**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three (Resident #4, #19, and #21) out of three sampled residents. The facility's census was 41. 1. Review of the facility's Bed Hold/Retention Policy, undated, showed the record did not direct staff to provide a bed hold notification, explains the duration of bed-hold, if any, and the reserve bed payment policy. 2. Review of Resident #4's medical record showed the resident discharged from the facility to the hospital on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 3. Review of Resident #19's medical record showed the resident discharged from the facility on 12/31/24 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 4. Review of Resident #21's medical record showed the resident discharged from the facility on 03/15/25 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 5. During an interview on 04/24/25 at 12:00 P.M., Licensed Practical Nurse (LPN) C said the nurse who does the discharge is responsible to give the bed hold policy, and check the box in the electronic medical record (EMR) under the discharge summary saying you gave it. LPN said he/she was not aware they should keep them on file to show it was given. During an interview on 04/24/24 at 12:38 P.M., the Director of Nursing (DON) said the nurse is responsible for this at the time of discharge. The nurses will make a note that it was done, but they don't retain a copy of what is given. The DON said this is a new policy the facility just started, and is unsure what it states. The DON said there is no way to for sure to tell if or when it is given to the resident or their reresentative due to it is just check marked in the system as given. During an interview on 04/24/25 at 1:04 P.M. the administrator said the nurse who discharges the resident should be completing the bed hold information at time of discharge. The administrator said she was not aware the policy did not contain the required information, and did not think about the benefit of this notification being kept on file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility staff failed to complete a Comprehensive Significant Change Minimum Data Set (MDS), a federally mandated resident assessment tool, for three residents (Resident #12, #28, and #37) out of five sampled residents who had either improvements and/or declines in condition. The facility census was 41. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0, dated October 2024, Omnibus Budget Reconcilliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -A significant change in status assessment (SCSA) is appropriate when there is a determination that significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline in two weeks; -A significant change is any decline in two or more of the following: decision making has changed; presence of a resident mood item no previously reported by the resident or staff and /or an increase in symptom frequency in Section E; changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since last assessment; any decline in an Activities of Daily Living (ADL) physicial functioning area where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual functioning; residents incontinence patters changes or placement of indwelling catheter; emergence of unplanned weight loss, emergence of a new pressure ulcer at stage II (partial-thickness skin loss) or higher, a new unstageable pressure ulcer/injury (depth and extent of the tissue damage cannot be determined ), a new deep tissue injury or worsening in pressure ulcer status (where the skin remains intact, but the underlying tissues are damaged); -A significant change is any improvement in two or more of the following: any improvement in ADL physical functioning area where a resident is newly coded independent, set up or clean-up assistance, or supervision or touching assistance since last assessment and dates does not reflect normal fluctuations in that individuals functioning; a decrease in areas where behavioral symptoms are coded as being present and/or the frequency of a symptom decreases; resident's decision making improves; and the resident's incontinence pattern improves; -A significant change assessment must be completed within 14 days after a determination has been made that a significant change in status has occurred and submitted within 14 days of the care plan completion date. 2. Review of Resident #12's Annual MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Mood severity code of one (score ranges between 0 and 27, indicates the potential for depression symptoms); -Rejection of care one to three days; -Did not wander; -Required supervision or for eating, oral hygiene, and wheelchair locomotion 50 feet with two turns; -Dependent on staff for personal hygiene. Review of the resident's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Mood severity score of 0; -Did not reject care; -Wandered one to three days; -Required set up or touch for eating and wheelchair locomotion 50 feet with two turns; -Required partial to moderate assistance for oral hygiene; -Required substantial to maximal assistance for personal hygiene. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment for improvements and declines in two or more areas of function. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said the resident waxes and wanes (mental status shifts back and forth) so that is why a significant change was not done on her. He/She said the decision to make the resident a significant change was not discussed or documented for this resident. 3. Review of Resident #28's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -No social isolation; -Verbal behaviors one to three days; -No psychosis; -Delusions present; -No functional limitations; -Required supervision for eating, lying to sitting, wheelchair locomotion 50 feet with two turns and 150 feet; -Required substantial to maximum assistance for oral hygiene, lower body dressing, putting on and removing footwear, and toilet transfers; -No weight loss. Review of the resident's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Sometimes socially isolative; -No verbal behaviors; -Psychosis present; -No delusions; -Functional limitation of range of motion to one lower extremity; -Required set up assistance for eating, lying to sitting, wheel chair locomotion 50 feet with two turns and 150 feet; -Required supervision for oral hygiene; -Required set up or touch for eating and wheelchair locomotion 50 feet with two turns; -Required partial to moderate assistance for putting on and removing footwear, lower body dressing, and toilet transfers; -Weight loss. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment for improvements and declines in two or more areas of function. