**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide the appropriate Center for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) for three residents (Residents #1, #60, and #61) out of three sampled residents whom the facility-initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 55. 1. Review of the facility's policy titled Transfer/Discharge Notice Appeal, dated 11/24/24, showed residents have the right to appeal transfer or discharge notices. Should the resident who received a notice of transfer or discharge disagree with the reasons for the transfer or discharge, the resident and/or their representative my file an appeal. When a resident exercises their right to appeal they will not be transferred or discharged while the appeal is pending unless failure to do so with endanger the health or safety of the resident or other individuals in the facility. 2. Review of Resident #1's medical record showed: -Medicare Part A skilled services started on 02/03/25; -Last covered day of Medicare Part A skilled services on 03/05/25; -Facility initiated discharge from Medicare Part A services; -Resident remained in the facility; -Did not contain a NOMNC. During an interview on 03/26/25 at 11:25 A.M., the Interim Administrator said the resident used 29 Medicare Part A days with 71 remaining. 3. Review of Resident #60's medical record showed: -Medicare Part A skilled services started on 11/19/24; -Last covered day of Medicare Part A skilled services on 12/27/24; -Facility initiated discharge from Medicare Part A services; -discharged to home on [DATE]; -Did not contain a NOMNC. During an interview on 03/26/25 at 11:25 A.M., the Interim Administrator said the resident used 38 Medicare Part A days with 62 remaining. 4. Review of Resident #61's medical record showed: -Medicare Part A skilled services started on 08/02/24; -Last covered day of Medicare Part A skilled services on 09/11/24; -Facility initiated discharge from Medicare Part A services; -discharged to home on [DATE]; -Did not contain a NOMNC. During an interview on 03/26/25 at 11:25 A.M., the Interim Administrator said the resident used 39 Medicare Part A days with 61 remaining. 5. During an interview on 03/26/25 at 10:40 A.M., the Social Services Director (SSD) said he/she is responsible to ensure the NOMNC forms are completed timely. The SSD said he/she did not complete any NOMNC forms for Medicare A residents since the Advance Beneficiary Notice (ABN) form came out last year. The SSD said he/she thought the new ABN form replaced both the old ABN form and the NOMNC form, so he/she did not complete the NOMNC for the resident's discharged from Medicare Part A services since last year. The SSD said he/she did not know he/she still needed to ensure the NOMNC form was completed when a Medicare Part A resident discharged from skilled services. During an interview on 03/26/25 at 1:10 P.M., the Interim Administrator said he/she has been the Administrator about a month, and he/she did not know NOMNCs were not being completed when a resident discharged from Medicare Part A services. The Interim Administrator said it is the SSD's responsibility to ensure these are completed prior to the last date of Medicare A coverage. The Interim Administrator said the NOMNC should be issued and signed by the resident or the responsible party at least 48 hours prior to discharge from the Medicare Part A last covered date.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to 33 of 55 residents (Residents #3, #4, #5, #6, #7, #8, 10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #28, #29, #30, #32, #34, #36, #37, #40, #42, #45, #46, #48, #51 and #58). The facility census was 55. 1. Review of the facility's Food and Nutrition Services Policy, dated 04/30/24, showed: -Each resident is provided with a nourishing, palatable, well-balance diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical , functional, and psychosocial factor that affect eating and nutritional intake and utilization; -A resident-centered diet and nutrition plan will be based on the assessment; -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Review of the facility's Therapeutic Diets Policy, dated 04/2024, showed: -Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes; -A therapeutic diet will be prescribed by the resident's physician (or non-physician provider). The physician may delegate this task to a registered or licensed dietitian as permitted by state law; -All menus will be approved by a registered dietitian and food will be prepared according to approved recipes and instructions;; -Diet order should match the terminology use by the food and nutrition services department; -If a mechanically altered diet is ordered, the provider will specify the texture modification. 2. Review of the facility menus dated 03/25/25 (Week 3, Tuesday), showed the menus directed staff to provide the residents on regular diets with one cup of chicken spinach alfredo. Review of Residents #3, #6, #8, #10, #11, #14, #15, #18, #19, #22, #32, #34, #36, #40, #45, #46, #48 and #51 Physician Order Sheets (POS), dated March 2024, showed the residents' physicians directed staff to provide the residents with regular diets. Observation on 03/25/25 at 11:53 A.M., showed staff served Residents #3, #6, #8, #10, #11, #14, #15, #18, #19, #22, #32, #34, #36, #40, #45, #46, #48 and #51, a #6 (5.3 ounce) scoop of chicken spinach alfredo (2.7 ounces less than directed by the menus). 