the skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when staff failed to lock residents' wheelchairs during transfers (Resident #31), failed to close base of legs during transfer (Resident #31), transfering resident in a hoyer with only one staff present (Resident #6) and staff locked brakes of lift (Resident #25) which affected three of 17 sampled residents, (Resident #31, #6 and #25). The facility census was 68. Review of facility policy, Lifting Machine, Using a Mechanical, dated July 2017, showed: -At least 2 nursing assistants are needed to safely move a resident with a mechanical lift. -Make sure lift is stable and locked. -Make sure all necessary equipment (slings, hooks, chiains, straps, and supports) are on hand and in good condition. -Place the sling under the resident. Visually check the size to ensure it is not too large or too small. -Lower sling bar closer to the resident. -Attach sling straps to sling bar, according to the manufacturer's instructions. -Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. -Check the residents comfort level by asking or observing for signs of pinching or pulling of the skin. -Slowly lift the resident. Only lift as high as necessary to complete the transfer. -Gently support the resident as he or she is moved, but do Not support any weight. -When transfer destination is reached, slowly lower the resident to the receiving surface. -Once residents weight is released, stop the lowering and ensure that the sling bar does not hit the resident. -Detach the sling from the lift. -Carefully removed the sling from under the resident. Be mindful of the resident's position and balance, and skin. Review of Lumex LF 1090 Bariatric Patient Lift Manual, dated 2005, showed: -Do not lock the brakes or block the wheels when lifting. The casters must be Free to roll to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed, or any stationary object. -During lifting or lower, whenever possible, always keep the patient lift legs in the maxium open position. -To facilitate movement, close patient lift legs before moving the lift. Review of Lumex LF 2020 Easy Lift Sit-to Stand Manual, dated 2005, showed: -Ensure that lift sling loops are correctly attached to the hooks to prevent hte patient from sliding or falling out of the sling, which could result in personal injury. -Do not lock the brakes or block the wheels when lifting. The casters must be Free to roll to allow the patient lift to stabilize iteself whent he patient is initially lifted from a chair, bed, or any stationary object. -To facilitate movement, close patient lift legs before moving the lift. Lift and transfer from chair showed: -Recommended that two attendants be used when transferring a patient to and from a wheelchair. -Before transfer, ensure wheelchair wheels locks are in locked position. Wheelchair wheel locks must be in [NAME] dposition before lowering the patient into the wheelchair, or unexpected wheelchair movement could result, which may result in serious injury to both patient and the attendants. -Push lift towards patient. open the base of the lift to go around the chair. Apply the brakes on both rear casters. -Release the brakes, close the base, and pull the lift away from the chair. 1. Review of Resident #31's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She was dependent on wheelchair; -He/She was dependent on staff for all transfers, personal hygiene, and toileting; -Diagnoses included: Stroke (damage to the brain from an interruption of its blood supply), Neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), and Asthma (person's airway becomes inflamed, narrow, and swell and produce extra mucus, making it difficult to breathe). Review of care plan, dated 4/2/24, showed: -He/She was unable to transfer independently; -He/She required one person extensive assistance with all transfers; -He/She required a mechanical lift to avoid skin friction/sheering; During an observation on 7/08/24 at 1:38 P.M. Certified Nurse Aide (CNA) A and CNA F utilized the Lumex LF 2020 easy lift sit to stand to transfer Resident #31 from his/her recliner to the toilet and from the toilet to his/her wheelchair. Once staff had lift sling under resident and hooked to lift, CNA A recognized the lift remote was missing. CNA F had to go to hall to locate a remote to attach to lift. During the lift from the chair the legs were locked. During mobilization from the chair with resident across the room to the toilet the legs of lift were left in open position, and during the lift from toilet to wheelchair staff kept the legs of the lift spread in open position when the manual advised the base should be closed. During the transfer from the lift to the wheelchair the staff did not ensure the wheelchair wheels were both locked. Observation showed that resident's right side of wheelchair was locked and left side of wheelchair was unlocked. During an interview on 7/8/24 at 1:48 P.M. CNA A said: -He/She did not know if base of lift should be closed; -He/She forgot to check wheelchair locks on resident's wheelchair before putting resident down in chair; -Resident's chair should have been locked. During an interview on 7/8/24 at 1:50 P.M. CNA F said: -He/She did not check if wheelchair was locked for resident before resident was lowered into his/her chair; -He/She did not know if base of legs of lift were to be closed during movement. During an interview on 7/9/24 at 6:36 A.M., CNA D said: -With the Lumix sit to stand lift the brakes were supposed to be locked when raising and lowering residents. 2. Review of Resident #6's Quarterly MDS, dated [DATE], showed: -He/She had moderately impaired cognition; -He/She had unclear speech; -He/She responded adequately to simple, direct communication only and had clear comprehension of others; -He/She had impairments to both sides of upper extremities; -He/She was dependent on wheelchair; -He/She required substantial/maximal assistance with eating, oral hygiene, personal hygiene, rolling left and right and going from sitting to lying positions; -He/She was dependent on staff for bathing, dressing, toileting, and transfers; -Diagnoses included: Diabetes (too much sugar in the blood), cerebral palsy (a congenital disorder of movement, muscle tone, or posture), Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), need for assistance with personal care, gastrostomy (an external opening to the stomach for nutritional support or gastric decompression), repeated falls, and apraxia (cause by brain disease or damage, the brain is unable to make and deliver correct movement instructions to the body). Review of care plan, dated 3/1/24, showed: -Two assist with hoyer lift for all transfers. Observation on 7/7/24 at 11:18 A.M. showed CNA G transferring resident from his/her bed into his/her broda chair independently with no other staff members present. During an interview on 7/8/24 at 1:48 P.M. CNA A said: -He/She usually did lift transfers by self even though he/she knew that he/she was not supposed to; During an interview on 7/9/24 at 3:09 A.M. Nurse Aide (NA) D said: -He/She did lift transfers by his/her self when facility did not have enough staff; -He/She would not deny helping a resident just because facility did not have enough staff. During an interview on 7/9/24 at 4:53 A.M., CNA D said: -He/She had to do transfers by themselves due to not having staffing to have two people in room during lift transfers. During an interview on 7/9/24 at 6:36 A.M., CNA D said: -He/She was completing transfers by themselves prior to becoming a certified nurse aide. -The charge nurse was aware that he/she was transferring residents by his/her self; -He/She preferred to have two staff during transfers. During an interview on 7/10/24 at 12:50 P.M, Director of Nursing said: -Wheelchair legs should be locked unless moving the lift; During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She was aware teh facility policy and manufacturer's guideliens for lifts did not line up; -Manual says not to lock the wheelchair legs; -The standard protocol for lift transfers is to lock the legs before lower and that was what facility policy said; -When staff use the sit to stand lift staff should have buckle fastened. 3. Review of Resident #25's Quarterly MDS, dated [DATE] showed: - Long and short term memory problems; - Upper and lower extremities impaired on both sides; - Dependent on the staff for eating, oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included Alzheimer's disease ( a progressive disease that destroys memory and other important mental functions), dementia (inability to think), anxiety, depression and chronic obstructive airway disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's undated care plan showed: - The resident was dependent on staff for ADLs. Staff have to brush the resident's hair, wash face and hands. Required full staff assistance of one staff for bathing, all personal cares, and oral care for the resident's own teeth. Required full staff assistance of two staff for dressing; - The resident had a potential for falls. Maintain mechanical lift transfers with assistance of two staff, Observation on 7/9/24 at 6:25 A.M., showed: - CNA A brought the Hoyer (mechanical ) lift into the room; - CNA C locked the brakes on the resident's Broda chair (reclining geri chair); - CNA C placed the mechanical lift under the resident's bed with the legs of the lift closed and locked the brakes on the lift; - CNA C and CNA A hooked the lift pad up to the lift; - CNA C raised the resident up in the lift, unlocked the brakes and backed away from the bed with the legs of the lift closed then opened the legs to go in sideways to the Broda chair. CNA C locked the brakes on the lift and lowered the resident into the Broda chair; - CNA A and CNA C unhooked the lift pad from the lift pad, unlocked the brakes on the lift and moved it out of the way. During an interview on 7/17/24 at 12:55 P.M., CNA C said: - The brakes on the mechanical lift should be locked when raising or lowering the resident; - The legs of the lift should be closed until you go around the resident's wheelchair or Broda chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff maintained the hydration status for five of the 17 sampled residents, (Resident #1, #10, #25, #58 and #63), when staff did not pass fresh ice water to the residents or offer thickened fluids to residents on special diets during the day or overnight hours. The facility census was 68. Review of the facility's policy for Resident Hydration and Prevention of Dehydration, dated October 2017 showed, in part: - The purpose is to ensure each resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status and the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment; - Based on a resident's comprehensive assessment, the facility must ensure that each resident is offered sufficient fluid intake to maintain proper hydration and health; - Nurses' Aides will provide and encourage intake of bedside snacks, meals, fluids, on a daily and routine basis as part of daily care. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/12/24 showed: - admission 3/7/23 with Advance Directive DNR (Do Not Resuscitation) (No life saving measures); - Cognitive impaired with a BIMS score of 9; - Diagnoses included: Vision impaired, Stroke, Thrombosis (blood clot), Depression, Hypertension (high blood pressure), Anxiety disorder, Constipation, and Hyperglycemia (diabetes). Review of the resident's care plan, dated 2/6/24 showed: - The resident required assistance in dressing, bathing, and toileting; - The resident has difficulty recalling events and requires assistance with mobility and transfers; - Resident is incontinent of bowel, has a urinary catheter and is at risk for pressure ulcers; - Resident is identified as a risk for weight loss and staff are to use verbal encouragement/cueing and assist the resident to maintain proper body weight. Review of resident updated care plan, dated 5/3/24 showed: - Resident is to be encouraged to have good fluid intake due to current Urinary Tract Infection (UTI). Review of the resident's physician order sheet (POS), dated July 2024 showed: - Start date: 5/6/24 puree diet with nectar thick liquids. Observations on 7/7/24 at 10:00 A.M., showed: - The resident sleeping in his/her w/c, no liquids or water on the resident's side of the room; Observations on 7/8/24 10:16 A.M. and 3:16 P.M., showed: - No water or fluids nearby for resident. Observations on 7/9/24 at 4:40 A.M., showed: - The resident lying in bed with TV on in the dark with no fluids within reach. Observations on 7/9/24 at 7:48 A.M., showed: - The resident up and in his/her wheel chair without any fluids within reach of the resident or in the room. Observations on 7/9/24 at 8:45 A.M., showed: - Resident drinking without aid multiple small glasses of fluids at breakfast in the dining room. Observations on 7/10/24 at 7:14 A.M., showed: - Resident alert and in wheel chair watching TV with no liquids in the room. Observations on 7/10/24 at 9:15 A.M., showed: - Resident returned to room from breakfast by food aid and there were no liquids in the room within reach of the resident. Observations on 7/10/24 at 11:28 A.M.; showed: - No liquids bedside or in the room for the resident. 2. Review of Resident #10's Quarterly Minimum Data Set (MDS), dated , 6/26/24, showed: - admitted on [DATE]; - Brief interview for mental status (BIMS) score of 14, indicating the resident was cognitively intact; - One to two staff for partial/moderate assistance for activities of daily living, personal hygiene, Sit to Stand electric lift for transfers, and dependent for bathing; - Uses a wheelchair for mobility; - Diagnoses included Depression, Stroke, Hypertension (high blood pressure), Hemiplegia (paralysis of one side of the body), Anxiety disorder, and Cardiac arrhythmia (irregular heartbeat). Review of the resident's care plan, dated 6/20/24, showed: - Assessments of fluid intake and hydration status are required; - Staff to give verbal cues to help prompt intake of fluids with meals and in between. During an Interview on 7/8/24 at 09:00 A.M., the resident said: - Water cups sometimes get filled one time daily. - Water cup has not been filled in the last 24 hours - There are days the water is not filled at all. Observations of resident on 7/9 at 9:10 A.M and 7/10 at 11:45 A.M. showed: - Ice water being refilled only one time per day and only after the resident requested more water. - One cup of water less than ¼ full with no ice was observed on the table next to the resident each day. 3. Review of Resident #25's Quarterly Minimum Data Set (MDS), dated , 4/9/24, showed: - admitted on [DATE]; - Unclear speech, unable to express wants or ideas, and unable to understand others; - BIMS score unable to be determined, severly impaired. - Impairment of motion on both sides of body; - Dependent on aid for eating, hygiene, and dressing, bed bound; - Requires total assistance with all ADLS; - Incontinent of bowel and bladder; - Diagnoses included: Hypertension (high blood pressure), Alzheimer's disease, Dementia, Depression, Anxiety disorder. Review of the resident's care plan, revised 4/9/24 showed: - Staff to assist with fluid intake and hydration must provide cues; - Nectar thickend liquids. Observations of resident on 7/7/24 at 11:11 A.M., showed: - No water or Nectar fluids in the room; Observations of resident on 7/8/24 at 10:28 A.M., showed: - No water or Nectar fluids in the room; Observations of resident on 7/10/24 at 7:12 A.M., showed: - No water or Nectar fluids in the room; Observations of resident on 7/10/24 at 11:28 A.M., showed: - No water or Nectar fluids in the room; During an interview on 7/10/24, at 09:00 A.M., CNA E said: - Every 2 hours water should be taken or offered by CNAs or NAs to residents in their rooms. - Resdient #1 is on a nectur thick purified diet. A cup of water should be in his/her room on the side table and he/she should be offered fluids each time staff enters the room. He/she can drink it on his/her own so it should be in arms reach. During an interview on 7/9/24, at 8:30 A.M., RN B said: - Every two hours residents should be offered water by any nursing staff, no record of doing this is kept but these are the expectations. - Resident #25 is on a puree diet with nectar thickened liquids. -Staff are expected to automatically offer him/her liquids and they should be kept in the room at night. - During the day fluids are to be made to the resident each time staff enter the room. - Any resident requiring staff assistance and nectar thickened liquids, should be offered. 