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said the resident should have a significant change of status MDS completed but must have missed it. 4. Review of Resident #37's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Physical behavior directed toward others one to three days; -No rejection of care; -Required supervision for oral hygiene, rolling from left to right, sitting to lying, lying to sitting, sit to standing, and chair to bed to chair transfers; -Required partial to moderate assistance for toilet hygiene, showers/baths, lower and upper body dressing, and tub/shower transfers; -Frequently incontinent of bowel. Review of the resident's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -No physical behaviors; -Rejection of care one to three days; -Required set up assistance for oral hygiene, rolling from left to right, sitting to lying, lying to sitting, sit to standing, and chair to bed to chair transfers; -Required supervision or touching for toilet hygiene, shower/baths, lower and upper body dressing, and tub/shower transfers; -Continent of bowel. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment for improvements and/or declines in two or more areas of function. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said he/she did not know why a significant change MDS was not completed for this resident and should have discussed it. 5. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said a significant change is a change in a residents condition that lasts longer than two weeks. If a significant change is observed, he/she takes the information to the Interdisciplinary team (IDT) to discuss and determine if there is a true significant change. He/She said the decision is not documented in the medical record. He/She said it is his/her responsibility to ensure the MDS assessments are completed by use of the RAI manual. During an interview on 04/24/25 at 12:13 P.M., the Director of Nursing (DON) said he/she does not know a lot about the MDS. He/She said a significant change is a decline in function such as transfers, more assistance with activities of daily living, or a change from the prior MDS assessment. The MDS Coordinator is responsible to ensure significant change of status MDS assessments are completed. He/She said the IDT does not discuss if a resident is a significant change of status for a MDS assessment. During an interview on 04/24/25 at 12:49 P.M., the administrator said a significant change of status assessment would include new wounds, changes in activities of daily living, and changes in weights. He/She said the MDS nurse is responsible to ensure the significant change of status MDS assessments are completed by use of the RAI manual. There should be a note in the medical record if a decision is made by staff to not complete a SCSA. He/She was not aware of residents that did not have a SCSA completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, facility staff failed to complete a baseline care plan within 48 hours of admission and failed to provide the resident and/or the resident's representative with a copy of the baseline care plan for two residents (Resident #3, and #192) out of two sampled residents. The facility's census was 41. 1. Review of the facility's policy titled, Care Plans-Baseline, dated 12/2016, showed: -To assure the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to the initial goals of the resident, a summary of the resident's medications and dietary restrictions. 2. Review of Resident #3's electronic medical record (EMR), showed staff documented the resident admitted to the facility on [DATE]. The EMR did not contain documentation staff completed a baseline care plan within 48 hours of admission or provided a summary of the baseline care plan to the resident and/or his/her representative. During an interview on 04/24/25 at 12:14 P.M., the Director of Nursing (DON) said he/she was not sure why staff did not complete a baseline care plan for the resident after admission and was not sure how it got missed by him/her. During an interview on 04/24/25 at 12:58 P.M., the Care Plan Coordinator (CPC) said he/she was not sure why staff did not complete a baseline care plan for the resident, and he/she did not provide a summary of the baseline care plan to the resident or his/her representative. 3. Review of Resident #192's EMR, showed staff documented the resident admitted to the facility on [DATE]. The EMR did not contain documentation staff completed a baseline care plan within 48 hours of admission or provided a summary of the baseline care plan to the resident and/or his/her representative. During an interview on 04/21/25 at 12:01 P.M., the resident said he/she had concerns staff had not administered all the medications the physician prescribed for him/her at the facility. He/She said his/her spouse requested staff provide him/her with a list of medications staff administered to the resident since his/her admission and was still waiting for the medication list. During an interview on 04/23/25 at 1:31 P.M., the DON said he/she was not sure why the charge nurse did not initiate or complete the resident's baseline care plan within 48 hours of his/her admission. He/She said he/she had not had a chance to follow up. During an interview on 04/24/25 at 12:00 P.M., Licensed Practical Nurse (LPN) C said he/she was the charge nurse responsible to initiate the resident's baseline care plan after admission and was not sure why he/she did not complete the baseline care plan or communicate to the oncoming nurse that the baseline care plan was not completed. During an interview on 04/24/25 at 12:58 P.M., the CPC said he/she was not sure why staff did not complete a baseline care plan for the resident, and he/she had not provided a summary of the baseline care plan to the resident or his/her representative. 