3. Review of the facility menus dated 03/25/25 (Week 3, Tuesday), showed the menus directed staff to provide the residents on soft and bite-sized textured diets with one cup of chicken spinach alfredo or a #10 scoop of minced and moist textured beef brisket, a #10 (3.2 ounce) scoop of minced and moist textured hominy and one half cup of fruits of the forest pureed pie. Review of Residents #4, #5, #17, #20 and #42 POS, dated March 2024, showed physicians directed staff to provide the resident with soft and bite-sized textured diets. Observation on 03/25/25 at 11:53 A.M., showed staff served Residents #17, #20 and #42, a #6 scoop of chicken and spinach alfredo (2.7 ounces less than directed by the menus), a two ounce scoop of coarsely chopped hominy (1.2 ounces less than directed by the menus) and a slice of regular fruits of the forest pie. Observation showed staff served Residents #4 and #5 a #20 (1.6 ounce) scoop of minced and moist textured beef brisket (half the amount directed by the menus), a two ounce scoop of coarsely chopped hominy (1.2 ounces less than directed by the menus) and a slice of regular fruits of the forest pie. 4. Review of the facility menus dated 03/25/25 (Week 3, Tuesday), showed the menus directed staff to provide the residents on minced and moist textured diets with a #10 scoop of minced and moist textured beef brisket, a #10 scoop of minced and moist textured hominy, a #10 scoop of pureed wheat roll and a half cup of pureed fruits of the forest pie. Review of Resident #29's POS, dated March 2024, showed the resident's physician directed staff to provide the resident with a minced and moist textured diet. Review of Residents #37 and #58 POS, dated March 2024, showed the residents' physicians directed staff to provide the residents with mechanical soft textured diets. Observation on 03/25/25 at 11:53 A.M., showed staff served Residents #29, #37 and #58, a #20 scoop of minced and moist textured beef brisket (half the amount directed by the menus), a two ounce scoop of coarsely chopped hominy (1.2 ounces less than directed by the menus), a two ounce scoop of pureed pie (half the amount directed pie the menus) and a regular dinner roll. 5. Review of the facility menus dated 03/25/25 (Week 3, Tuesday), showed the menus directed staff to provide the residents on pureed textured diets with #10 scoops of pureed beef brisket and pureed hominy, and one half cup of pureed fruits of the forest pie. Review of Residents #7, #12, #13, #16, #23, #28 and #30 POS, dated March 2024, showed the residents' physicians directed staff to provide the residents with pureed textured diets. Observation on 03/25/25 at 11:53 A.M., showed staff served Residents #7, #12, #13, #16, #23, #28 and #30, a #20 scoop of pureed beef brisket (half the amount directed by the menus), a #20 scoop of pureed hominy (half the amount directed by the menus), and two ounces of pureed pie (half the amount directed by the menus). During an interview on 03/28/25 at 10:11 A.M., the Dining Service Director (DSD) said staff diet order should match the diets used on the menus and the facility did not have a menu for mechanical soft textured diets. The DSD said he/she tries to review the diet orders ever six months and whenever nursing brings him/her a diet communication form to ensure the physician ordered diets match those diets used by the facility, but he/she does not always catch them all. The DSD said staff should served the minced and moist textured menus to resident with physician orders for mechanical soft textured diets. 6. During an interview on 03/25/25 at 11:53 A.M., [NAME] B said he/she did not review the menus prior to service in their entirety, because staff trained him/her to always use a #6 scoop for casseroles and #20 scoops for pureed and mechanically altered textured food items despite what the menus says to use. During an interview on 03/28/25 at 10:11 A.M., the DSD said staff are expected to serve meals in accordance with the menus, which would include the portion sizes listed on the menus, unless the resident requests other wise and staff are trained on this requirement. The DSD said he/she never directed staff to always use the same size scoops for different foods, but he/she is not always the person who trains the new staff and [NAME] B is a new employee. During an interview on 03/28/25 at 11:23 A.M., the interim administrator said staff should serve the menus as planned, which would include the specific portion sizes and food items listed for the various diets, and staff have been trained on this requirement. The interim administrator said the menus should be available in the service station and staff should review the menus prior to service. The interim administrator said the DSD is responsible to ensure physician ordered diets match the diets used by the facility and that staff follow the menus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to use enhanced barrier precautions (EBP) (an infection control practice that requires staff to wear personal protective equipment (PPE) (protective equipment such as gowns, gloves, goggles, and masks used to prevent or minimize exposure to hazards) for the care of residents) for four residents (Resident #59, #7, #33 and #13) of seven sampled residents and failed to ensure two residents' catheter (indwelling tube placed directly in the bladder to drain urine) bags did not touch the floor for two residents (Resident #48 and #7) out of three sampled residents. The facility census was 55. 