4. Review of Resident #63's admission MDS, completed on 5/31/4., showed: - Total care of all ADLS - Behaviors of refusing care. - Not cognitively intact - History of repeated UTI - Chronic Urinary Retention with a Urinary Catheter. -Diagnoses: Depression, Anxiety, Repeated Falls, Muscle weakness and wasting. Review of the residents undated care plan showed: - The resident has a history of mulitple Urinary Tract Infections and fluid intake should be monitored and encouraged. -The care plan does not address risk for dehyrdation. During an observation on 7/7/24 at 12:47 P.M., the resident was seen lying in bed with overbed table in front of him/her and breakfast beverage untouched. During an observation on 7/8/24 at 10:12 A.M., the resident was seen lying in bed with breakfast beverage and meal untouched. No water in the room to drink. During an interview on 7/9/24 at 9:12 A.M., CNA A said the resident can drink if he/she wants too. During an interview on 7/9/24 at 9:35 A.M., CNA B said he/she was unsure if resident could hold a glass or cup by their self. During an interview on 7/9/24 at 4:21 P.M., NA B said: -Did not know if the resident could drink by their self. -Did not know if nurse should be notified. 5. Review of Resident #58's admission MDS, dated [DATE] showed: - Cognitive skills intact; - Required assistance with set up and clean up with eating and oral hygiene; - Diagnoses included diabetes mellitus, high blood pressure, anxiety, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). Review of the resident's care plan, dated 6/12/24 showed: - The resident was at risk for skin breakdown. Encourage fluid intake to assist with proper hydration; - The resident had an indwelling urinary catheter (sterile tube inserted into the bladder to drain urine). Assess fluid intake and hydration status. Observation and interview on 7/8/24 at 7:49 A.M., showed: - The resident's water pitcher sat on his/her over the bed table and was only half full with no ice in it; - The resident said if the staff pass fresh ice water every shift, he/she did not get it and would like to have some. During an interview on 7/10/24 the Director of Nursing said: - Residents who need assistance with drinking should be offered assistance with drinking and meals at meals and in between. - She could not be sure if ice water was being passed three times a day. Thickened liquids previously were kept in a refrigerator. During an interview on 7/10/24, at 12:50 P.M. the Administrator said: - Ice water should be passed to residents three times a day during waking hours. - CNA's are expected to request from the kitchen premade liquids for resident's on thickened liquids since once the container is opened it is required to be refrigerated and then cannot be kept bedside overnight.

Based on observations, interviews and record review, the facility failed to discard expired medications and biologicals stored within the medication room. The facility census was 68. The facility's undated policy for storage of medications showed it did not address expired medications. Observation and interview on 7/9/24 at 10:06 A.M., of the central supply cabinet showed: - Unopened bottle of Calcium 600 milligrams (mg.) with Vitamin D (supplement), expired 6/24; - Unopened bottle of Zinc Sulfate 220 mg., for dietary supplement, expired 3/24; - A box of Bisacodyl Suppositories used for constipation, expired 11/22; - The Assistant Director of Nursing (ADON) said he/she thought Certified Medication Technician (CMT) C checked for expired medications. The expired medications should be destroyed and not used. During an interview on 7/10/24 at 12:50 P.M., the Administrator said: - Medical Records or CMT C should check for expired medications every Tuesday. There should not be expired medications in the room. We have trained staff when pulling medications to look at the expiration dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of Resident #32's Quarterly MDS dated [DATE]., showed: -Cognition intact; -Independent with ambulation; -Minimal assist with bathing; -Diagnoses: hypertension (high blood pressure), gout(inflammation of joints), weakness. During an observation at the resident council meeting on 7/8/24 at 2:00 P.M., resident #32 discussed concerns within the group regarding frustration that BBQ chicken thighs were on the menu that day for lunch, but they were served breaded chicken nuggets. During an interview on 07/08/24 09:31 A.M., the resident said that the food that is served is not always what is on the menu. He/she states he/she is unsure what to choose from the menu options due to the inconsistency of the menu being followed. During an interview on 07/10/24 at 12:50 P.M., the Administrator said she would expect menus to be followed so that residents could make meal choices. Based on observation and interview the facility failed to ensure meals were served to meet the needs of the residents when staff failed to prepare food according to the registered dietician approved recipes, failed to follow dietary preferences, and failed to post a list of available menu substitutions for residents. This deficient practice affected five of seventeen sampled residents, (Resident #22, #21, #48, #31 and #32) The facility census was 68. The facility did not provide a policy on menus and nutritional adequacy. 1. Review of Resident #22's Quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 5/28/24 showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - He/She required set up assistance for meals; - Diagnoses included: Paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). During an interview on 7/7/24 at 2:53 A.M., Resident said he/she was allergic to dairy products and whey. He/She asked dietary staff several times to add his/her allergies to his/her meal ticket and they had not. Observation on 7/7/24 at 2:53 P.M. of meal ticket showed resident on regular diet. His/Her likes or dislikes were not addressed. 2. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required set up or clean up assistance for meals; -Diagnoses included: Heart failure, diabetes (too much sugar in the blood), and asthma (a condition making it difficult to breathe). During an interview on 7/7/24 at 2:34 P.M., Resident said he/she did not always get what he/she ordered at supper. 3. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required set up or clean up assistance with meals; -Diagnoses included: diabetes and gastro-esophageal reflux disease (when stomach acid or bile irritates the food pipe lining) During an interview on 7/7/24 at 12:12 P.M., resident said he/she could not have cranberry juice as requested with all his/her meals and facility stated juice was only offered at breakfast. 4. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required set up or clean up assistance with eating; -He/She was dependent on wheelchair; -Diagnoses included stroke (damage to the brain from an interruption of its blood supply), neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), and asthma. During an interview on 7/7/24 at 10:36 A.M. resident said facility used to offer salt and pepper in bag with utensils, now facility had not been offering salt and pepper. He/She ate his/her meals in his/her room. 5. During an observation on 7/7/24 at 11:55 A.M. showed no alternative menu posted. During a continuous observation in the kitchen from 6:03 A.M.-9:53 A.M., showed: -6:32 A.M. Boiling water on stove, staff brought out quick oats box dated 7/2, poured quick oats into boiling water and did not measure out amount of oats to add per portions; -6:43 A.M. Dietary Aide B added farina to water on stove, farina was poured into a container on the stove and was not measured. -7:05 A.M. Dietary Aide C making pancakes with no cooking instructions or portion amount, no menus used; -7:12 A.M. Dietary Aide B used a blender to puree food, puree container sat in two compartment sink and hot water ran into it. -7:41 A.M. Dietary Aide B adjusted original mixture of pancake mixture by adding more batter powder. No original recipe followed and two different staff mixing up batter. Dietary Aide B added more batter mix to same bowl previously mixed up by Dietary Aide C. Observation on 7/9/24 at 7:50 A.M. showed an a-la-carte menu posted in dietary manager's office with options of cheeseburger, grilled cheese, hot ham and cheese, lunch meat sandwich, chicken noodle soup, minestrone soup, tomato soup, baked potato soup, chef salad, side salad, cottage cheese, fruit cup, applesauce, green beans, pudding, and ice cream. 6. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -He/She determined the residents food preferences of likes and dislikes by going around and asking residents what they thought about the food once per week; -He/She did not use a formal assessment tool for food preferences; -He/She had not had training on using the tools available on the computer; -A-la-carte menu was not posted in dining room; -A-la-carte menu items were handed out to residents upon admission; -He/She had more a-la-carte orders when fish was on menu; During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected dietary staff to follow a menu when preparing foods; -He/She had provided training to staff on following menus; -He/She expected dietary preference assessments to be completed on admission and at minimum annually. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -He/She followed the recipe when he/she prepared meals except this morning he/she did not use the recipe and made pancakes from the recipe on the package; -He/She ran out of pancakes during breakfast but they always cook and prepare more pancakes to ensure pancakes on steam table do not get soggy or cold; During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Resident food preference was noted on resident's meal ticket; -Dietary Manager talks to residents periodically once a week or once a month to determine preferences; -Resident's cards will show in bold words what they are allergic to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature and burnt food was served to 10 of 17 sampled residents (Resident #21, #48, #35, #10, #27, #32, #41, #43, #3, and #32) The facility had a census of 68. Review of facility policy, food safety requirements, dated 9/1/21, showed: -Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. -When preparing food, staff shall take precautions in critical control points in food preparation process to prevent, reduce, or eliminate potential hazards. -Holding - staff shall monitor food temperatures while holding for delivery to ensure properly hot and cold holding temperatures are maintained. Staff shall refer to the current FDA food Code and facility policy for food temperatures as needed. -Ready-to eat foods that require heating before consumption must be heated to at least 135 degrees. Review of facility policy, serving temperature for hot and cold foods, dated 2016, showed: -Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods. These are minimum serving/holding temperatures and may vary based on state regulations. -Meats and casseroles, vegetables, potatoes, gravy, soups 135 degrees Fahrenheit (F) to 170 degrees F; -Hot beverages: follow facility guidelines; -Cold beverages, fruits, desserts, salads, and dairy: 41 degrees F or below; -Cereal: 135 degrees F to 160 degrees F; -The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. Food temperatures will be recorded. Review of facility policy, monitoring food temperatures for meal service, dated 2016, showed: -Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. -If the serving/holding temperature of hot food item is not 135 degrees F or higher when checked prior to meal service, the item will be reheated to at least 165 degrees F. -Meals served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at point of service are preferred to be at 120 degrees F or greater to promote palatability for the resident. -Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. -The temperature for each food item will be recorded on the food temperature log. Foods that required a corrective action; will have the new temperature recorded with a circle around it next to the original temperature. 1. Review of Resident #21's quarterly Minimum Data Set (MDS, a federally required assessment completed by the facility staff), dated 5/4/24, showed: -Cognitive skills intact; -He/She required set up or clean up assistance for meals; -Diagnoses included: Heart failure, diabetes (too much sugar in the blood), and asthma (a condition making it difficult to breathe). During an interview on 7/724 at 2:34 P.M. Resident said that morning he/she received bacon that was burnt and no toast. Resident sent his/her food back to kitchen and received back the same burnt bacon and added toast. He/She said the food was sometimes served cold. 2. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required set up or clean up assistance with meals; -Diagnoses included: diabetes and gastro-esophageal reflux disease (when stomach acid or bile irritates the food pipe lining) During an interview on 7/7/24 at 12:12 P.M., resident said his/her room tray was usually cold. Resident said he/she could hardly cut meat or chew it. Vegetables were cold. 3. Review of Resident #35's admission MDS dated [DATE], showed: -Severe cognitive impairment; -He/She required set up clean up assistance with meals; -Diagnoses included Parkinson's (a disorder of central nervous system that affected movement), high blood pressure, dementia (a condition causing loss of memory, language, problem-solving, and other thinking abilities) During an interview on 7/7/24 at 10:15 A.M. resident said food did not taste good, meat was tough. His/Her room tray was generally cold when he/she received it. 4. Review of Resident #10's, quarterly MDS dated [DATE], showed: -Cognitive skills intact; -He/She required supervision or touching assistance with meals; -Diagnoses included stroke, depression, and osteoarthritis of right wrist (a degenerative joint disease). During an interview on 7/7/24 at 10:08 A.M. resident said he/she was not offered salt and pepper with his/her meals. Food did not taste great, sometimes food was cooked to death and sometimes needed to be cooked more. During an interview on 7/8/24 at 9:59 A.M., resident said food was not hot, warm at best. 100% of the time his/her food was not hot. 5. Review of Resident #27's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required set up or clean up assistance with meals; -Diagnoses included: anemia and schizophrenia (a condition that affected a person's ability to think, feel, and behave clearly) During an interview on 7/7/24 at 10:29 A.M. he/she said pork and chicken was tough. He/She ate in dining room and green beans were usually cold. 6. Review of Resident #32's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required supervision or touching assistance with meals; -Diagnoses included diabetes, fracture of right wrist, and neuropathy (weakness, numbness, and pain from nerve damage). During an interview on 7/8/24 at 9:31 A.M. resident said baked goods had been served burnt on bottom. 