4. During an interview on 04/24/25 at 12:14 P.M., the DON said baseline care plans are used to let the Certified Nurse Assistant (CNA)s know a resident's prior level of care, current diet, transfer status, etcetera. He/She said the charge nurse is responsible to complete the baseline care plan within 48 hours of admission and either the DON or Assistant DON (ADON) is responsible to check within 72 hours to ensure it was completed. During an interview on 04/24/25 at 12:49 P.M., the administrator said baseline care plans are used to help direct a resident's care, the admission nurse is responsible to complete the baseline care plan within 48 hours after a resident is admitted to the facility, and the DON/ADON is responsible to check within 72 hours to ensure it was completed. During an interview on 04/24/25 at 12:58 P.M., the CPC said baseline care plans are used to give direct care staff an idea of each resident's care needs before a full/comprehensive assessment is completed. He/She said the charge nurse is responsible to complete the baseline care plan within 48 hours of a resident's admission, and the DON checks within 72 hours to ensure the baseline care plan was completed. He/She said he/she often initiates the comprehensive assessment within a few days after admission, and is usually responsible to give the resident or his/her representative a signed copy of the care plan summary. During an interview on 04/24/25 at 1:13 P.M., CNA A said the nurses complete residents' care plans, the CNAs access the care plans via the EMR and use the care plans to get information on a resident's diet, how to transfer, and special precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff did not complete neurological assessments after unwitnessed falls for seven residents (Resident #13, #19, #21, #23, #28, #35 and #38) of seven sampled residents. The facility census was 41. 1. Review of the facility's policy titled, Assessing Falls, revised 02/24, showed staff are directed as follows: -If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to resident; -Perform neuro checks if indicated: -Resident states head was struck during fall; -If any signs or symptoms present that may indicate a head injury such as pain, bleeding, changes in mental status, or body language indicators. Review of the facility's Post Fall 72-Hour Monitoring Report, showed staff are directed to: -Complete this assessment at the following intervals for follow up for all falls. -A fall that is unwitnessed, or in which the head is struck, requires neurological checks; -Initial assessment, followed by every 15 minutes for one hour, every 30 minutes for two hours, every one hour for two hours and every shift for 72 hours. 2. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/16/25, showed staff assessed the resident as: -Severe cognitive impairment; -Two or more falls without injury since last MDS; -Dependent of staff for all ADL Cares; -Diagnosis of Dementia. Review of the resident's electronic fall event report, dated 3/07/25, showed staff documented the resident had an unwitnessed fall. The resident was found on the floor on the fall mat on his/her knees leaning over the bed. Review of the resident's electronic fall event report, dated 3/10/25, showed the resident had an unwitnessed fall when staff reported the resident on the floor. Review of the resident's electronic fall event report, dated 4/03/25, showed the resident had an unwitnessed fall when the resident found on the floor mat next to bed. Review of the resident's electronic fall event report, dated 4/11/25, showed the resident had an unwitnessed fall. The resident was found on his/her knees on the fall mat leaning over the bed. Upon nurse arrival, resident was on his back on the floor mat. Review of the resident's Electronic Medical Record (EMR) dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 03/07/25, 03/10/25, 04/03/25, and 04/11/25. 3. Review of Resident #19's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -History of falls one month prior to admission and two to six months prior to admission; -Diagnosis of Atrial fibrillation (irregular heartbeat) and dementia. Review of the resident's electronic fall event report, dated 02/08/25, 02/17/25, 02/24/25, 02/25/25, 03/13/25 and 03/28/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's EMR dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 02/08/25, 02/17/25, 02/24/25, 02/25/25, 03/13/25, or 03/28/25. During an interview on 04/23/25 at 12:13 PM, the Director of Nursing (DON) said he/she could not find documented neurological checks for this resident. 4. Review of Resident #21's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Had two or more non-injury fall since admission; -Had one fall with injury (such as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain pain) since admission. Review of the resident's electronic fall event report, dated 03/22/25 at 7:03 P.M., showed staff documented the resident had an unwitnessed fall. The resident was found on the foot pedals of the wheelchair, it was leaning to the front, and almost turned over. Review of the resident's electronic fall event report, dated 03/23/25 at 3:50 P.M., showed staff documented the resident had a witnessed fall. Staff documented the resident's roommate came out of room yelling for help, Licensed Practical Nurse (LPN) to room to find resident of floor on fall mat. Review of the resident's electronic fall event report, dated 04/03/25 at 1:15 A.M., showed staff documented the resident had an unwitnessed fall. Staff found resident on the fall mat in the floor next to his/her bed with their back against the bed. Staff documented from his/her position, it was not likely that he/she hit head and resident denied hitting their head. Review of the resident's EMR dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 03/22/25, 03/23/25, and 04/03/25. 5. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Two or more falls without injury and one fall with injury since last MDS; -Diagnosis of Traumatic brain injury. Review of the resident's electronic fall event report, dated 01/04/25, showed the resident had an unwitnessed fall when the resident slipped out of bed onto his/her knees. Review of the resident's electronic fall event report, dated 01/16/25, showed the resident had an unwitnessed fall when the resident was found on his/her side in the floor next to bed with his/her head at the opposite end of the bed. Review of the resident's fall event report, dated 02/12/25, showed the resident had an unwitnessed fall. Review of the resident's EMR, dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/04/25, 01/16/25, and 02/12/25. 6. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Two or more falls since prior assessment. -Diagnosis of dementia. Review of the resident's electronic fall event report, dated 02/07/25, 03/02/25, and 03/19/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's EMR, dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 02/07/25, 03/02/25, or 03/19/25. During an interview on 04/23/25 at 12:13 P.M., the DON said he/she could not provide documentation for neurological exams for the falls that occurred on 02/07/25, 03/02/25, or 03/19/25. 