1. Review of the facility policy titled Enhanced Barrier Precautions, undated, showed EBP that employs targeted gown and glove use during high contact resident care activities. The facility will ensure staff are trained in EBP and will maintain sufficient supplies to support implementation of EBP. EBP expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDRO) (bacteria or fungi that have developed resistance to one or more classes of antimicrobial agents, making them difficult to treat) to staff's hands and clothing. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheostomies. EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheter), and wound care. The resident's care plan will address the need for EBP and will be communicated to the caregivers. Facility staff will be trained in enhanced barrier precautions. 2. Review of Resident #59's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/16/25, showed staff assessed the resident as: -Unable to assess cognitive status; -Short and long term memory problems; -Dependent on staff for toileting and lower body dressing; -Required substantial/maximal assistance from staff for shower/bathe self and upper body dressing; -Had one venous/arterial ulcer (painful skin wounds caused by poor blood circulation in the lower extremities); -Diagnosis of peripheral vascular disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the Physician's Order Sheet (POS), dated March 2025, showed: -Arterial spot left inner foot: cleanse with wound cleanser, pat dry, apply skin prep daily; -Arterial spot on left heel: cleanse with wound cleanser, pat dry, apply skin prep daily; -Arterial wound left shin: cleanse with wound cleanser, pat dry, apply medihoney (used to treat or prevent wounds) to wound bed, cover with calcium alginate (a treatment that helps promote wound healing), and cover with 2 x 2 boarder gauze daily. Observation on 03/25/25 at 10:15 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP. Observation showed the resident's room did not have PPE inside or outside. Observation on 03/27/25 at 9:37 A.M., showed Licensed Practical Nurse (LPN) K performed wound care to all wounds on resident's left leg arterial ulcer. LPN K did not wear a gown while he/she completed the wound care. During an interview on 03/27/25 at 2:21 P.M., LPN K said EBP is used for residents that have feeding tubes, catheters, and tracheostomies (a surgical opening in the windpipe with a tube to provide an airway). LPN K did not know if EBP is required for wounds, but using EBP is extra precautions to prevent residents from getting an infection. LPN K said there are not any residents on EBP, or at least there are no signs, but there should be. LPN K said he/she did not know why it was not being done at the facility, but he/she did ask management about it and had not received an answer. LPN K said he/she did not receive instruction on how or when to use EBP, and that not using PPE can potentially spread infection to the resident. 3. Review of Resident #7's Annual MDS, dated [DATE], showed staff assessed resident as follows: -Severe cognitive impairment; -Indwelling urinary catheter; -Hospice care; -Diagnoses of Stroke, Neurogenic Bladder (a condition where the nerves that control bladder function are damaged, leading to abnormal bladder control), and Dementia. Review of the resident's POS, dated March 2025, showed staff to provide urinary catheter care every shift. Observation on 03/26/25 at 8:58 A.M., showed Certified Nurse Aide (CNA) F and CNA H entered the resident's room with a mechanical lift. CNA F washed hands his/her hands applied gloves and provided catheter care to the resident. CNA H washed hands and applied gloves before he/she emptied the resident's catheter bag. CNA F and CNA H rolled the resident from side to side in bed, as they changed the resident's clothing and placed a mechanical lift sling under the resident. CNA F and CNA H did not wear a gown during catheter care, dressing the resident or during the transfer. During an interview on 03/27/25 at 2:31 P.M., CNA F said he/she had heard of EBP and it is used for resident's anytime they have a feeding tube, catheter, or if the staff comes in contact with body fluids. CNA F said if a resident requires EBP there should be signs posted on the door. The CNA said he/she does not know why the resident does not have an EBP sign posted at the door, because he/she should. The CNA said the charge nurse is responsible for posting the signs as soon as the resident requires EBP. The CNA said he/she is supposed to wear a gown and gloves for a resident on EBP. The CNA said the facility does not have any gowns in any of the residents' rooms, and they should. The CNA said he/she did not wear a gown during the residents care because he/she did not know he/she needed to. During an interview on 03/27/25 at 2:38 P.M., CNA H said he/she does not know what EBP is. The CNA said he/she did not wear a gown during the resident's care because he/she did not know he/she had to. During an interview on 03/28/25 at 9:16 A.M., Registered Nurse (RN) I said staff are supposed to wear a gown when providing contact care or catheter care for residents with catheters. The RN said he/she doesn't know why the aides are not wearing gowns. The RN said he/she would think the charge nurse is responsible for making sure the aides are wearing gowns and the Infection Preventionist (IP) should probably be auditing. 4. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident with mild cognitive impairment, PVD, and diabetes mellitus. Review of the resident's POS, dated March 2025, showed; -Unstageable (a wound with full thickness loss where the base is obscured by injured tissue) left heel: cleanse with wound cleanser, pat dry and paint with betadine; -Unstageable right heel: cleanse with wound cleanser, pat dry and paint with betadine. Observation on 03/26/2025 at 1:27 P.M., showed outside the resident's room did not have an EBP sign or PPE station. CNA/Certified Medication Technician (CMT) M and CNA/CMT N provided perineal care to the resident and did not wear a gown. During an interview on 03/28/25 at 11:44 A.M., the Director Of Nursing (DON) said the resident should be on EBP. 5. Review of Resident 13's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows; -Severe cognitive impairment; -Dependent on staff members for assistance with all Activities of Daily Living (ADL)s; -Hospice care; -Wheelchair; -Diagnosis of Dementia. Review of the resident's POS, dated March 2025, showed arterial wound: Left 1st toe, cleanse with wound cleanser, pat dry, cover with Xeroform (wound care gauze), wrap with kerlix, and secure with tape daily. Observation on 03/27/25 at 10:06 A.M., showed there is not an EBP sign posed outside the resident's room and PPE is not observed in the room or in the hallway. RN I and LPN L provided wound care to the resident and did not wear a gown. The LPN without gloves or a gown on begun to hold the resident's hand and hugged the resident during wound care. During an interview on 03/27/25 at 2:41 P.M., LPN L said staff are supposed to wear gloves and a gown during care with any residents who have catheters or indwelling medical devices. The LPN said EBP signs should be posted outside the rooms so staff know to use the PPE. The LPN said the PPE should be readily available to the staff. The LPN said he/she doesn't know who is responsible for posting the EBP signs but the charge nurses should put the PPE out for staff. The LPN said he/she doesn't know why the PPE is not out. The LPN said he/she should have worn a gown and gloves during wound care for the resident but he/she didn't because, he/she was there for resident comfort. During an interview on 03/28/25 at 9:16 A.M., RN I said EBP is used to prevent the spread of MDROs. The RN said he/she questioned during wound care whether or not he/she should have had a gown on. The RN said the resident should be on EBP and there should be EBP signs posted outside the resident's room and he/she does not know why there isn't any signs posted. The RN said he/she would not know where to go to get a gown. During an interview on 03/27/25 at 2:40 P.M., the infection preventionalist said EBP is the protocol that requires a gown and gloves to be worn for close proximity care provided for an extended period of time for a resident deemed necessary to be on EBP. The infection preventionalist said residents are deemed necessary for EBP at the facilities discretion and if the resident is colonized, has a wound, feeding tube, tracheostomy, or catheter. The infection preventionalist said there are some residents with active pressure wounds and catheters that would require the EBP protocol. The infection preventionalist said implementing EBP has been in process for a while and items have been purchased for the implementation. It has not been fully implemented because staff have not found a way that works to maintain a home-like environment for the residents. The infection preventionalist said staff have been educated on the EBP protocol and the IP and other department heads have attended meetings and webinars about the process. During an interview on 03/28/25 at 11:40 A.M., The DON said the purpose of EBP is to prevent spread of MDROs from the residents to staff. The DON said residents who have indwelling medical devices, including catheters, and chronic wounds should be on EBP. The DON said EBP would includes wounds and surgical wounds. The DON said he/she does not know why residents with catheters and wounds are not on EBP and he/she is responsible. The DON said EBP signage should be posted and he/she doesn't know why the signs are not posted. The DON said gowns can be stored in the residents' rooms and he/she does not know why the gowns are not in the rooms. During an interview on 03/28/25 at 12:32 P.M., the administrator said anyone with an indwelling medical device, or open wound should be on EBP. The administrator said the IP and nursing staff are responsible for placing residents on EBP, and determining what PPE is required and what precautions should be posted outside the rooms. The administrator said the facility has struggled with finding what the facility could use for storage of the PPE that is homelike. The administrator said, We just haven't figured out our process for EBP yet. 6. Review of the facility policy titled Urinary Catheter Care, undated, directed staff to be sure the catheter tubing and drainage bag is kept off the floor. 7. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Indwelling urinary catheter; -Wheelchair; -Diagnosis of Neurogenic Bladder. Review of the resident's care plan, dated 02/26/2025, showed staff documented the resident used an indwelling urinary catheter. Review of the resident's POS, dated March 2025, showed orders for catheter care every shift and to change the catheter bag and tubing monthly. Observation on 03/25/25 at 11:21 A.M., showed the resident in a wheelchair in his/her room with his/her catheter bag hung under the wheelchair. The catheter bag rested on the floor. Observation on 03/25/25 at 3:27 P.M., showed the resident in a wheelchair in his/her room with his/her catheter bag hung under the wheelchair. The catheter bag rested on the floor. Observation on 03/26/25 at 9:34 A.M., showed resident in a wheelchair in his/her room with his/her catheter bag hung under the wheelchair. The catheter bag rested on the floor. During an interview 03/26/25 at 9:34 A.M., the resident said staff put his/her catheter bag under his/her wheelchair after they dress him/her and transfer him/her. Observation on 03/27/25 at 2:11 P.M., showed the resident sat in his/her wheelchair. The resident's catheter bag rested on the floor under his/her wheelchair. Observation on 03/28/25 at 9:32 A.M., the resident sat in his/her wheelchair, in his/her room, and looked at a newspaper. The resident's catheter bag rested on floor under his/her wheelchair. The resident propelled his/her wheelchair across his/her room and down hallway. The resident's catheter bag slid on the floor, under his/her wheelchair. CNA F approached the resident, said hello and walked away. The CNA did not fix the catheter bag. During an interview on 03/28/25 at 9:41 A.M., CNA J said he/she got the resident up this morning and hung the resident's catheter bag on the wheelchair. The CNA said he/she can see the resident's catheter bag sliding on the floor. The CNA said the resident's catheter bag is not supposed to touch the floor, because of germs, bacteria and it can cause Urinary Tract Infections. The CNA walked away and started care for other residents and did not fix the catheter bag on the floor. During an interview on 03/28/25 at 9:44 A.M., RN P said he/she sees the resident's catheter bag sliding on the floor. The RN said the aides should hang catheter bags under the wheelchairs, and off the floor. The RN said the charge nurse is responsible to ensure aides are doing that. The RN said staff doesn't want the catheter bag to touch the floor, because there is all kinds of organisms on the floor, that can cause infection. 8. Review of Resident #7's Annual MDS, dated [DATE], showed staff assessed resident as: -Severe cognitive impairment; -Indwelling urinary catheter; -Wheelchair. Review of the resident's POS, dated March 2025, showed urinary catheter care every shift. on Review of the resident's care plan, 03/05/2025, showed staff documented the resident had an indwelling urinary catheter. Observation on 03/25/25 at 10:06 A.M., showed the resident sat in wheelchair, in his/her room. The resident's catheter bag hung under his/her wheelchair and rested on the floor. Observation on 03/25/25 at 3:39 P.M., showed the resident sat in wheelchair, in his/her room. The resident's catheter bag hung under his/her wheelchair and rested on the floor. Observation on 03/27/25 at 2:31 P.M., showed the resident sat in wheelchair, in his/her room. The resident's catheter bag hung under his/her wheelchair and rested on the floor. During an interview on 03/27/25 at 2:31 P.M., CNA F said the resident's catheter bag is touching the floor. The CNA said the resident's catheter bag is not supposed to touch the floor as it can cause infections such as a UTI. The catheter bag can get caught on something, there is a lot of reasons it can't be on the floor. 9. During an interview on 03/28/25 at 9:16 A.M., RN I said when aides hang catheter bags under the residents wheelchairs, the tubing and bag should not touch the ground because of infection concerns. During an interview on 03/28/25 at 11:40 A.M., the DON said staff should put catheter bags in slings and secure them to the wheelchairs so they do not touch the floor. The DON said it is an infection control concern for a catheter bag to be on the floor, and he/she doesn't know why staff are not keeping the bags off the floor. The DON said him/her, the ADON and the charge nurses should identify catheter bags on the floor, and take the time to educate staff. During an interview on 03/28/25 at 12:32 P.M., the administrator said he/she expects staff to hang catheter bags under wheelchairs, where it is not touching the ground. The administrator said staff doesn't want it to touch the ground, because of infection control. The administrator said nurses are responsible to ensure aides keep the catheter bags off the ground, it should be a standard of practice. The administrator said if staff see a catheter bag on the ground they should change the catheter bag.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff also failed to properly wash, sanitize and air-dry mechanically washed dishes to prevent cross-contamination and the growth of foodborne pathogens. This has the potential to affect all residents. The facility census was 55. 1. Review of the facility's Receiving and Storage of Food Policy, dated 10/2023, showed: -Foods shall be received and stored in a manner that complies with safe food handling practices; -Food in designated dry storage areas shall be kept off the floor (at least 18 inches); -Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system; -Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers; -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); -Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils; -Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. Review of the facility's Refrigerators and Freezers Policy, dated 11/2024, showed: -All food will be appropriately dated to ensure proper rotation by expiration dates; -Use by dates may be completed with expiration dates on all prepared food in refrigerators; -Supervisors/designee will be responsible for ensuring food items in