7. Review of Resident #41's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required set up or clean up assistance with eating; -Diagnoses included diabetes, renal failure (when kidneys cannot filter waste from the blood), and heart failure During an interview on 7/7/24 at 11:20 A.M. said breakfast was usually cold. 8. Review of Resident #43's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She required set up or clean up assistance with eating; -Diagnoses included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), coronary artery disease (damage to heart's major blood vessels), diabetes (too much sugar in the blood), and stroke (damage to the brain from interruption of blood supply). During an interview on 7/7/24 at 2:30 P.M. said food was rarely served hot, it usually arrived cold to his/her room. 9. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -He/She required set up or clean up assistance with eating; -He/She was dependent on wheelchair; -Diagnoses included stroke (damage to the brain from an interruption of its blood supply), neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), and asthma (person's airway becomes inflamed, narrow, and swell and produce extra mucus, making it difficult to breathe). During an interview on 7/7/24 at 10:36 A.M. resident said he/she ate meal in room and food was not hot. All meals served were not up to temperature and it was not just specific to a certain time of day that food temperatures were an issue. 10. Review of Resident #32's Quarterly MDS(minimum data set), a mandatory assessment completed by facility staff on 6/24/24., showed: -Cognition intact; -Independent with ambulation; -Minimal assist with bathing; -Diagnoses: hypertension (high blood pressure), gout(inflammation of joints), weakness. During an interview on 7/8/24 at 9:31 A.M., the resident stated that the baked goods that were prepared in the kitchen have been served burned to the residents, specifically, cookies and cake. The resident stated that it is common for the bottom of the baked goods to be black. 11. Observation in kitchen on 7/7/24 at 9:25 A.M. showed there was no temperature log for July in log book. The last temperature recorded was on 6/27. During a continuous observation in the kitchen from 6:03 A.M.-9:53 A.M., showed: -6:24 A.M. Breakfast sausage patties laid out on baking pans by Dietary Aide; -6:31 A.M. Second pan of breakfast sausage added to oven; -7:06 A.M., Dietary Aide B temperature checking sausage patties. Temperature showed 183.5 degrees. He/She used a scouring pad dipped in soap and water to wipe off thermometer. Temperature was not documented anywhere. Dietary aide B temperature checked second pan of sausage patties at 187.1 degrees; -7:33 A.M., Dietary Aide B temperature checked brownies, did not document; -8:06 A.M. Dietary Aide B removed steam table covers from food; -8:09 A.M. Window to dining room opened, Dietary Manager told Dietary Aide B to temperature check foods first; -8:17 A.M. foods were temperature checked: sausage patty 170.9, oatmeal 179.4, low concentrated sugar oatmeal 182.3, ground sausage 148.8, farina hot wheat cereal 167.1, pureed sausage 180.6, pancakes were not temperature checked. -8:43 A.M., observed burnt pancakes being served; -9:06 A.M., burnt pancakes being added to hall trays, Dietary Manager continued to cook pancakes on griddle; -9:08 A.M., Food has not been temperature checked on steam table since start of meal service; -9:32 A.M., Dietary Manager instructed Dietary Aide B to take food temperatures. Observation showed Sausage patty 145.0, oatmeal 155.1 degrees, low concentrated sugar oatmeal 152.6 degrees, ground sausage 121. 2 degrees, farina 152. 9 degrees, pancake 127 degrees, Dietary Aide B made no efforts to raise temperature of ground sausage or pancakes; -9:58 A.M. Test tray received and temperature observed as farina 130.4 degrees, oatmeal 134.4, sugar free oatmeal 120.3, sausage patty 130.0 degrees, ground sausage 118.5 degrees, pureed oatmeal 131.9 degrees, pancake 117.6 degrees. Review of dietary menu book showed pureed sausage, maintain 135 degrees of above, maintain holding 135 degrees or above. During an interview on 7/9/24 at 3:09 A.M., Nurse Aide (NA) D said: -He/She had received complaints from residents that their food was cold when receiving room trays; -He/She had residents complain about burnt toast being served. During an interview on 7/9/24 at 4:53 A.M., Certified Nurse Aide (CNA) D said: -Residents complain about taste of their food all the time. During an interview on 7/9/24 at 7:27 A.M., Dietary Manager said: -Food should be temperature checked at least three times during a meal, twice before the food is served and once after meal had been served; -Dietary Aide B had not recorded food temperatures during meal service on 7/9/24; -Temperature that was recorded on food temperature log was when food came out of oven; -Facility had monthly in-services and had covered temperatures, sanitation, and food borne illnesses; -He/She was aware of resident's who complained of being served burnt food; -He/She expected if food was burnt that it should not be served; -He/She saw onion rings that were burnt at previous nights meal but those items did not leave the kitchen and were thrown out. During an interview on 7/10/24 at 6:36 A.M., CNA D said: -He/She had residents complain about cold food; -He/She received complaints about burnt desserts such as cookies being served. During an interview on 7/10/24 at 9:24 A.M., Dietician said: -He/She expected staff to follow the menu when preparing foods; -Resident food preference assessments should be completed on admission and at minimum annually. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Food should be temperature checked before serving, between serving, and after our last serve; -Food should be held at a minimum of 145 degrees on steam table; -Food should be brought to temperature by using microwave. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -He/She was aware of complaints of food being cold and burnt food; -He/She would not serve burnt food or will use burnt food for mechanical diets; -If food was too crunchy for regular diet, he/she can just add juice to mechanical soft diets to make foods juicer. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She did not expect burnt food to be served to residents; -He/She expected food to be served at a safe and appetizing temperature to residents; -Hot food should be served hot. MO237626

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure infection prevention measures where followed when the facility staff failed to place three residents on enhanced barrier precautions ( Residents #63, #34, and #23) and failed to maintain proper infection prevention practices when providing care for resident with a urinary catheter (Resident #58) out of the 17 sampled residents. The facility census was 68. Review of the facility's Infection Control Compliance Policy, dated August 2019., showed: - Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and procedures. - The infection preventionist or designee will monitor the compliance and effectivness of the infection prevention and control practices. - Program oversight including planning, organizing, implementing, operating, monitoring, and maintenance of all elements of the program and to ensure that the facility's intradisciplinary teamis involved in infection prevention. - Resident health will be monitored for infections, isolation, training, vaccinations and immunizations. Review of the facility's Urinary Catheter Care, dated August of 2022., showed: -Use aseptic technique when handeling or manipulating the drainage collection system. Tubing and drainage bag should be kept off the floor. -Ensure univeral precautions are maintained with gloving and handwashing with care and management of the urinary catheter tubling during resident care. Review of the current CMS (Center for Medicare and Medicaid Services) and CDC (Center for Disease Control) Guidlines for Enhanced Precuations,dated March 20, 2024 states in part: - New CMS guidance for State Survey Agencies and long term care (LTC) facilities on the use of Enhanced Barrier Precautions (EBP) to align with nationally accepted standards. - EBP recommendations now to include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status (MDOR). - The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control. - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. - EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. - EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. - Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. 1. Review of Resident #34's Annual MDS (Minimum Data Set), A mandated assessment completed by facility staff on 6/10/24., showed: - Severely Impaired Cognition with advanced dementia; - History of Stroke ( paralysis to one or both sides of the body); - Inability to speak, swallow, or make needs known; - Gastric tube for enteral feeding (A tube inserted into the stomach for liquid nutrition to be administered through); - Total assist of 2 people for all activities of daily living (ADL); - Staff to anticipate and meet all needs of the resident. Review of undated care plan showed: - Resident required total care. - Frequently Incontinet of bowel and bladder. - Requires a gastric feeding tube for nutrition. - No care plan regarding risk for MDRO infections. - No care plan to address minimize risk for infections with staff interventions for use of PPE (Personal Protective Equipment-such as gloves, gowns). Observation of the resident from 7/7/24 through 7/10/24., showed: - No identification of enhanced precautions for the resident was placed outside the resident's room or on the door. - No resources to alert staff on what type of PPE should be used when providing personal cares for the resident. 2. Review of Resident #63's admission MDS, completed on 5/31/4., showed: - Total care of all ADLS - Behaviors of refusing care. - Not cognitively intact - History of repeated UTI - Chronic Urinary Retention with a Urinary Catheter. -Diagnoses: Depression, Anxiety, Repeated Falls, Muscle weakness and wasting. Review of undated care plan showed: - Resident required total care. - Frequently Incontinet of bowel . - Requires a urinary catheter for emptying of bladder and staff to manage. - No care plan regarding risk for MDRO infections. - No care plan to address minimize risk for infections with staff interventions for use of PPE (Personal Protective Equipment-such as gloves, gowns) when provide personal care or management of urinary catheter. Observation of the resident from 7/7/24 through 7/10/24., showed: - No identification of enhanced precautions for the resident was placed outside the resident's room or on the door. - No resources to alert staff on what type of PPE should be used when providing personal cares for the resident. 3. Review of Resident #23's Five Day Medicare MDS, completed on 5/17/24., showed: -The resident was re-admitted from hospital with infected hardware from hip repair; -History of Multi Drug Resistant Organisms; -Impaired Cognition; -Assistance with all Activities of daily living (ADL); -Diagnoses: Anxiety, Delusional Disorders (altered reality), Fracture of left femur bone, Significantly impaired mobility upper and lower extremities, as well as back and spinal disorders, and Depression. Review of undated care plan showed: - Resident required total care. - Frequently Incontinet of bowel and bladder. - No care plan regarding risk for and history of MDRO infections. - No care plan to address minimize risk for infections with staff interventions for use of PPE (Personal Protective Equipment-such as gloves, gowns) when provide personal cares. Observation of the resident from 7/7/24 through 7/10/24., showed: - No identification of enhanced precautions for the resident was placed outside the resident's room or on the door. - No resources to alert staff on what type of PPE should be used when providing personal cares for the resident. During an interview on 7/7/24 at 11:30 A.M,. NA A said: -He/She did not know if resident #23 should be on enhanced isolation precuations. - He/She was not sure if resident had a history of infections. - He/She was not sure what type of PPE should be used when caring for the resident. During an interview on 7/7/24 at 3:20 P.M., CNA C., said: - He/She was not sure what enhanced barrier precautions was. - Was not sure if resident #34, #63 should be on isolation. - Was aware that resident #34 was provided nutrition through a tube in the stomach. - Was aware that resident #63 has a urinary cath. During an interview on 7/8/24 at 9:11 A.M., CNA D., said: - He/She did not belive that resident #34 or #63 should be on isolation, and was not told that in report. - Did not know if an isolation should be worn with peri care. During an interview on 7/10/24 at 11:30 A.M., NA C., said she did not know what equipment would be needed for enhanced precuations or if the resident should be on isolation at all.4. Review of the facility's policy for hand washing/hand hygiene, revised October 23, showed, in part: - The facility considered hand hygiene the primary means to prevent the spread of healthcare -associated infections; - Hand hygiene is indicated: immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids or contaminated surfaces, after touching a resident, after touching the residetn's environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Review of Resident #58's admission MDS, dated [DATE] showed: - Cognitive skills intact; - Required assistance with set up and clean up with eating and oral hygiene; - Dependent on staff assistance for toilet use and transfers; - Supervision or touch assistance with personal hygiene; - Had a catheter (sterile tube inserted into the bladder to drain urine); - Occasionally incontinent of bowel; - Diagnoses included diabetes mellitus, high blood pressure, anxiety, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). Review of the resident's care plan, dated 6/12/24 showed: - The resident had a urinary catheter. Catheter care every shift. Observation on 7/9/24 at 5:36 A.M., showed: - CNA D entered the resident's room, did not wash his/her hands and applied gloves; - CNA D obtained supplies and arranged them on the resident's over the bed table; - CNA D removed gloves, washed his/her hands and applied new gloves; - CNA D unfastened the resident's incontinent brief and turned the resident on his/her side; - CNA D cleaned fecal material from the resident's buttocks, removed gloves, did not wash his/her hands and applied new gloves; - CNA D continued to clean fecal material from the resident's rectal area; - CNA D removed gloves, did not wash his/her hands and applied new gloves; - CNA D placed a clean incontinent brief under the resident then turned the resident on his/her side and provided perineal care to the front skin folds. CNA D removed gloves and washed his/her hands and put items away. During an interview on 7/10/24 at 6:35 A.M., CNA D said: - He/she should wash his/her hands when entering the resident's room, between glove changes, after cleaning fecal material and before leaving the resident's room. During an interview on 7/10/24 at 9:15 A.M. the Director of Nursing and the Assistant Director of Nursing together both said they were unsure which resident's should currently be on enhanced precuations, and what the current criteria and recommendations were. During an interview on 7/10/24 at 12:10 P.M., the Administrator said she would expect all residents who met the criteria for enhanced precuations, be placed on enhanced precuations During an interview on 7/10/24 at 12:50 P.M., the DON said; - Staff should wash their hands anytime walk in the he resident's room, between glove changes, when cleaning fecal material and before leaving the resident's room. .