7. Review of Resident #35's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Had two or more non-injury falls since admission; -Had two or more falls with injury (such as skin tears, abrasions, lacerations, superficial bruises) since admission. Review of the resident's electronic fall event report, dated 01/23/25, showed staff documented the resident had an unwitnessed fall. The resident found sitting on the floor in his/her bedroom between the bed and his/her wheelchair with his/her back against the wheelchair. Review of the resident's electronic fall event report, dated 03/01/25, showed staff documented the resident had an unwitnessed fall. The resident on the floor in his/her bathroom and said he/she did not hit his/her head. Review of the resident's electronic fall event report, dated 03/07/25, showed staff documented the resident had an unwitnessed fall. The resident on the floor in his/her bathroom. Review of the resident's electronic fall event report, dated 04/18/25, showed staff documented the resident had an unwitnessed fall. The resident found on the floor of his/her bedroom in front of his/her bed. Review of the resident's electronic fall event report, dated 04/22/25, showed staff documented the resident had an unwitnessed fall. The resident found on the floor in his/her bathroom. Review of the resident's EMR, dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/23/25, 03/01/25, 03/07/25, 04/18/25, and 04/22/25. During an interview on 04/24/25 at 12:00 P.M., LPN C said the resident could tell you if he/she hit his/her head but given his/her cognitive ability, the nurse should complete neurological checks on the resident if he/she had an unwitnessed fall. During an interview on 04/23/25 at 1:35 P.M., the DON said staff are still expected to document neurological checks on paper for up to 72 hours after some unwitnessed falls, but staff have not had the need to document neurological checks for the resident recently. 8. Review of Resident #38's Significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Had two or more non-injury fall since admission; -Had one fall with injury (such as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain pain) since admission. Review of the resident's electronic fall event report, dated 01/13/25 at 10:42 A.M., showed staff documented the resident had an unwitnessed fall. Nurse called to memory care unit, resident was found sitting on the floor in the dining room while staff was in shower with another resident. Review of the resident's electronic fall event report, dated 02/24/25 at 11:45 P.M., showed staff documented the resident had a witnessed fall. Staff reported the resident on floor. Resident fell out of bed onto floor. Review of the resident's electronic fall event report, dated 03/28/25 at 7:55 P.M., showed staff documented the resident had an unwitnessed fall. Staff found the resident sitting in the floor beside her bed, resident had a small indentation on his/ her right foot. Review of the resident's EMR dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/13/25, 02/24/25, and 03/28/25. 9. During an interview on 04/24/25 at 11:52 A.M., LPN C said when a resident falls the nurse is to assess if the resident hit their head. He/She said neurological checks are started when there is an indication that the resident hit their head. He/She said indications like a hematoma, small bruise, or if they are in a position that looks like they hit their head. He/She said if resident is sitting on their buttock upon arrival, they may have not hit their head, but said that he/she really doesn't know for sure if they did or not. He/She said if a resident is not cognitive and able to tell staff if they hit their head then the nurse assesses the position that the resident is in upon arrival. He/She said that he/she questions him/herself a lot about starting neuros because a resident can change positions at any time. He/She said if he/she is unsure then he/she should go ahead and start neurological checks. He/She said if there is a roommate, and they are alert that it would be okay to ask them if resident hit their head during fall plus based on nursing assessment. He/She said they use the post fall 72-hour monitoring report paper form when they do neurological checks. During an interview on 4/24/25 at 12:20 P.M., the DON said the nurse is to do a body assessment after a fall. He/She said if a fall is unwitnessed, then the nurse can ask the resident questions about hitting their head during the fall or if there is an indication that the resident hit their head then neurological checks should be started. He/She said if the resident is not cognitive the nurse should do a more physical assessment to determine if the resident hit their head. He/She said if there is no indication that the resident hit their head then a neurological check does not have to be done. He/She said the post fall 72-hour monitoring report form was not created by the facility and it does not follow the facility policy, but they do use the form to complete their neurological checks. The DON confirmed that a confused resident could change their position after a fall before the nurse arrived to assess, which means staff might not know if resident hit their head or not. The DON said he/she does not 100% agree with the facility policy, but it does state that neurological checks are not needed for unwitnessed falls unless there is indication that resident hit his/her head. During an interview on 4/24/25 at 12:55 P.M., the administrator said nurses are to do a full body assessment after a fall. She said if a fall is unwitnessed and there is an indication that resident hit their head or if the resident says they hit their head, then neurological checks should be started. She said indications that a resident may have hit their head could be a wound, physical appearance, or the position of their body. She said it is possible that non-cognitive resident could changed positions before staff arrived to assess them. She said she relies on the nurse assessment and if they believe that neurological checks should be started. The administrator said staff should not depend on another residents witness of the fall to determine if a resident hit their head. The administrator said if there is not a neurological form for a fall then it was not done. She said she thinks it's a good practice that unwitnessed falls have neurological checks completed.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received ground and pureed diets. The facility census was 41. 1. Review of the facility's Kitchen Weights and Measures policy, revised April 2007, showed food services staff will be trained in proper use of cooking and serving measurements to maintain portion control. Review showed serving utensils used will be consistent with choice of metric or U.S. measure used. Review of the facility's Standardized Recipes policy, revised April 2007, showed standardized recipes shall be developed and used in the preparation of foods. 2. Review of the facility's recipe for ground white chicken chili showed the recipe directed staff to serve eight ounce portions. Observation on 04/23/25 at 11:30 A.M., showed [NAME] G served three residents six ounces of white chicken chili, which was two ounces less than the directed amount. 