pantries, refrigerators, and freezers are not expired or past perish dates. Observations on 03/25/25 at 9:06 A.M., showed the baker's station contained: -Opened and undated 11 pound containers of chocolate fudge and cream cheese frostings stored under stand mixer; -An undated bulk container which contained sugar removed from the original packaging; -An opened and undated one gallon bottle of apple cider vinegar; -An opened and undated one gallon bottle of white vinegar stored next to a 32 ounce (oz. unlabeled spray bottle of blue liquid; -A can of vegetable oil pan release spray without it's nozzle cover cap, stored next to 23 oz. bottle of multi-surface cleaner. During an interview on 03/25/25 at 9:12 A.M., [NAME] B said the unlabeled spray bottle with blue liquid is diluted multi-surface cleaner. The cook said food items should not be stored next to chemicals. Observations on 03/25/25 at 9:23 A.M., showed walk-in refrigerator #2 contained: -A sign on the door to the walk-in that read Items in the fridge and/or freezer must be labeled, dated (mm/dd/yy) & properly stored. Label/date MUST be facing outward.; -Opened and undated one gallon containers of mayonnaise, mild cocktail sauce and dijon honey mustard; -Two opened and undated containers of [NAME] Caesar Dressing; -Two opened and undated containers of sweet pickle relish; -An opened and undated bag of cut broccoli; -An undated plastic resealable bag of boiled eggs; -11 uncovered and undated baked pies stacked on top of each other in multiple areas of the walk-in. Observations on 03/25/25 at 9:34 A.M., showed the walk-in freezer contained: -A sign on the door to the walk-in that read Items in the fridge and/or freezer must be labeled, dated (mm/dd/yy) & properly stored. Label/date MUST be facing outward.; -Cases of waffles and buttermilk pancakes stored on the floor; -An undated bag of chicken breast opened to the air; -Two sheets of puff pastry dough removed from original package stored in an undated plastic resealable bag; -Four unlabeled and undated styrofoam bowls which contained and unidentifiable brown substance. During an interview on 03/25/25 at 9:40 A.M., [NAME] B said the stryofoam bowls contained ice cream, but they should be labeled with what they are and dated when they were made. The cook said the pies in the walk-in refrigerator were made on 03/24/25 for use at dinner on 03/25/25, they should be covered, and he/she did not know why the baker did not cover them. The cook said opened food items, like the gallon containers, should be dated when opened so staff know when to discard them and staff should use all of one food item before they open another unless the food has gone bad or expired. The cook said he/she did not know why there were multiple containers of salad dressing and pickle relish open in the walk-in. Observations on 03/25/25 at 10:28 A.M., showed walk-in refrigerator #1 contained: -A sign on the door to the walk-in that read Items in the fridge and/or freezer must be labeled, dated (mm/dd/yy) & properly stored. Label/date MUST be facing outward.; -Cases of shelled eggs and raw chicken stored on the floor; -Opened and undated one gallon bottles of Worcestershire sauce, soy sauce, barbeque sauce, hot sauce and salsa; -An opened and undated half gallon bottle of sweet and sour sauce; -An opened and undated 48 oz. jar of dijon mustard; -An opened and undated 32 oz. container of chopped garlic. During an interview on 03/25/25 at 10:35 A.M., Dietary Aide (DA) A said the food trucks deliver on Mondays and Tuesdays, but the truck had not arrived for the day so the food stored on the floor would be from the previous day. The DA said food should not be stored on floor, but he/she thought the food was stored on the floor because the Dining Service Director (DSD) over ordered on the food supply due to going on vacation, and they did not have enough room to put everything away properly. The DA said he/she believed there was probably enough room now to store the food off of the floor and he/she did not know why staff continued to store food on the floor. During an interview on 03/25/25 at 10:37 A.M., [NAME] B said the food trucks deliver on Mondays and Tuesdays, but the truck had not arrived for the day so the food stored on the floor would be from the previous day. The cook said food should not be stored on floor and he/she did not know why staff stored food on the floor as he/she did not work the previous day. Observations on 03/27/25 at 12:10 P.M., showed walk-in refrigerator #1 contained: -A sign on the door to the walk-in that read Items in the fridge and/or freezer must be labeled, dated (mm/dd/yy) & properly stored. Label/date MUST be facing outward.; -Opened and undated one gallon bottles of Worcestershire sauce, soy sauce, barbeque sauce, hot sauce and salsa; -An opened and undated half gallon bottle of sweet and sour sauce; -An opened and undated 48 oz. jar of dijon mustard; -An opened and undated 32 oz. container of chopped garlic. Observations on 03/27/25 at 12:10 P.M., showed walk-in refrigerator #2 contained: -A sign on the door to the walk-in that read Items in the fridge and/or freezer must be labeled, dated (mm/dd/yy) & properly stored. Label/date MUST be facing outward.; -Opened and undated one gallon containers of mayonnaise, mild cocktail sauce and dijon honey mustard; -Two opened and undated containers of [NAME] Caesar Dressing; -Two opened and undated containers of sweet pickle relish; -An opened and undated bag of cut broccoli. During an interview on 