Based on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 68. The revised facility Antibiotic Stewardship policy,dated December 2016 showed in part: The purpose of antibiotic stewardship is to monitor the use of antibiotics in our residents and to include training, orientation, and education of staff with emphasize on the importance of antibiotics stewardship, and inappropriate use of antibiotics. Antibiotics usage and outcome will be collected and documented using a facility-approved antibiotics surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. 1. The facility did not provide Antibiotic Stewardship Program documentation that should include ongoing monthly survelliance and monitoring of the following: - Protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic; - Procedures to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; - Procedures to promote and implement a facility-wide system to monitor the use of antibiotics including a system of reports related to monitoring antibiotic usage and resistance data; - Designated appropriate facility staff accountable for promoting and overseeing antibiotic stewardship; - Accessing pharmacists and others with experience or training in antibiotic stewardship; - Implementation of a policy or practice to improve antibiotic use; - Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; - Educate staff and residents about antibiotic stewardship. During an interview 07/09/24 04:21 PM, the Director of Nursing said: - She is now in charge of Antibiotic Stewardship and infection prevention. - The antibiotic tracking book I have doesnt have much information in it. - She started in May, and was not aware of who had been in charge of Infection Prevention prior to her start date. - Was unsure at the time of the interview who was on antibiotics or where data to show trends and antibiotic activity had been monitored and tracked in previous months. During an interview on 7/10/24 at 12:20 P.M. the Administrator said: - Antibiotic Stewardship is important and should be followed and monitored. - The Director of Nursing is new to her position and is now also managing infection control and antibiotic stewardship.

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, did not ensure refrigerator and freezer temperatures were checked daily, did not ensure proper function of dishwasher by testing and logging it daily, did not use sanitizer solution on kitchen food preparation surfaces, did not keep food stored off the floor, did not ensure proper storage and labeling of foods, and when dietary staff did not wear hairnets prior to entering kitchen. The facility census was 68. 1. Review of facility policy, food receiving and storage, revised November 2022, showed: -Dry Food Storage: -Food in designated dry storage areas are kept at least 6 inches off the floor. -Refrigerated/Frozen storage: -All foods stored in the refrigerator or freezer are covered, labeled, and dated with use by date. -Refrigerated foods are stored in such a way that promote adequate air circulation around food storage containers; -Foods in walk in are stored off the floor. -Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to the state-specific requirements. -Refrigerated foods are labeled, dated, and monitored so they are used by their 'use by' date, frozen, or discarded. -Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. -Food and Snacks kept on nursing units: -Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines. -Soaps, detergents, cleaning compounds, or similar substances will be stored in separate storage areas from food storage and labeled clearly. 2. Observation on 7/7/24 during initial tour showed a daily cleaning list for cooks was posted on wall by stove showed: -Write morning fridge temperatures; -Write food temperatures: breakfast, lunch, and dinner; -Clean cereal cart; -Wipe down toaster; -Wash all pots and pans; -Put away all dishes; -Sweep and mop; -Take out trash; -Label and date all products -Wipe and sanitize all surfaces; -Wash can opener; -Clean flat top. Observation on 7/9/24 at 8:01 A.M. showed grease and grime coating the condiment baskets on the drink cart. Observation on 7/9/24 at 8:02 A.M. showed the recipe menu books are coated with a grime and film that when touching the books a sticky substances comes off outside. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -All staff had tasks that they were to do before leaving their shift; -He/She had cleaning lists but felt his/her team was better than cleaning lists; -He/She felt cleaning lists held his/her staff back as there was more to do than what was on cleaning lists. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Main cleaning was completed by the night shift crew; -After each meal, they ensured dining room tables were cleaned off. During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected everything to be clean and sanitary in kitchen. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected food preparation surfaces to be cleaned and sanitized before use. 3. Review of facility policy, cleaning instructions: floors, dated 2016, showed: -Kitchen floors will be swept and cleaned after each meal. -At least once a month large appliance will be moved to clean behind and underneath them Observation in the kitchen on 7/7/24 at 9:01 A.M. showed feet stuck to floor as walked throughout the kitchen. Observation in the kitchen of dry storage room on 7/7/24 at 9:40 A.M. showed: -garbage and debris on floor and food storage racks. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Floors were swept and mopped at end of shifts. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Cleaning routine in kitchen included sweeping and mopping done at end of every shift. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected the floors in kitchen to be swept and mopped between every meal; 4. Review of facility policy, Cleaning Instructions: Food Carts, dated 2016, showed: -Wipe up any spills or debris on food carts; -Use a sanitizing solution and a clean cloth to wipe the inside and outside of each cart. Observation on 7/7/24 at 9:05 A.M. showed a three-tiered cart sitting next to griddle with spilled food on all three tiers of shelf. Observation in kitchen on 7/7/24 at 9:25 A.M. showed the hall tray food service carts had food drippings and spills coated to metal rungs on sides of cart and shelf holders. Observation on 7/9/24 at 6:07 A.M. showed the three-tiered cart by griddle had food crumbs on each shelf of unit. The metal hot box carts used for food room tray service had dried on food spilled on metal rungs and sides of units. During an interview on 7/9/24 at 7:27 A.M., Dietary Manager said: -Food carts should be wiped down at night and before use; -Evening shift power washed food carts; -Food carts were currently cleaned every night and when needed; -Night shift sprayed food carts down and used squeegee and longer brush to scrub each hot box and food cart. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -The three-tiered carts were to be sprayed down, scrubbed with wire brush each evening. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected food carts to be free from rust, grime, and food particles. 5. Review of facility policy, Cleaning Instructions: Food preparation appliances, dated 2016, showed: -Small food preparation appliances, such as blenders, food processors, and mixers will be cleaned and sanitized following each use. -Disassemble all removable parts (cup, lid, blade). Rinse with warm water and place in dishwasher or sink. Wash and rinse according to manual guidelines for dish washing. Allow to air dry. -Rinse exterior of appliance with a clean cloth dipped in hot, soapy water. Then, rinse with hot water. Observation in kitchen on 7/7/24 at 9:25 A.M. showed the food processor was laying in right side of two compartment sink. The left side of two compartment sink had standing water in it approximately 6 inches high and did not drain. There was two clean blades of food processor located sitting on their side on a tray which sat on shelf above the two compartment sink. The tray was observed to have black, white, and brown food crumbs and 3 bread ties. During an interview on 7/9/24 at 7:27 A.M., Dietary Manager said: -Steam table should be cleaned every night; - Food processor should be ran through dishwasher, however it gets filled with water to let it soak prior to washing it; 6. Review of facility policy, Cleaning Instructions: Microwave Oven, dated 2016, showed: -Microwave oven will be cleaned, sanitized, and deodorized on a regular basis. -Remove any food particles from inside the oven, then wipe down with hot, soapy water. Rinse with clean water and sanitize. Leave the oven door open to air dry. Observation in the kitchen on 7/7/24 at 9:45 A.M. showed: -Food debris in top of microwave and on sides. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Microwave was cleaned by his/her staff daily. 7. Review of facility policy, Cleaning instructions: Walk-In refrigerator and freezer, dated 2016, showed: -Walk in refrigerator and freezer will be cleaned and sanitized on a regular basis. -Each month, remove items from shelves in preparation for thorough cleaning. -Wipe down shelves with sanitizing solution. -Sweep floor. -Wipe doors and frame inside and outside with sanitizing solution. Observation in the kitchen of walk in freezer on 7/7/24 at 9:35 A.M. showed: -Steak fries scattered about on floor of freezer unit. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Food should not be on floor of walk in freezer. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected floor of walk in freezer to be free from food particles; -All food items should be stored off the floor by 6 inches. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -There should not be food on floor of walk in cooler; -Food should be stored six inches off the floor, not on the floor; 8. Review of facility policy, Cleaning instructions: Reach-in refrigerator and freezer, dated 2016, showed: -Clean up spills and wipe down outside of refrigerator and freezer with a clean cloth dipped in sanitizing solution as needed. Observation in the kitchen on 7/7/24 at 9:05 A.M. showed the bottom of the double door refrigerator on back wall had food particles covering bottom of unit. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Refrigerator and freezer should be wiped out as needed; -There should be no food spills in unit. 9. Review of facility policy, cleaning instructions: range, dated 2016, showed: -The range will be cleaned and sanitized after each use. Spills and food particles will be wiped up as they occur. -Scrape off all burned food particles and grease with a non-metal scouring pad. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Kitchen food preparation surfaces should be wiped down after everything is done; -Stove top should be cleaned daily and should not have burnt on food and food spills on it; During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected food preparation surfaces to be cleaned and sanitized before use. 10. Review of facility policy, cleaning instructions: conventional oven, dated 2016, showed: -Ovens will be cleaned regularly, according to cleaning schedule; -Scrape burned particles from inside oven with scraper. Remove and discard all particles from interior. Observation in the kitchen on 7/724 at 9:06 A.M. showed the oven had black caked on food that had been spilt inside unit, brown crumbles and crusted on food pieces were caked on bottom of unit of oven. The edges of the oven door were stained brown and black. The ledges of the oven door had spilt food and crusted black pieces of food particles. Observation on 7/9/24 at 6:07 A.M. showed the stove top had burnt on food particles, food crumbs, the front ledge of the stove had grease spattered, red pieces of uncooked meat, egg splatter, and other spill remnants. The stove top had not yet been used for the day. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Kitchen food preparation surfaces should be wiped down after everything is done; -Oven should be cleaned daily and should not have food caked on it. During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected the stove and oven to be free from caked on food. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Kitchen staff was responsible for using oven cleaner on stove. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected food preparation surfaces to be cleaned and sanitized before use. 11. Review of facility policy, cleaning instructions: flat-top grill, dated 2016, showed: -Grill will be cleaned following each use; -Empty drip pan and wash with hot detergent solution. Observation in the kitchen on 7/7/24 at 9:05 A.M. showed griddle grease reservoir had ¼ inch of grease and was filled with empty eggshells. Observation on 7/9/24 at 6:05 A.M. showed the dip trays on the griddle contained egg shells, a white sponge, and dried grease. No items had been cooked or prepared yet for the day. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Grease trap on griddle should be cleaned out at end of every shift and when needed. During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected the grease trap to be free of grease and food. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Kitchen staff was responsible for cleaning griddle and emptying grease trap; -Grease trap should be emptied every evening; -The grill top griddle is cleaned after and between meals. 12. Review of facility policy, cleaning instructions: can opener, dated 2016, showed: -Both hand held and electric can openers will be cleaned following each use. Observation in kitchen on 7/7/24 at 9:25 A.M. showed the can opener had a buildup of gunk and food substances coated to metal of can opener. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Kitchen food preparation surfaces should be wiped down after everything is done. 13. Review of facility policy, refrigerator and freezer temperatures, dated 2016, showed: -In order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators in nourishment rooms. -Dining services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift. Corrective actions are taken as necessary to insure only safely stored foods are served to residents. -Each refrigeration and freezer unit in the main kitchen is checked at department opening and before any food product is used for the day. -Temperatures are to be taken from the thermometer located inside the unit. -The temperature of each refrigeration and freezer unit is checked by the staff member who is closing the department for the day. -Each refrigeration or freezer unit located outside the main kitchen is checked daily and recorded on the refrigeration/freezer temperature log. Observation on 7/07/24 at 8:56 A.M. in the kitchen showed the double door refrigerator on the back wall by dietary manager's office had temperature log with only one entry on 7/5/24 on P.M. shift. The rest of the log was blank with no entries on A.M. on 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, or 7/7 and no entries for P.M. on 7/1, 7/2, 7/3, 7/4, 7/6. Observation in kitchen on 7/7/24 at 8:56 A.M. in the kitchen showed the white fridge/freezer on the back wall by the dietary manager's office had a temperature log showing freezer and fridge temperatures with only one entry under each column. The freezer log showed 0 degrees on 7/5/24 P.M. shift. The rest of the log was blank with no entries on A.M. on 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, or 7/7 and no entries for P.M. on 7/1, 7/2, 7/3, 7/4, 7/6. The refrigerator log had one entry on 7/5 P.M. shift showing 35 degrees. The rest of the log was blank with no entries on A.M. on 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, or 7/7 and no entries for P.M. on 7/1, 7/2, 7/3, 7/4, 7/6. Observation in kitchen of walk-in freezer on 7/7/24 at 9:30 A.M. showed the freezer log outside of walk-in freezer had not been filled out at all for the month. Observation on 7/9/24 at 6:07 A.M. showed the refrigerator and temperature logs that had previously been primarily blank during initial tour have now been filled in. During an interview on 7/7/24 at 8:57 A.M., Dietary Manager said the other refrigerator in the kitchen was not in service, and he/she had to move everything over to the two fridges on the back wall to keep everything cold. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -All refrigerators and freezers should have thermometers in units; -He/She only had one thermometer in the refrigerator and freezer units currently. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Refrigerator and freezer temperatures are to be checked twice a day, if it was not done during day shift the evening shift was good about doing the temperature log; -Temperatures of refrigerators and freezers should be logged on logs outside of refrigerator and freezer units; -Refrigerator and freezer units should have thermometers in them. During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected freezer and refrigerator temperatures to be checked daily. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected a thermometer to be in all refrigerator and freezer units; -He/She expected temperatures to be checked in refrigerators and freezers daily on each shift. 14. Review of facility policy, storing utensils, tableware, and equipment, dated 2016, showed: -Cleaned and sanitized utensils and equipment will be stored at least six inches off the floor in a clean, dry location in a way that keeps them from contamination by splash, dust, or other means. -Clean and sanitize drawers and shelves before clean items are stored. -Clean and sanitize trays and carts used to carry clean tableware and utensils. Do this daily or as often as necessary. -Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination. Cups, glasses, bowls, plates, and similar items should be handled so as not to touch any surface that may come into contact with food or a resident's mouth. -Glasses and cups should be stored inverted; Observation in the kitchen on 7/7/24 at 9:04 A.M. showed 12 trays of serving bowls were stored with openings up. All plates were stored face up. Six trays of bowls by the microwave stand were stored upright. Observation on 7/9/24 at 6:07 A.M. showed shelves of bowls and plates stored upright. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -He/She thought proper storage of bowls and plates was to have the opening facing up. During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected plates, glasses, and bowls to be stored inverted; During an interview on 7/10/24 at 9:54 A.M., Dietary Aide A said: -Cups, plates, and bowls should be stored face down or inverted. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Bowls should be stored faced down; -Plates and cups should be stored so water can flow down, plates should be left on drying rack and then put on plate warmer. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected cups and glasses to be stored face down. 15. Review of facility policy, Dishwashing: Machine Operation, dated 2016, showed: -Dining services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. -Check the dishwashing machine each morning before first set of dishes are to be washed. This is usually before the breakfast meal and again in the P.M. or generally before the supper meal. If the dishwashing machine had not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. Check the dials to ensure that the wash and rinse cycles are achieving proper temperature per the manufacturer guidelines. If a chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use. If not at the correct hot water temperature or the proper chemical sanitizing concentration, do not proceed to wash dishes. -Check the dishwashing machine for cleanliness before the start of each meal. Sanitize the clean work table before starting dishes at each meal. Clean bottom drain cover as necessary during dishwashing to ensure food debris does not build up. Wipe down the dishwashing machine and clean per equipment cleaning procedure at the end of each work day. Remove any built up debris, lime, or scale as necessary or generally complete a thorough de-liming per cleaning schedule or one time weekly. -Clean and sanitize the entire work area, both dirty and clean drain boards. Observation on 7/7/24 at 8:49 A.M. in the kitchen showed: -Dish washer sanitizer log had a June log posted on side of machine; -The June 2024 log had not been filled out on 6/27 for A.M. and P.M., 6/28 on A.M. shift, 6/29 on A.M. shift, and 6/30 on A.M. shift; -No July log was found; -Top of dishwasher was covered in brown crumbly substance; -Food was stuck to drain grate; -Dirt and gunk was underneath the dishwasher; -A white bottle of chemical with a spray top was laying on it's side underneath the dirty tray return; -A plastic spoon and fork were laying on the ground underneath sanitizer. -Observation on 7/9/24 at 6:35 A.M. showed Dietary Aide C ran test strip of parts per million of dishwasher, showed 100 parts per million (PPM). During an interview on 7/9/24 at 6:35 A.M. Dietary Aide C said: -He/She records completed test strip readings on log on side of dishwasher; -The log had not been updated on side of unit from June 2024; -He/She was not sure where July log was located. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -He/She was supposed to have log to record sanitizer readings; -May log was hanging on wall; -Dishwasher sanitation and temperature should be tested and logged when using machine; -His/Her staff was good at completing the log; -There was not a log started for July. During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected the dishwasher to be free from crumbs. During an interview on 7/10/24 at 9:54 A.M., Dietary Aide A said: -He/She tested the dishwasher by taking test strips, running dishwasher through a full cycle, then taking test strip and sticking it in the dip pan and ensure the solution was at appropriate levels; -He/She documented sanitizer readings on the log; -He/She had not documented on sanitizer log for July; -The sheet hanging on dishwasher was from June; -He/She tried to clean gunk from dishwasher after every meal by wiping gung and grease, ensuring chemicals were full, and emptying the drain piece that comes out of base of unit. During an interview on 7/10/24 at 10:11 A.M., Dietary manager said he/she delimed the dishwasher approximately once a month. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -The dishwasher was to be delimed once per week, evening shift was responsible for deliming; -Dishwasher should be tested twice daily in the morning and on evening shift; -Testing of dishwasher should be logged on paper on front of dishwasher machine. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -He/She expected the dishwasher to be delimed and cleaned per facility policy. 16. Review of facility policy, Food Storage (Dry, Refrigerated, and Frozen), dated 2016, showed: -Food shall be stored on shelves in a clean, dry area, free from contaminants. -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. -Discard food that has passed the expiration date, and discard that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared foods will be stored in covered, labeled, and dated containers in refrigerators and/or freezer. -Poisonous materials and chemicals will be stored separated from food in a cleaning closet or cabinet which can be locked. -Never leave any food item uncovered and not labeled. -Dry storage: store dry food on shelves six inches off the floor to allow for proper sanitation. Review of facility policy, Labeling and Dating Foods (Date Marking), dated 2020, showed: -Date marking for refrigerated storage food items -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date. -Once package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. -Prepared food or opened food items should be discarded when: -The food item does not have a specific manufacturer expiration date and had been refrigerated for 7 days; -The food item is leftover for more than 72 hours; -The food item is older than the expiration date. Review of facility policy, handling leftover food, dated 2016, showed: -Standardized recipes and production charts shall be utilized to minimize overproduction and waste. -Once food is cooled to 41 degrees or less, it is sealed tightly and labeled to identify the contents and has a use by date that is clearly visible. -Leftover food stored in the refrigerator shall be wrapped, dated, labeled with a use by date that is no more than 72 hours from the time of first use. -Refrigerated leftovers stored beyond 72 hours shall be discarded. -Leftover foods stored in the freezer shall be wrapped in air-tight and moisture proof, dated, and labeled. The date, item, and amount shall be clearly posted on freezer inventory clipboard. Observation on 7/07/24 at 8:54 A.M. in the kitchen showed a pitcher of orange juice had no label identifying content or date juice was mixed. A frozen 32 ounce (oz) container of frozen concentrated orange juice was sitting on counter cold. Observation in the kitchen on 7/7/24 at 8:59 A.M. showed: Refrigerator unit: -Undated and unlabeled applesauce in a reused container of 5 lb sour cream; -Three undated and unlabeled plastic storage bags of unknown meat in a marinade; -Outdated 6/1 container labeled watermelon and cantaloupe showed watermelon and cantaloupe in container stored in reused 5 pound (lb) container of sour cream; -Outdated 7/2 container labeled main soup; -Outdated 6/29 unlabeled container of gravy; -Outdated and labeled 6/11 cream of mushroom soup stored in reused 5 lb soup cream container, top of lid of container had a written date of 5/20; -Outdated 6/26 labeled tomato soup stored in reused 5 lb container of sour cream; -Unlabeled and undated gravy in 5 lb container of cottage cheese; -Illegible label dated of 6/? With cheese inside container of reused 5 lb container cottage cheese, use by date on container read 6/25; -Outdated 6/26 labeled creamed corn stored in 5 lb elbow macaroni salad container; -Opened sour cream with hand written date on lid of 7/2; -Opened and undated, label is illegible, container cottage cheese; -Outdated 6/27 labeled green bean stored in reused 5 lb container of sliced strawberries; -Opened container thickened apple juice dated 6/18; -Creamy Caesar dressing with no opened date; -Box of 18/22 count bacon resting on top of tray of tomatoes, onions, peppers, zucchini, and cabbage; -Celery on top shelf of fridge browning; -Undated and unlabeled metal container of ground beef covered in foil; -Opened and undated yellow mustard 3.8 oz; -Opened and undated thousand island dressing; -Eight uncovered serving bowls of fruit cocktail on tray In fridge; -Two uncovered glasses of apple juice. Observation in kitchen on 7/7/24 at 9:25 A.M. showed the spices sat on three trays on a shelf on top of the two-compartment sink. -Undated and opened 8 oz rosemary leaves; -Opened and dated 12/12/23 12 oz pure baking soda; -Opened and undated 16 oz garlic powder; -Opened and undated 18 oz ground white pepper; -Opened and undated 16 oz ground allspice; -Opened and undated 5 oz oregano leaves; -Opened and unreadable date of 18 oz chili powder; -Opened dill weed with multiple dates, the bottle showed 7/7 written with marker, the faded sticker showed 12/12/23; -Opened and exposed to air 5 lb container mashed potatoes granules, white plastic seal is opened with date of 4/30/24, lid was observed laying directly on metal shelf next to powdery white substance; -Opened plastic 5 lb bag of Italian style breadcrumbs was not sealed, date on plastic bag showed 6/4; -Opened second 5 lb bag of Italian style breadcrumbs was not sealed and exposed to air, dated 6/1/24; -Opened and dated 7/2 6 lb bag of yellow cake mix was not in sealed bag. Observation in kitchen of walk-in freezer on 7/7/24 at 9:31 A.M. showed: -Opened bag of French fries were exposed to air; -Opened box of cookie dough was uncovered and dough was exposed to air; -Bag of Italian hamburger buns were on floor. Observation in the kitchen of dry storage room on 7/7/24 at 9:40 A.M. showed: -Undated and opened