3. Review of the facility's pureed cornbread/margarine recipe showed the recipe directed staff to prepare four servings by adding four servings of cornbread, three-fourths cup of milk, and one tablespoon plus one teaspoon of margarine. Review showed the recipe directed staff to serve one #10 (3.2 ounces) scoop. Observation on 04/23/25 at 11:48 A.M., showed [NAME] G add five servings of cornbread and an unmeasured amount of milk to a food processor. [NAME] G pureed the cornbread and divided it into three small dessert bowls, which was more than the directed serving size. Observation showed the dessert bowls were placed on the steam table and were served to three residents. Observation showed the recipe set on the prep counter while [NAME] G prepared the cornbread. During an interview on 04/23/25 at 11:43 A.M., [NAME] G said he/she served the ground chili using a six ounce ladle because he/she could not find another eight ounce ladle. [NAME] G said he/she served one ladle plus a little more to make eight ounces. [NAME] G said he/she usually follows the recipes but did not know why he/she didn't follow it today. During an interview on 04/24/25 at 1:35 P.M., the Dietary Manager (DM) said he/she was responsible for ensuring staff were trained on kitchen policies and procedures to include recipes and portion sizes. The DM said all staff preparing meals were responsible for following recipes to include serving sizes when preparing and serving food. The DM said he/she was not aware staff were not following recipes and providing directed portion sizes. The DM said there were plenty of serving utensils available in the kitchen.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff also failed to properly wash dishes to prevent cross-contamination and the growth of foodborne pathogens. Facility staff failed to maintain an air gap in one ice machine drain. These failures have the potential to affect all residents. The facility census was 41. 1. Review of the facility's Refrigerators and Freezer policy dated, November 2022, showed: -Information regarding acceptable storage periods for perishable foods are kept in the supervisor's office. A condensed version is posted by each refrigerator and freezer for reference; -All food is appropriately dated to ensure proper rotation by expiration dates; -Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened foods are observed and use by dates are indicated once food is open; -Supervisors are responsible for ensuring food items in the refrigerators and freezers are not past the use by or expiration dates; -Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. Review of the facility's Food Receiving and Storage policy, dated October 2017, showed: -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); -All food items to be kept in the refrigerator at the nurse station should be labeled with the use by date; -Beverages must be dated when opened and discarded after twenty-four hours; -Partially eaten food may not be kept in the refrigerator; -Other open containers must be dated and sealed or covered during storage. Observation on 04/21/25 at 1:06 P.M., showed in the refrigerator on the secured unit contained: -One container of fruit punch dated 04/15-04/20; -One container of orange juice dated 04/17-04/18; -One container of Cranberry juice dated 04/13-04/18; -Several single serve plastic cups with what appears to be different flavors of jello and whipped cream on top of a plastic tray, undated and unlabeled; -An aluminum cake pan half filled with an undated and unlabeled and uncovered product that appears like a cheesecake or other type of cake; -Several plastic small containers of an unknown substance dated 10/13; -An undated and unlabeled plastic zipperseal bag with what appears to be slices of oranges; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag. Observation on 04/22/25 at 08:38 A.M., showed inside the refrigerator on the secured unit contained: -One container of fruit punch dated 04/15-04/20; -One container of orange juice dated 04/17-04/18; -One container of cranberry juice dated 04/13-04/18; -Several single serve plastic cups with what appears to be different flavors of jello and whipped cream on top of a plastic tray, undated and unlabeled; -An aluminum cake pan half filled with an undated and unlabeled and uncovered product that appears like a cheesecake or other type of cake; -Several plastic small containers of an unknown substance dated 10/13; -An undated and unlabeled plastic zipperseal bag with what appears to be slices of oranges; -The crisper with a plastic bag that contained a plastic container with a lid that was undated and unlabeled that was stuck to the bottom of the crisper; -Two undated/unlabeled containers of a brown fluid; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag. Observation on 04/23/25 at 08:20 A.M., showed inside the refrigerator on the secured unit contained: -One container of orange juice dated 04/15-4/20; -One container of Cranberry juice dated 04/15-4/20; -Several plastic small containers of an unknown substance dated 10/13; -The crisper with a plastic bag that contained a plastic container with a lid that was undated and unlabeled that was stuck to the bottom of the crisper; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag and a plastic bag with what appears to be waffles dated 04/22. Observation on 04/23/25 at 02:35 P.M., showed inside the refrigerator on the secured unit contained: -Two containers of cranberry juice dated 04/15-4/20; -Several plastic small containers of an unknown substance dated 10/13; -The crisper with a plastic bag that contained a plastic container with a lid that was undated and unlabeled that was stuck to the bottom of the crisper; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag and a plastic bag with what appears to be waffles dated 04/22. During an interview on 04/23/25 at 02:35 P.M., Certified Nurse Aide (CNA) D said he/she is not sure who cleans the refrigerator but will if he/she notices it needs it. He/She said the staff that put food/fluids into he refrigerator are the ones who need to date or label the items so staff know what it is. He/She said he/she is not sure how long the food is good once it is opened and would still use something such as juice if it was dated 4/20. During an interview on 04/24/25 at 08:52 A.M., CNA E said the only thing he/she does with the refrigerators is get items for the residents and is not sure who is responsible to clean it. He/She said the kitchen staff come down a couple times a week and replaces items and thinks the numbers on the food/fluids are dates but