03/27/25 at 12:20 P.M., the DSD said staff should date, label and cover opened and prepared food items and foods should not be stored on the floor or next to chemicals. The DSD said staff are expected to use all of one food item before they open another of the same thing unless the items has gone bad or expired. The DSD said he/she is responsible to monitor the food storage multiple times a day and the cooks are also responsible to monitor the food storage multiple times a day to ensure food is stored appropriately. The DSD said he/she had not looked at the food storage that day. The DSD said staff are trained on proper food storage requirements and should make corrections as needed. During an interview on 03/28/25 at 11:05 A.M., the administrator said staff should date, label and cover opened and prepared food items and foods should not be stored on the floor or next to chemicals. The administrator said staff are expected to use all of one food item before they open another of the same thing. The administrator said the DSD is responsible to monitor the food storage at least weekly and designate someone to be in charge of that in his/her absence. The administrator said he/she did not know if the DSD appointed anyone specifically to monitor food storage while during his/her recent absence, but the cooks should also routinely monitor it during their shift and when they put the truck away. The administrator said staff are trained on proper food storage requirements and if they identify an issue with food storage, they should dispose of the items not stored properly. 2. Review of the facility's Dishwashing Machine Use Policy, dated 11/2024, showed: -Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspect of proper use and sanitation; -Dishwashing machines that use hot water to sanitize will maintain the following wash solution temperatures: b. 160 dF for single tank, conveyor, dual temperature machines; -Dishwashing machine hot water sanitation rinse temperatures may not be fore than 194 dF, or less than: a. 165 dF for stationary rack, single temperature machines; b. 180 dF for all other machines; -The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately; -If hot water temperatures do not meet requirements, cease use of the dishwashing machine immediately until temperatures are adjusted. Observations on 03/25/25 at 8:48 A.M., showed DA C washed soiled dishes in the heat sanitizing conveyor mechanical dishwasher. Observations during two cycles of the dishwasher showed the machine's gauges measured the temperature of the wash cycle water at 153 dF and the temperature of the rinse cycle water at 169 dF. Observation during a third cycle of the dishwasher showed the machine's gauges measured the temperature of the wash cycle water at 158 dF and and the temperature of the rinse cycle water at 175 dF. Observation showed the DA did not look at the gauges on the dishwasher during the three cycles. Observation showed the area did not contain any visible information related to the proper temperatures for the machine's wash and rinse cycles. During an interview on 03/25/25 at 8:55 A.M., DA C said he/she forgot what the wash and rinse temperature of the dishwasher is suppose to be and he/she does not look at the machine gauges very often. During an interview on 03/27/25 at 12:20 P.M., the DSD said the wash temperature of the dishwasher should be 160 dF and the rinse temperature should be 180 dF. The DSD said staff are expected to check the temperature of the dishwasher before they wash dishes and multiple times a day and they should not wash dishes in it until it reaches the proper temperature. The DSD said staff, including DA C who had worked at the facility for multiple years, have been trained on the proper temperatures for the dishwasher and to not use the dishwasher if it is not at the proper temperature. During an interview on 03/28/25 at 11:10 A.M., the interim administrator said the wash and rinse temperatures of the dishwasher should be in accordance with the facility policy and staff should verify the dishwasher has met the required temperatures before they use it to wash dishes. The interim administrator said staff should monitor the dishwasher temperatures each time they are going to use the dishwasher and staff are trained on proper dishwasher temperatures and procedures. 3. Review of the facility's Dishwashing Machine Use Policy, dated 11/2024, showed the policy directed staff to all items washed in the dishwashing machine to air-dry after they are ran through an entire cycle. Observations on 03/25/25 at 8:48 A.M., showed DA C washed soiled dishes in the mechanical dishwashing station. Observations showed the DA then removed wet dishes from the clean side of the station and stacked them together the on utility carts. Observation on 03/25/25 at 9:05 A.M., showed five metal pans of various sizes stacked together wet on the storage rack in the kitchen. Observation on 03/25/25 at 10:44 A.M., showed the dining room service station contained nine service trays and seven insulated plate covers stacked together wet in storage. During an interview on 03/27/25 at 12:20 P.M., the DSD said staff should allow cleansed dishes to air-dry before they are put away and staff, including DA C who had worked at the facility for multiple years, have been trained on that requirement. During an interview on 03/28/25 at 11:10 A.M., the interim administrator staff should allow dishes to air-dry before they are put away and staff are trained on that requirement.