tea bag box; -Opened and illegible date on cocoa mix box; -Undated and opened thickener; -Undated and unsealed hot dog bun bag; -Opened shortening and oil box exposed to air; -Crates of hot cocoa mix stored directly on floor. Observation in the kitchen on 7/9/24 at 6:25 A.M. showed: -Leftover desserts sitting on tray in refrigerator covered partially covered with parchment paper, exposed to air; -Two hamburger patties were sitting in 2 inches of water, unthawed, covered in plastic wrap, no date or label on container. During an interview on 7/07/24 at 8:49 A.M., Dietary Manager said: -Food should be dated anytime it gets put in the refrigerator, then thrown out after three days; -The barbequed chicken in bags in the fridge should have a date and label on them. During an interview on 7/09/24 at 7:27 A.M., Dietary Manager said: -Food should be dated as using items and before putting food away; -All staff was responsible for disposing outdated leftovers; -Spices should be dated and labeled when they are opened; -Spices should be thrown out when out of date or if passed expiration; -Spices can be maintained for twelve months after open date; -He/She has always reused food containers to store foods. During an interview on 7/10/24 at 9:24 A.M., the Dietician said: -He/She expected food to be dated and labeled when it came in to kitchen, when it was opened; -Food should all have a use by date labeled on it; -He/She expected leftover foods to be thrown out after by use by date or by 7 days; -He/She had provided training to staff on labeling and dating foods; -He/She expected no food to be stored on the floor. During an interview on 7/10/24 at 9:54 A.M., Dietary Aide A said: -Anytime a drink is made or opened it should have a date or label on it. During an interview on 7/10/24 at 10:58 A.M., Dietary Aide B said: -Food should be dated when it came in off truck by writing received date; -Leftovers should be dated and labeled and put in a container with lid on it; -Cook was responsible for throwing out leftover every three days. During an interview on 7/10/24 at 12:50 P.M., Administrator said: -Food should be dated and labeled when received in kitchen, when opened, and when placed in fridge; -Food should have a date and label on it; -He expected expired food or items having reached date limit to be discarded; -He/She expected labels and dates on food should be legible; -He/She expected opened spices to have labels and dates; -He/She expected food containers to be sealed with lids on them; -He expected food in freezer to not be exposed to air; -He/She expected there to be no food stored on the floor in the freezer. 16. Review of facility policy, Garbage and Rubbish Disposal, dated 2016, showed: -All containers will be provided with tight-fitting lids or covers, and will be leak proof. All garbage and rubbish containing food waste are covered when not in immediate use so as to be inaccessible to vermin. Observation on 7/7/24 at 8:49 A.M. in the kitchen showed there was no lid on the trash can by dishwasher. Obse[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff treated residents in a manner that maintained their dignity when staff stood to assist residents to eat which affected three of 15 sampled residents, (Resident #26, #27 and #261). The facility census was 60. Review of the facility's policy for dignity, revised February 2021, showed, in part: - Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay; - When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/18/23 showed: - Short term and long term memory problems; - Inattention and disorganized thinking occurred continuously; - Dependent on the assistance of two staff for transfers; - Required limited assistance of one staff with eating; - Diagnosis included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness and difficulty with balance and coordination). Review of the resident's physician order sheet (POS) dated February 2023, showed: - Order date: 11/22/22- regular, fortified foods, health shakes three times daily. Review of the resident's undated care plan, showed: - The resident had difficulty swallowing; - Remind the resident to tuck chin when swallowing; - The care plan did not address the resident's diet or assistance required for meals. Observation on 2/19/23 at 8:52 A.M. showed: - Certified Medication Technician (CMT) B stood beside the resident and assisted him/her to eat breakfast. Observation on 2/19/23 at 12:33 P.M., showed: - CMT B stood beside the resident during during the noon meal and assisted him/her to eat lunch. 2. Review of Resident #27's annual MDS, dated [DATE] showed: - Short term and long term memory problems; - Inattention and disorganized thinking occurred continuously; - Required the extensive assistance of one staff with eating; - Diagnoses included arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and dementia (the impaired ability to remember, think or make decisions that interferes with doing everyday activities). Review of the resident's POS, dated February 2023, showed: - Order date:10/31/22 to puree, fortified foods with breakfast and lunch, nectar thick liquids. Review of the resident's undated care plan, showed: - The resident was dependent on the assistance of staff for activities of daily living (ADLs); - The resident required full assistance with meal set up and eating. Observation on 2/19/23 at 8:52 A.M., showed: - CMT B stood beside the resident and assisted him/her to eat breakfast. During an interview on 2/22/23 at 11:52 A.M., CMT B said: - He/she usually stood when assisting residents to eat because he/she was short and when standing, he/she was able to see all of the dining room. 3. Review of Resident #261's initial care plan, dated 2/14/23, showed: - Regular diet; - Required set up with eating; - The care plan did not indicate the resident needed staff to assist him/her with eating. Review of the resident's admission MDS, dated [DATE] showed: - The resident was not able to complete the brief interview for mental status (BIMS); - Required extensive assistance of one staff with eating; - Diagnoses included arthritis and anxiety. Review of the resident's POS, dated February 2023, showed: - Order date: 2/20/23 - puree diet, fortified foods with breakfast and lunch, nectar thick liquids. Observation on 2/19/23 at 8:52 A.M., showed: - Nurse Aide (NA) A stood beside the resident and assisted him/her to eat breakfast. 4. During an interview on 2/22/23 at 2:45 P.M., NA A said: - He/she should not be standing when assisting the residents to eat. During an interview on 2/23/22 at 2:04 P.M., the Director of Nursing (DON) said she expected the staff to be sitting when they are assisting residents to eat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the resident or responsible party when a resident's money reaches $200 within the Supplemental Security Income (SSI) (program provides monthly payments to adults and children with a disability or blindness who have income and resources below specific financial limits. SSI payments are also made to people age [AGE] and older without disabilities who meet the financial qualifications.) resource limit ($5,301.85) in the resident trust account. This affected one resident who the facility held funds for (Resident #6). The census was 60. Review of the Resident Trust Fund Management policy dated December 2021 showed: - The facility resident funds are to be maintained in a bank checking account used exclusively for those funds. Transactions are to be handled and records are to be kept in accordance with established directives and in conformance with State and Federal requirements. Timely reporting to the Accounting Office regarding resident trust fund transactions will be performed. The facility will maintain the integrity of funds handled by the personnel; -When a resident's account balance exceeds $4,800.00 in the Resident Fund Accounts, the Bookkeeper will advise the resident or fiduciary, in writing, that the resident may lose eligibility for Medicaid. This balance should include any credit balance held in Accounts Receivable. Maintain a copy of the notification letter in the resident's business office folder; -The Bookkeeper who is responsible for the Resident Trust Fund must know the residents' balances at all times, whether or not he/she has access to the computer. Review of Resident #6's trust fund showed: -On 2/22/23, his/her trust fund balance was $6,557.25; -No letter showing the facility notified the resident or responsible party that he/she was within $200 of the SSI limit or over the limit. Review of the resident's admission Minimum Data Set (MDS) (is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs.) dated 1/9/23 showed his/her Brief Interview for Mental Status (BIMS) (The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment.) was a 13 out of a score of 15. During an interview on 2/23/23 at 11:28 A.M., the Business Office Manager (BOM) said Resident #6 had $6,557.25 this included stimulus money and rent receipts. He/she recently had hip surgery and had no time to spend the extra money. There was not a letter sent to Resident #6 regarding the money over the allotted Medicaid amount. During an interview on 2/23/23 at 11:48 A.M. the Administrator said Resident #6 had received every stimulus check. He/she had been bed ridden for six months due to a broken hip. He/she was told by Corporate that stimulus checks did not count towards Medicaid money, but had been aware of Resident #6's amount in his/her trust fund. During an interview on 2/23/23 at 2:06 P.M. the Administrator said when the trust fund has been identified at $200 below the Medicaid eligibility limit, the facility would notify the resident or their responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services with reasonable accommadtion of the residents' rights and preferences when staff did not honor four of 15 sampled residents, (Resident #6, #8, #11, and #15) preferences for having at least two showers a week and failed to ensure staff provided bedtime snacks for four sampled residents (Residents #8, #11, #15, and #48). The facility census was 60. Review of the facility's policy for bathing and showering, revised February 2018, showed, in part, the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation included: - The date and time the shower/tub bath was performed, the name and title of the individual who assisted the resident with the shower; all assessment data (any reddened areas, sores, etc. on the resident's skin) obtained during the shower; - If the resident refuses the shower, the reason why and the intervention taken; - The signature and title of the person recording the data; - Notify the supervisor of the resident refuses the shower; - Notify the physician of any skin areas that may need to be treated; - Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #6's care plan for ADLs/toileting preferences, dated 8/30/19, showed: - Bathing assistance of one staff - The resident's care plan did not direct staff on how often the resident preferred to be assisted with a shower. Review of the resident's shower sheets for December 2022, showed: - 12/6/22 - the resident had a bed bath; - 12/12/22- the resident had a shower; - 12/16/22- the resident had a bed bath; - 12/19/22- the resident had a bed bath; - 12/26/22- the resident had a shower. Review of the resident's shower sheets for January 2023, showed: - 1/2/23- the resident had a shower; - 1/6/23 - the resident had a shower; - 1/11/23- the resident had a shower; - 1/18/23- the resident had a shower; - 1/25/23- the resident had a shower; - 1/29/23- the resident had a bed bath. Review of the resident's admission Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/23, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Supervision of one staff with bathing; - Diagnoses included history of hip fracture and anxiety. Review of the resident's shower sheets for February 2023, showed: - 2/3/23 - the resident had a shower; - 2/6/23 - the resident had a shower; - 2/13/23 - the resident had a shower. During an interview on 2/19/213 at 2:48 P.M., the resident said: - He/she has not been getting his/her showers; - He/she did not feel clean without his/her showers. During an interview on 2/22/23 at 11:34 A.M., Registered Nurse (RN) A said: - Showers are a work in progress; - Not all the residents get two showers twice a week; - If the resident does not get their showers, they try to give them a bed bath. 2. Review of Resident #8's undated care plan showed: - Requires one person extensive assistance with bed mobility. - Unable to dress independently. - Requires two person assistance with sit-to-stand lift for transfers. - Requires one person to assist with bathing - The care plan did not direct staff on how often the resident preferred to be assisted with a shower or bed bath. Review of the resident's MDS, dated [DATE], showed: - Cognitive status moderately impaired; - Needed extensive staff assistance of two or more staff for bed mobility, transfers, dressing, and toilet use; limited staff assistance for personal hygiene; - Neede one person physical assistance with bathing; - Diagnoses include stroke with right, dominant side, impaired. Review of the resident's shower sheets for December 2022 showed: - 12/1/22 resident had a shower. - 12/7/22 resident had a shower. - 12/16/22 resident had a shower. - 12/19/22 resident had a shower. - 12/28/22 resident had a shower. Review of the resident's shower sheets for January 2023 showed: - 1/2/23 resident had a shower. - 1/11/23 resident had a shower. - 1/16/23 resident had a shower. - 1/20/23 resident had a shower. - 1/25/23 resident had a shower. - 1/30/23 resident had a shower. Review of the resident's shower sheets for February 2023 showed: - 2/3/23 resident had a shower. - 2/6/23 resident had a shower. - 2/13/23 resident had a shower. - 2/22/23 resident had a shower. Observation and interview on 2/19/23 at 10:00 A.M., showed and the resident said: - His/her hair felt very oily and looked bad; his/her hair felt bad when it was not washed at least twice a week. - Staff are supposed to provied showers two times a week, but they are once a week, and with sometimes 10 days between. - The resident's hair lay flat against his/her head, straight, with shiny and wet appearance. 