not really sure. He/She said he/she does not track how long items are good for since that is the kitchens job. During an interview on 04/24/25 at 08:55 A.M., the Dietary Manager (DM) said it has been a debate who is responsible for the refrigerator on the secured unit but believes it fell on dietary. He/She is not sure when it was last cleansed and not sure how often it should be cleansed. Food and fluids should be labeled and dated to ensure food safety and should not use the items after the dates on the food/fluids since that means they are expired and no longer good. He/She said he/she does not do anything with the food or fluids in the refrigerator but thinks there should not be anything in there except a meal for a resident who did not come down right away or some snacks or juice. He/She was not aware of any food or fluids undated or unlabeled in that refrigerator. During an interview on 04/24/25 at 12:13 P.M., the Director of Nursing said dietary is responsible for dating, labeling and cleaning the refrigerator on the secured unit. He/She said his/her staff is not educated on expiration dates and would expect the kitchen to pull expired food and fluids and if nursing would give out expired foods the resident could get sick. He/She was not aware of any expired food in the refrigerator. During an interview on 04/24/25 at 12:49 P.M., the administrator said dietary is responsible to check the dates and label the foods and fluids in the refrigerator and would expect any staff clean up any mess in the refrigerators. He/She is not aware of any issues with undated or unlabeled foods in the secured unit refrigerator. The Administrator said the dates indicate a used by date and if the food/fluids are used beyond those dates, it could make the residents sick. 2. Review of the facility's Food Preparation and Service policy, revised April 2019, showed food preparation staff adhere to proper hand hygiene and sanitary practices to prevent the spread of foodborne illness. Review showed food and nutrition services staff were directed to wash hands before serving food, after collecting soiled plates or food waste prior to handling food trays. Review showed gloves are single use items and are discarded after each use. Observation on 04/23/25 at 12:07 P.M., showed [NAME] G served residents during the noon meal. Observation showed [NAME] G left the serving line, opened the refrigerator door and removed a package of sliced cheese with gloved hands. [NAME] G placed slices of cheese on bread which was on the grill. [NAME] G removed a paper ticket from the meal ticket printer, used a ladle to serve chili and used a gloved hand to add salad to a bowl which was served to a resident. Observation showed [NAME] G used gloved hands to place a bowl of soup in the microwave and removed gloves. [NAME] G then donned new gloves and did not wash his/her hands before using his/her gloved hands to serve another resident salad. Observation on 04/23/25 at 12:23 P.M., showed [NAME] H used gloved hands to fill three bowls with lettuce and cut tomato which were placed on the salads. [NAME] H rubbed his/her nose with back of his/her gloved hand and cut additional tomatoes which were added to the salads. [NAME] H opened the refrigerator door with his/her gloved hand, removed a bag of shredded cheese and used his/her gloved hand to add cheese to the salads. [NAME] H did not wash his/her hands or change gloves after rubbing his/her nose or touching the refrigerator door handle. Observation on 04/23/25 at 12:46 P.M., showed [NAME] H opened the refrigerator with gloved hands, remove hamburger patties which were placed on the grill. [NAME] I used gloved hands to add onion to grill and did not wash his/her hands. [NAME] H washed his/her hands, turned the faucet off with wet hands, dried his/her hands and donned gloves. [NAME] H removed his/her right glove, went in the walk in the cooler and retrieved a package of turkey. [NAME] H came out of the cooler and donned the same glove on his/her right hand, grabbed a knife by the blade and cut open the turkey packaging. [NAME] H used his/her gloved hand to remove bread from a bag and did not wash his/her hands. Observation on 04/23/25 at 12:21 P.M., showed Dietary Aide (DA) I precleaned dirty dishes and placed them on a rack, loaded the dish machine, pulled a rack from the clean side, loaded more dishes to a dirty rack, pulled a clean rack out of the machine, advanced another dirty rack, then removed clean items and placed on drying racks. Observation showed DA I did not wash his/her hands before handling clean kitchen wares. During an interview on 04/23/25 at 12:30 P.M., DA I said he/she should wash hands when going from dirty to clean, but he/she sanitized hands by submerging them in the sanitizer sink. DA I said he/she did not use running water to wash his/her hands. During an interview on 04/24/25 at 1:35 P.M., the Dietary Manager (DM) said staff should wash hands when entering the kitchen, after completing dirty tasks, and before and after donning gloves. The DM said staff should turn off the faucet with a paper towel after washing hands. 3. Observation on 04/22/25 at 3:07 P.M., showed a placard on the dish machine indicated minimum wash and rinse temperatures of 120 degrees Fahrenheit (F). Observation showed an operating instruction sign posted in the dish washing area instructed staff to report to supervisor if machine temperature was lower than 120 degrees F or higher than 160 degrees F. Observation on 04/22/25 at 3:00 P.M., showed the dish machine maximum temperature reached was 102 degrees F as indicated on the machine thermometer. Observation on 04/22/25 at 3:05 P.M., showed the maximum temperature was 113 degrees F when checked with a calibrated digital thermometer. Observation on 04/23/25 at 12:37 P.M., during a dish machine test load showed the maximum water temperature, using a calibrated digital thermometer, was 100 degrees F. During an interview on 04/22/25 at 3:05 P.M., DA J said the dish machine temperature was usually 100 to 110 degrees F. DA J said the DM told him/her the machine temperature had to be less than 120 degrees F to prevent chlorine breakdown. During an interview on 04/23/25 at 12:35 P.M., DA I said staff checked the dish machine water temperature before use, but he/she had not checked it yet. DA I said the water temperature should be between 90 and 100 degrees F. During an interview on 04/24/25 at 1:35 P.M., the Dietary Manager (DM) said he/she believed the dish machine water temperature should be less than 120 degrees Fahrenheit (F). The DM said he/she did not know the machine instructions indicated a minimum water temperature of 120 degrees F. During an interview on 04/24/25 at 12:20 P.M., the maintenance director said the dish machine water temperature should be 150 degrees F for the wash cycle and 180 degrees F for the rinse cycle. The maintenance director said the dish machine was installed in the past three months so he/she assumed it was working correctly. 4. Observation on 04/22/25 at 2:45 P.M., showed the end of the ice machine drain was connected to a section of clear plastic tubing which entered a curved white plastic elbow which was connected to the floor drain. Observation showed there was not a gap between the end of the ice machine drain and the floor drain. During an interview on 04/22/25 at 2:46 P.M., the DM said he/she thought the air gap was taken care of after last survey. The DM said the ice machine was moved some time ago and he/she did not look at the drain after it was moved. During an interview on 04/24/25 at 12:20 P.M., the maintenance director said he/she was not familiar with the required ice machine drain air gap. During an interview on 04/24/25 at 3:15 P.M., the administrator said the DM was responsible for traning kitchen staff and ensuring they followed proper hygiene procedures. The administrator said staff should wash hands before touching ready to eat foods, before handling clean dishes, before donning new gloves and after completing a dirty task or touching anything that may be considered dirty. The administrator said staff should turn off the water with a paper towel after washing hands. The administrator said he/she was not sure of the dish machine operating temperature but he/she could look at the machine and find out. The administrator said he/she expected staff to follow the dish machine operating instructions. The administrator said he/she was not aware the dish machine was not running at the proper temperature.The administrator said he/she was of aware of the required ice machine air gap. The administrator said he/she did not know the air gap was missing.

Based on interview and record review, facility staff failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. facility census was 39. 1. Review of the facility's Grievance/Complaint filing policy, revised April 2017, showed staff were directed as follows: - All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response; - Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations a submit a written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint; - The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any, need to be taken.; - The resident, or person filing the grievance and/or complaint on behalf of the resident will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems; - The Administrator, or his or her designee, will make such reports orally within __ working days of the filing of the grievance or complaint with the facility; - A written summary of the investigation will also be provided to the resident, and a copy will be filed in the social services office; - The results of all grievances filed, investigate and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. Review of the facility's Resident Rights policy date, December 2017, shows staff were directed as follows: - Residents may voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Residents have the right to have the facility respond to his or her grievances. Review of the facility records showed the record did not contain grievance reports for a period of no less than three years. During an interview with the resident council on 2/9/23 at 2:07 P.M., the council members said the following: -Staff do not take the time to look at their grievances; -Staff write down their concerns during the council meeting and then they shelve it; -Residents do not get written answers to their grievances; -Residents do not get meeting minutes until the day of the council meeting so they don't know what problems have been addressed; -Staff say they are going to do something about the problem but they don't follow through. During an interview on 2/10/23 at 9:00 A.M., activities assistant (A) said grievances are typed up and given to the department heads. He/she was unsure of what was done by staff after that. During an interview on 2/10/23 at 9:10 A.M., the activity director said they take grievances to the department heads in written form. The residents are then told by the department heads during the next council meeting what will be done. During an interview on 2/10/23 at 9:51 A.M., the director of nursing said resident council can invite staff to their meeting and a response to a grievance is done verbally. They don't do a formal written response with rationale to a grievance. During an interview on 2/10/23 at 9:50 A.M., the administrator said the activities department takes grievances from the resident council to the related department head who will if invited come and tell the members what he response is. This is then entered into the minutes for resident council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to store food in a manner to protect from potential contamination and out-dated use. The facility census was 39. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -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 food that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. -Never leave any food item uncovered and not labeled. Observation on 02/07/23 at 9:45 A.M., showed the reach-in freezer contained a box of waffles opened to the air. Observation on 02/07/23 at 9:47 A.M., showed the reach-in refrigerator contained: -a container of grated cheese opened and undated; -a 32 ounce container of strawberry preserves opened and undated; -a 20 ounce container of strawberry jam opened and undated; -a sliced onion, partially wrapped in plastic, opened to the air and undated. Observation on 02/07/23 at 9:53 A.M., showed the kitchen dry storage area contained: -a 16 ounce container of fennel seeds opened and undated; -a cheese shaker labeled as garlic opened and undated; -a 32 ounce container of browning sauce opened and undated; -a five and 1/4 pound container of garlic powder opened and undated; -a 36 ounce container of celery salt opened and undated; -a 16 ounce container of [NAME] jerk seasoning opened and undated; -a 20 ounce container of salt free seasoning opened and undated; -a six ounce container of rosemary leaf opened and undated; -a one and one-half pound container of Italian seasoning opened and undated. Observation on 02/07/23 at 10:00 A.M., showed the baker's area contained: -a 250 milliliter container of olive oil opened and undated; -a five pound container of ground cinnamon opened and undated; -a one pound container of ground cloves opened and undated; -a one pound container of ground ginger opened and undated; -a 28 ounce container of cream of tarter opened and undated; -a