3. Review of Resident #11's 1/4/22 care plan showed: - The resident has potential for skin breakdown. - Staff to assist with ambulation, toileting, and transfers; - The care plan did not address the resident's ADL care including preferences for showers. Review of the resident's significant change in condition MDS, dated [DATE], showed: - Cognitive status moderately impaired; - The resident rated having ability to choose between a shower, bath or sponge bath as very important - Independent with bed mobility and transfers; and required supervision only for dressing, toilet use and personal hygiene; - The resident required limited assisted with bathing and only needed assistance with transferring. Review of the resident's shower sheets for December 2022 showed: - 12/3/22 Resident had a shower. - 12/8/22 Resident had a shower. - 12/14/22 Resident had a shower. - 12/21/22 Resident had a shower. - 12/28/22 Resident had a shower. Review of the resident's shower sheets for January 2023 showed: - 1/6/23 Resident had a shower. - 1/13/23 Resident had a shower. - 1/18/23 Resident had a shower. - 1/27/23 Resident had a shower. Review of the resident's shower sheets for February 2023 showed: -2/1/23 Resident had a shower. -2/6/23 Resident had a shower. -2/13/23 Resident had a shower. During an interview on 2/19/23 at 10:00 A.M., the resident said: - Staff only assisted him/her to shower one time a week. - He/she would like to have two showers a week. 4. Review of Resident #15's care plan, dated 11/30/18, showed: - Taking a shower was fine with the resident; - The care plan did not indicate the resident's preference for showering or bathing; - The resident needs assistance from one person for dressing, transfers and bathing. Review of the resident's MDS, dated [DATE], showed: - Brief interview for mental status (BIMS) score of 13, cognitively intact. - The resident rated having ability to choose between a shower, bath or sponge bath as very important; - Required extensive assistance with bed mobility, transferring, and dressing; - Required total assistance for toilet use and limited assistance with personal hygiene; - Required one staff person's physical assistance with bathing. Review of the resident's shower sheets for December 2022 showed: - 12/5/22 Resident had a shower. - 12/9/22 Resident had a shower. - 12/15/22 Resident had a shower. - 12/19/22 Resident had a shower. - 12/28/22 Resident had a shower. Review of the resident's shower sheets for January 2023 showed: - 1/2/23 Resident had a shower. - 1/11/23 Resident had a shower. - 1/16/23 Resident had a shower. - 1/19/23 Resident had a shower. - 1/24/23 Resident had a shower. - 1/30/23 Resident had a shower. Review of the resident's shower sheets for February 2023 showed: - 2/3/23 Resident had a shower. - 2/6/23 Resident had a shower. - 2/13/23 Resident had a shower. - 2/22/23 Resident had a shower. During an interview on 2/19/23 at 10:00 A.M., the resident said: - The facility used to always offer showers twice a week, now they are once every week to 10 days. - He/she would like for it to return to two times a week. 5. During an interview on 2/23/23 at 8:30 A.M., Nurse Aide (NA) A said: - He/she started working at the facility about three weeks ago. - Certified Nurse Aide (CNA) B does the showers and when he/she is not working a list is left for the CNAs, telling them who needs showers. During an interview on 2/23/23 at 8:50 A.M., CNA C said: - He/She worked at the facility for four years and recently started as PRN (as needed). - There is an assigned shower person every day. -There is a list with Monday through Saturday with the residents' that need a shower. Shower sheets and schedule are at the desk or in the Assistant Director of Nursing's (ADON) office. During an interview on 2/23/23 at 10:10 A.M., CNA D said: - Showers are supposed to be given a minimum two times a week. - List of days and evenings showers was kept on dry erase board at the back nurses' station. - Usually that portion of the facility has a CNA, NA , and a certified medication technician (CMT) working. The CMT can assist the NA watching the floor while the CNA does showers. During an interview on 2/23/23 at 11:00 A.M., CNA B said: - Showers are supposed to be done for each resident two times a week. - He/She was formerly full time, but now works as needed or as his/her schedule allows. - CNA B has been assigned as the designated shower aide most of the shifts worked. - When someone missed their shower, they are prioritized to have their shower before the people on the current days list. During an interview on 2/23/23 at 2:04 P.M., the Director of Nursing (DON) said: - They do not have a designated shower aide; - They have two aides who work as needed and they will do the showers; - On the back hall, the aides do the residents' showers; - On the front hall if no one is listed on the shower sheet as the shower aide, the other aides working know they are responsible for the showers; - Usually the residents get one shower a week or their preference; - They ask the resident's preference on admission. 6. Review of the Resident Council meeting minutes, dated 9/20/22, showed: - No snacks offered at all; - When they ask for snacks, they are told to go get them from the desk, but the residents are unable to go to the desk for themselves. Observation on 2/21/23 at 7:25 P.M., showed: - There was a snack basket on top of the chart rack; - It had one baggie with fig newtons, two baggies with vanilla wafers and two oatmeal cream pies. Observation on 2/21/23 at 7:34 P.M., showed a small dining area in the back hall with a snack tray on top of microwave which contained: - Three half cheese spread sandwiches; - Two small baggies with vanilla wafers; - Two small baggies with fig newtons; - Two snickerdoodle cream pies; - Two packets of fruit puree. Observation on 2/21/23 at 7:45 P.M. in the kitchenette showed: - One package of peanut butter crackers, two bags of fig newtons, three pimento cheese sandwiches, two bags of vanilla wafer minis, and two oatmeal creme pies; - One expired grape juice container in bottom cabinet dated 11/19/22; - Two applesauce containers in the refrigerator. 7. Review of Resident #8's 1/21/22 care plan showed: - Refer to dietitian for evaluation; - Encourage to eat and drink; encourage good nutritional intake; - Offer nutritional supplement support; - Monitor nutritional intake. Review of the resident's Minimal Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/27/23, showed: -Cognitive status moderately impaired. -Diagnoses include stroke with right, dominant side, impaired. -Resident rated having a snack offered very important. Review of the resident's physician order set (POS), dated 2/1/23, showed: - Offer snack at bedtime and document if the resident refuses; order date 12/5/22; - Regular diet, no added salt (NAS), fortified foods; - No order for any house supplements. During interview on 2/19/23 at 10:00 A.M., the resident said: - Staff do not come to the room to offer snacks. - Another resident said a basket of snacks is at the nurses station, but he/she did not know if that was true or when they were there. - He/She could not get to the nurses' station independently. - He/She could not reach up from wheelchair to get a snack if they are on the nurses' station counter. - He/She would like to be offered a snack and would eat one most evenings if available. During an interview on 2/21/23 at 7:41 P.M., the resident said: - No one offered a snack this evening. - Staff offered a snack the previous evening for the first time since he/she was admitted in January of 2022. 8. Review of Resident #15's care plan dated 11/30/18 showed: - Needs assistance from one person for dressing, tansfers and bathing. - At risk for pressure ulcers. - Staff are to encourage good nutritional intake. Review of the resident's MDS dated [DATE] showed: - Brief interview for mental status (BIMS) score of 13, cognitively intact. - Rated having snack available as somewhat important. Review of the resident's POS, dated 2/1/23, showed: - An order to offer snack at bedtime and document if resident refuses. During interview on 2/19/23 at 10:05 A.M., the resident said: - No one comes to the room to offer snacks in the evening. - Someone told him/her snacks were at the nurses station. During an interview on 2/21/23 at 7:41 P.M., the resident said: - No one offered a snack this evening. 9. Review of Resident #11's undated care plan showed: - Potential for weight changes and skin breakdown. - Staff are to encourage resident to eat and drink. - Staff are to provide diet as ordered. - Staff are to provide snacks or supplements. Review of the resident's MDS dated [DATE], showed: - Cognitive status moderately impaired; - Rated having snack available as somewhat important. Review of the POS, dated 2/1/23, showed: - An order to offer snack at bedtime and document if resident refuses, order date 12/5/22; - Regular diet, fortifed foods, double portions- thin liquids. During interview on 2/19/23 at 10:30 A.M., the resident said: - Nobody comes to the room to offer a snack. - Most times he/she would eat a snack if offered. During an interview on 2/21/23 at 7:41 P.M., the resident said: - No one offered a snack this evening. 10. Review of Resident #48's undated care plan showed: - Resident has type 2 diabetes that requires monitoring of blood sugars. - Resident requires one person extensive assist with bed mobility, transfers and bathing; - Needs set up and supervision while eating; - Encourage good nutritional intake. Review of the resident's MDS dated [DATE] showed: - Resident is cognitively intact. - Resident rated having a snack offered very important. Review of the POS dated 2/1/23 showed: - An order to offer snack at bedtime and document if the resident refuses, order date 12/5/22; - Regular diet with thin liquids. During interview on 2/19/23 at 12:14 P.M., the resident said: - Snacks in the evening have not been offered. - Family members brought in fresh fruit and healthy snacks. During an interview on 2/21/23 at 7:41 P.M., the resident said: - No one offered a snack this evening. - They have only offered a snack once since admission, and it was last night. 11. During an interview on 2/21/23 at 12:50 P.M. Nurse Aide (NA) B said typically the residents turn their call lights on and ask for snacks. Snacks are located in the drink room and on both nurses' stations. Residents and staff can grab the snacks from those areas. Cold snacks are kept in the kitchen. If specified, the aides will go to the kitchen for the cold snacks. Nurses mostly know who get snacks. During an interview on 2/21/23 at 7:35 P.M., Licensed Practical Nurse (LPN) A said snacks are passed at evening medication pass. Staff ask each resident if they want a snack with their pills. Some residents refuse. Diabetics have orders for snacks and if their blood sugars are high then a snack is warranted like a peanut butter sandwich or peanut butter crackers. Snacks are in the small kitchenette next door. The door is shut, but accessible to all residents. During an interview on 2/21/23 at 7:31 P.M., LPN B said: - The orders for HS snacks are on the medication administration record (MAR)/treatment administration record (TAR) for all the residents; - The dietary staff brings the HS snacks out and leaves them at the desk at the nurses' station; - They have what is in the basket plus what is in the refrigerator to pass out to the residents; - The refrigerator had three pimento sandwiches and two squeeze containers of applesauce; - The HS snacks are just for the 100 and 300 hall; - They had a total of 10 snacks for the residents on the 100 and 300 hall; - He/she said they have enough snacks for all the residents on the 100 and 300 hall. During an interview on 2/21/23 at 7:52 P.M., LPN B said every resident is offered a snack, even an assisted diner. Cold items are in the kitchenette. Snacks are at the nurses' station. Some nights there are not enough snacks, but they had a backup stash in the kitchenette in the drawer under the microwave. During an interview on 2/21/23 at 7:53 P.M., Certified Medication Technician (CMT) D said: - He/she did not always take the snack basket with him/her but they ask the resident if they want a snack and then he/she gets it for them; - If there was not enough for all the residents on the 100 and 300 hall, he/she would go get more from the kitchen. The kitchen is usually locked but he/she tried to get more snacks before they leave. During an interview on 2/22/23 at 11:27 A.M., Dish Aide A said he/she fills two trays with five peanut butter and jelly sandwiches cut in half. Half of the sandwiches go to both halls. Cookies, chips, and crackers are also at the nurses' stations. Applesauce and pudding are for residents with a pureed diet. When he/she does it, he/she puts 20 items on a tray for each hall. During an interview on 2/22/23 at 11:42 A.M., the Dietary Manager (DM) said on the therapy unit side they should have plenty of snacks because most of the residents go to sleep early. The 400 hall asks for snacks before they leave the dining room. If they run out of snacks before kitchen staff leave, there are snacks in the drawer in the kitchenette. During an interview on 2/22/23 at 11:52 A.M., CMT B said: - Any staff can pass the HS snacks; - The staff document it on the CMTs' MAR; - Some of the residents come up and ask the staff for a snack; - There is usually a basket with snacks on the front hall; - There is not always enough snacks for all the residents on the hall; - He/she could get more snacks from the kitchen if it was open. During an interview on 2/23/23 at 2:04 P.M., the Director of Nursing (DON) said: - All the residents have an order for HS snacks; - Every single resident should be asked if they want an HS snack; - There should be a snack available for every single resident; - The staff document if the resident accepted or refused the snack.

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made four medication errors out of 28 opportunities for error, a medication error rate of 14.29%, which affected two of 15 sampled residents, (Resident #41 and #52). The facility census was 60. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy for instillation of eye drops, revised January 2014, showed, in part: - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; - To steady the eye dropper during the instillation process, rest your hand on the bridge of the resident's nose or on his/her forehead; - When administering two or more different eye drops allow three to five minutes between each application; - Be careful not to touch the dropper to the eyelash or eyelid; - Gently pull the lower eyelid down. Instruct the resident to look up; - Drop the medication into the mid lower eyelid; - Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops; - Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye; - The policy did not specify how long to apply lacrimal pressure (placing a finger at the corner of the eye near the nose for one or two minutes). Review of the website, https:// www. webmd.com for Systane eye drops showed: - Be careful not to touch the dropper to the eyelash or eyelid; - Tilt the head back, look up and pull the lower eyelid down to make a pouch; - Place the dropper directly over the eye and squeeze out one or two drops; - Look down and gently close your eye for one or two minutes and place one finger at the corner of the eye near the nose and apply gently pressure. This will prevent the medication from draining away form the eye. 1. Review of Resident #41's physician order sheet (POS), dated February 2023, showed: - Order dated 12/19/22 - Systane gel 0.4 %- 0.3 % eye drops, one drop in both eyes at 8:00 A.M., 2:00 P.M., and 8:00 P.M. for dry eyes. Review of the resident's medication administration record (MAR), dated February 2023, showed: - Systane gel 0.4 %- 0.3 % eye drops, one drop in both eyes at 8:00 A.M., 2:00 P.M., and 8:00 P.M. for dry eyes. Observation on 2/21/23 at 1:16 P.M., showed: - Certified Medication Technician (CMT) A administered one drop in the resident's left eye, touched the tip of the eye dropper to the resident's eye lid and did not apply lacrimal pressure; - CMT A administered one drop in the resident's right eye, touched the tip of the eye dropper to the resident's eye lid and did not apply lacrimal pressure. During a telephone interview on 2/22/23 at 2:34 P.M., CMT A said: - He/she should not have touched the tip of the eye dropper to the resident's eyelash or eyelid; - He/she should apply lacrimal pressure for one minute. 2. Review of the website, https://mayoclinic.org for administration of prednisolone eye drops (used to treat eye infections and inflammation) showed: - Tilt your head back and, pressing your finger gently on the skin just beneath the lower eyelid, pull the lower eyelid away from the eye to make a space. Drop the medicine into this space; - Let go of the eyelid and gently close your eye. Do not blink; - Keep the eye closed and apply pressure to the inner corner of your eye with your finger for one or two minutes to allow the medicine to be absorbed by the eye. Review of the website, https:// www.medlineplus.gov for administration of trusopt eye drops (used to treat glaucoma, increased pressure within the eyeball causing loss of sight) showed: - Avoid touching the dropper tip against your eye or anything else; - While tilting your head back pull down the lower lid of your eye with your index finger to from a pocket; - Hold the dropper (tip down) with the other hands, as close to the eye as possible without touching it; - While looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid; - Close your eye for two to three minutes and tip your head down as though looking at the floor; - Try not to blink or squeeze your eyelids; - Place a finger on the tear duct and apply gentle pressure. Review of Resident #52's POS, dated February 2023 showed: - Order date 1/19/23: prednisolone acetate 1% eye drop, instill one drop in left eye every other day for glaucoma; - Order date - 11/8/22: trusopt 2% eye drop, instill one drop in both eyes twice daily for glaucoma. Review of the resident's MAR, dated February 2023 showed: - Prednisolone acetate 1% eye drop, instill one drop in left eye every other day for glaucoma; - Trusopt 2% eye drop, instill one drop in both eyes twice daily for glaucoma. Observation on 2/22/23 at 8:15 A.M., showed: - CMT C administered Trusopt one drop in the resident's left eye and instructed the resident to apply lacrimal pressure but did not specify for how long. The resident applied lacrimal pressure for four seconds. The tip of the eye dropper touched the resident's eyelashes; - CMT C administered Trusopt one drop in the resident's right eye and instructed the resident to apply lacrimal pressure but did not specify for how long. The resident applied lacrimal pressure for three seconds. The tip of the eye dropper touched the resident's eyelashes; - CMT C administered Prednisolone one drop in the resident's left eye and did not instruct the resident to apply lacrimal pressure. The resident applied lacrimal pressure for one second. The tip of the eye dropper touched the resident's eyelashes and eyelid. During an interview on 2/22/23 at 2:24 P.M., CMT C said: - The tip of the eye drop should not touch the eyelid or eyelashes; - Should apply lacrimal pressure for one minute. During an interview on 2/23/23 at 2:04 P.M., the Director of Nursing (DON) said: - The tip of the dropper should touch the resident's eyelashes or eyelids; - Staff should apply lacrimal pressure for one minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure they prepared food under sanitary conditions when they failed to keep food labeled, dated, and sealed. The facility census was 60. Review of Labeling and Dating Foods (Date Marking) dated 2016 showed: -Date marking for dry storage food items o Once a case is opened, the individual food items from the case are dated. -Date marking for refrigerated storage food items o Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in -first out method of rotation; o Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date; - Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date; -Prepared food or opened food items should be discarded when: o The food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days; o The food item is leftover for more than 72 hours; o The food item is older than the expiration date; - If food items are mixed together, the use by date of the oldest food becomes the new use by date for the mixed food. The facility did not provide a policy related to handwashing. Observation on 2/19/23 at 8:30 A.M. showed: -Breakfast refrigerator: -An open bag of hard boiled eggs without any open or use by dates; -A la cart and desserts refrigerator had an open sliced ham lunch meat, cheddar cheese, [NAME] cheese, and mozzarella cheese without any open or use by dates; -There are three bowls of ambrosia salad not covered or dated; -Large square clear bowl of diced peaches without any open or use by dates; -Leftovers refrigerator -A bag of chicken quarters and a bag of unknown meat in the door with no open or use by dates; -Toast in a bag without a use by date; -Drinks and Produce refrigerator: -An open orange juice pitcher without use by date; -Soy sauce did not have an opened date; -Dry macaroni noodle bag was open with no open or use by dates; -Long grain rice box was open without an opened date or use by date on it; -Tub of popcorn kernels not labeled with what was inside; -Tub of sugar was not closed and not dated; -Freezer: -A hushpuppy bag ripped open and had no open date; -Lemon juice sat on the shelf above the vegetable cleaning sink without a lid on it open to air without an open date. No manufacturers expire date on it either; -Ground ginger, parsley flakes, cinnamon, paprika, onion powder, poultry seasoning, bay leaves, whole black pepper, chili powder had all of their lids open and did not have any open dates; -Peppered gravy, cornstarch, turkey gravy, pork gravy, and biscuit mix packages were all open to air, not clipped shut, and without any opened dates. Observation on 2/20/23 at 8:17 A.M. showed: -All seasonings did not have open dates and were still open; -Lemon juice had no lid on it and was sitting out on counter top with seasonings; -The lemon juice showed it is supposed to be refrigerated after opening. Observation on 2/21/23 at 3:25 P.M. showed [NAME] B: -He/she was cutting a tomato then took off his/her gloves and with a bare hand opened the lid to the trash can instead of using foot pedal. - Then he/she proceeded to the breakfast refrigerator and opened it. - Then washed his/her hands. Observation on 2/21/23 at 3:34 P.M. showed [NAME] B: -He/she took their gloves off after chopping hard boiled eggs. -He/she lifted the lid of the trashcan to drop in the gloves without using the foot pedal. -Immediately, he/she grabbed the shredded cheese and lunch meat without washing his/her hands. Observation on 2/21/23 at 5:29 P.M. showed: -Peanut butter was open on the back shelf without an open date on it. Observation on 2/21/23 at 5:51 P.M. showed: -Cook B washed his/her hands and dried his/her hands with a paper towel; - Then opened the trash can lid with his/her hand without utilizing the foot pedal. Observation on 2/21/23 at 5:52 P.M. showed: -Cook B washed and put a potato in the microwave, turned it on, and opened the trash can lid with bare hands to throw away paper towel. -He/she immediately went to put desserts on the trays and put them in the hall tray cart. -When done with this task, he/she threw away trash by grabbing the trash can lid with bare hands. -He/she washed his/her hands again and with bare hands grabbed the trash can lid. Observation on 2/21/23 at 6:00 P.M. showed: -Cook B washed his/her hands again and opened the trash can lid with bare hands. -He/she put on gloves to handle a baked potato he/she previously put in the microwave. During an interview on 2/21/23 at 3:13 P.M. [NAME] A said use by dates are dated for three days out. At the time an item was opened, was when the open and use by dates are put on. If he/she forgot, someone else could date the item for me. During an interview on 2/21/23 at 3:56 P.M. [NAME] B said when an item was opened is when an open and use by date is put on it. Depending on what the item is, depends on what the date is actually put on for the use by date. During an interview on 2/21/23 at 4:04 P.M. Dietary Manager (DM) said when the items are initially opened is when the labels are put on them. He/she said the lemon juice should be thrown away since it was to be refrigerated after opening and it had not been refrigerated. He/she said he/she had washed all of the opened seasonings and threw away the opened turkey and pork gravy, cornstarch, and biscuit mix. During an interview on 2/21/23 at 4:09 P.M. [NAME] A said to wash hands often from changing tasks like from dirty to clean tasks. One should definitely wash hands after touching the trash can. During an interview on 2/21/23 at 4:39 P.M. DM said he/she did not know that opened seasonings needed to have an open date, but will keep it under consideration. Staff are to wash their hands after leaving the serving table, changing tasks, and changing trash. During an interview on 2/22/23 at 11:27 A.M. Dish Aide A said when we open spices or seasonings the open date is put on and the lids to the containers are to be shut. During an interview on 2/22/23 at 11:39 A.M. [NAME] C said when we open the seasonings and spices we put an open date on it and when done with it we close the lid. During an interview on 2/23/23 at 2:30 P.M. Administrator said spices should be labeled when they are opened and identify what it is. Handwashing in the kitchen is to follow the policy-wash hands before and after gloving and before and after preparing foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents when they did not identify and address a black substance on restroom ceilings and did not address stained ceiling tiles. The facility census was 61. 1. Observations during the facility tour on 1/7/20 through 1/8/20 at various times, showed: - Resident room [ROOM NUMBER] restroom had a dark speckled substance on the ceiling. - Resident room [ROOM NUMBER] restroom had a three-inch by one-half inch dark substance on the ceiling. - Resident room [ROOM NUMBER] restroom had a dark substance covering one-fourth of the ceiling area and a six-inch long by five-inch wide dark substance on the restroom wall. Observation and interview on 1/8/20 at 11:44 AM showed the physical therapy gym restroom had a six-inch by six-inch dark substance on the ceiling. The Rehab Therapy Coordinator looked at the restroom ceiling and said the dark substance looked like mold. 2. Observations and interviews during the facility tour on 1/7/20 through 1/8/20 at various times, showed: - Three ceiling tiles with brown stains ranging in size from two-inches by two inches to six-inches by four-inches located outside the dish wash area corridor to the dining room. - A one-foot by one-foot brown stained area on the ceiling tile in the corridor outside the MDS office. - A one-foot by one-foot brown stained area on the ceiling tile in the corridor outside room [ROOM NUMBER]. - A four-inch round brown stain on the ceiling tile in the main dining room near the 400 hall access doors. 3. During observations and interviews on 1/7/20 and 1/8/20 at various times, the Maintenance Supervisor (MS) said: - The brown stained ceiling tiles were not homelike. He/she would not want the stained tiles in his/her home. The stained tiles had been in that condition for months. He/she has not gotten around to replacing them. - The dark substance on restroom ceilings looked like mold. He/she had not checked the restroom ceilings during his/her monitoring of the facility. Staff did not notify him/her on the MS log or inform him/her about the mold. During an interview on 1/8/20 at 10:00 A.M., the Housekeeping Supervisor said he/she was unaware of the black mold like substance on restroom ceilings until it was discovered by the MS on 1/7/20. He/she questioned his/her staff and none were aware of the dark substance on restroom ceilings. As part of housekeeping duties, staff should look up at ceilings to assure they are clean. Staff needed training to assure they are checking ceilings for cleaning and environmental services. 4. During an interviews on 1/7/20 at 4:00 P.M., the Administrator said: - Staff should monitor ceilings to assure they are clean and homelike. - The black substance on restroom ceilings needed addressed immediately.