cheese shaker, which contained an unidentifiable white powder, opened to the air, undated and unlabeled. Observation on 02/07/23 at 10:06 A.M., showed the area next to the grill contained an cheese shaker, which contained small unidentifiable yellow flakes, opened to the air, undated and unlabeled. Observation on 02/07/23 at 10:08 A.M., showed the cook's station contained: -a plastic container of frosted flakes cereal opened to the air and undated; -a plastic container of corn flakes cereal opened and undated; -a plastic container of toasted oat O's cereal opened and undated; -three loaves of white bread opened and undated; -a package of hot dog buns opened and undated; -a loaf of rye bread opened and undated. Observation on 02/07/23 at 10:21 A.M., showed the dry goods pantry contained: -a 10 pound bag of semolina pasta tubes opened and undated; -a large bag of small shell pasta opened and undated; -a large bag of fruit whirls opened and undated; -a large bag of toasted oat O's opened and undated; -a large bag of 10 inch linguini dated 10-11 opened to the air. Observation on 02/07/23 at 10:27 A.M., showed the walk-in freezer contained: -a large unidentifiable piece of meat in a plastic resealable bag unlabeled and undated; -a box of beef country fried steak opened to the air; -a box of pork loin fritters opened to the air. Observation on 02/07/23 at 10:32 A.M., showed the walk-in refrigerator contained: -an undated five gallon bucket of kosher deli pickles partially opened to the air with the lid to the container soiled with black debris; -a large plastic bag of an unidentifiable ground meat unlabeled and undated; -a long rectangle metal container covered with aluminum foil, which contained an unidentifiable brown meat-type substance, unlabeled and undated. During an interview on 02/07/23 at 10:41 A.M., the Dietary Manager (DM) said opened food items should have a date received and a date opened. The DM said leftovers should be dated for five days past the original preparation date. Observation on 02/08/23 at 11:33 A.M., showed the walk-in freezer contained: -a case of beef country fried steaks opened to the air; -a chunk of unidentifiable meat in plastic resealable bag unlabeled and undated; -two cases of frozen cookie dough, a case of peas, a five gallon carton of chocolate ice cream, a five-gallon carton of vanilla ice cream, and a case of grape juice concentrate stored on the floor. Observation on 02/08/23 at 11:38 A.M., showed the dry goods pantry contained: -a large plastic bag of linguini noodles dated 10/11 stored on the shelf opened to the air; -a large plastic bag of fettuccini noodles opened and undated; -a large plastic bag of conchigliette pasta shells opened and undated; -a large plastic bag of rigatoni noodles opened and undated. Observation on 02/08/23 at 12:07 P.M., showed the cook's station contained undated plastic storage containers of toasted oat O's, raisin bran, frosted flakes, cornflakes and fruit whirls cereals removed from their original packaging. Observation on 02/08/23 at 12:21 P.M., showed the reach-in refrigerator in the aide's station contained an opened and undated 12 pound container of commercially prepared mustard potato salad and an opened and undated 10 pound container of peeled hard cooked eggs. Observation on 02/08/23 at 12:34 P.M., showed an large unlabeled and undated bulk container in the spice storage area which contained an unidentifiable grain-like substance removed from its original packaging. During an interview 02/08/23 at 12:34 P.M., the DM said the bulk container contained cornmeal and the container should be dated and labeled with the product name. Observation on 02/08/23 at 12:35 P.M., showed the reach-in freezer contained a case of waffles dated 12-9 opened to the air and a plastic bag of hashbrown patties opened to the air and undated. During an interview on 02/08/23 at 12:38 P.M., the DM said opened food items, including the spice containers, should be stored sealed, labeled and dated. The DM said all staff are responsible to ensure food is stored correctly and staff usually go through coolers to look for outdated food items twice a week. The DM said the food delivery truck came in the afternoon of the previous day and, while food should not be stored on the floor, he/she just not had time to put all the food away. During an interview on 02/10/23 at 10:24 A.M., the administrator said opened food items, including the spice containers, should be dated and sealed before they are put away and if a food has been removed from original packaging, staff should also label the package with the product name. The administrator said staff had recently been trained on how to store food properly.

Based on interview and record review, facility staff failed to implement an infection surveillance program that included tracking of organisms responsible for infections and failed to review their Infection Prevention and Control Program (IPCP) on an annual basis. The facility census was 39. 1. Review of the facility's Surveillance for Infections policy, dated September 2017, showed: -The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated infections, to guide appropriate interventions and to prevent future infections. Review of the facility's undated Infection Control and Prevention Program Evaluation Policy showed: -The effectiveness of the infection prevention and control program is reviewed no less than annually with findings reported to the QA committee and integrated in the resident safety program; -This review will include an evaluation of results of surveillance findings and analysis to determine opportunities. Review of the facility's undated IPCP showed the record did not contain the following: -A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; -An annual review or update of the program. During an interview on 2/09/23 at 11:32 A.M., the Infection Preventionist (IP) said he/she was new to the position and still learning. He/she said the lab sends culture results, but there was no formal way to monitor trends in infection sources. During an interview on 2/09/23 at 11:34 A.M., the Director of Nursing (DON) said infection control policies should be reviewed and/or updated annually. The DON also said the facility did not get monthly summaries from the lab and the infection prevention staff haven't looked in depth at actual organism results, because they really don't have a mechanism to keep track of specific organisms or infection trends. During an interview on 2/10/23 at 10:18 A.M., the Administrator said he/she did not know the policy on how often infection control and prevention policies should be reviewed. The administrator said the IP should be tracking organisms that are causing infections.