Based on interview and record review, facility staff failed to follow professional standards when staff did not ensure one resident (Resident #6) out of one sampled residents received the required Prothrombin and International Normalized Ratio ((PT/INR) blood test that shows how long it takes to form a blood clot) blood test for the use of Warfarin (medication to thin blood and prevent blood clots). The facility census was 54. 1. Review of the facility's Medication and Treatment Order policy, dated 11/22/23 showed: -Orders for anticoagulants (blood thinning medications) will be prescribed only with appropriate clinical and laboratory monitoring; -The attending physician/practitioner must periodically record in the progress notes the results of the laboratory monitoring and the review for potential complications. Review of the Warfarin prescribed infromation located on www.accessdata.fda.gov showed: -Warfarin can cause major or fatal bleeding; -Perform regular monitoring of International Normalized Ratio ((INR) a measure of the time taken for your blood to clot) in all treated patients; -Monitoring: Obtain daily INR determinations upon initiation until stable in the therapeutic range. Obtain subsequent INR determinations every one to four weeks; -Drugs that increase bleeding risk: Closely monitor patients receiving any such drug. 2. Review of the Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/22/23, showed staff assessed the resident took anticoagulant. Review of the resident's Physican Order Sheet (POS), dated March 2024, showed an order for Warfarin Sodium 2 milligrams (mg), one tablet a day. Review showed the POS did not contain an order for a PT/INR. During an interview on 03/22/24, at 01:46 P.M., the Director of Nursing (DON) said if a resident has an order for Warfarin, the resident should also have an order for routine lab work to check the PT/INR. The DON said the omission in the resident's orders most likely was due to a glitch when the electronic medical record software was changed. The DON said the medication dosage needs to be monitored and adjusted to make sure a resident's blood does not get too thin which could cause uncontrolled bleeding or not effective enough to prevent blood clotting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for fourdependent residents with dementia (Resident #4, #7, #22, and #45) out of 18 sampled residents. The facility census was 54. 1. Review of the facility's activities program policy, dated 07/19/23, showed the activities programs are designed to meet the interests of and support the physical, mental, psychosocial well-being of each resident. Review showed activities offered are based on the comprehensive resident-centered assessment and the preferences of such resident. Review showed the residents' participation are documented in the residents' medical record. Review of the facility's scheduled activities calendar, dated March 2024, showed: -On the 19th at 10:00 A.M., catholic service and 02:00 P.M., Easter Door Crafts; -On the 20th at 10:00 A.M., therapy dog and 02:00 P.M., Vacation of the Month; -On the 21st at 10:00 A.M., devotions and 02:00 P.M., live music; -On the 22nd at 10:00 A.M., bingo and at 02:00 P.M., Spa day. 2. Review of Resident #4's Significant Change of status Minimum Data Set (MDS), a federally mandated assessment tool, showed staff assessed the resident as: -Cognitively impaired; -Very important to have books, magazines, and newspapers to read, do favorite activities, go outside when the weather is good and attend religious services; -Somewhat important to listen to favorite music, keep up with the news and do things with groups of people; -Diagnosis of stroke, cancer and dementia. Review of the resident's care plan, dated 03/11/24, showed staff are directed as follows: -Dependent on staff for meeting emotional, intellectual, physical, and social needs because of immobility and physical limitations; -Goal to attend/participate in activities of choice 4 times weekly; -Provide with activities calendar. Notify of any changes to the calendar of activities; -Enjoy bingo, live music, physical activities and cognitive activities; -All staff to converse with resident during providing care; -Ensure the activities he/she attends are compatible with physical and mental capabilities. Compatible with known interests and preferences. Adapted as needed (such as sitting close due to hearing and limited use of left hand). Compatible with individual needs and abilities, and age appropriate; -May need assistance with Activities of Daily living as required during the activity; -Need assistance going to/from activity functions; -Provide a program of activities that is of interest and empowers him/her by encouraging/allowing choice, self-expression and responsibility. Review of the resident's individual activity record, dated 3/19/24 through 3/21/24 showed staff did not document the resident participated in activities on 03/19 or 03/20. Observation on 3/19/24 at 02:47 P.M., showed the resident in his/her room in his/her wheelchair with eyes closed. The resident did not participate in the scheduled activity. 3. Review of Resident #7's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Moderate cognitive impairment; -Very important to be involved in favorite activities. Review of the resident's care plan, dated 02/05/24, showed staff are directed the resident will need one on one activities and is unable to attend out of room events. Review showed the resident preferred activities are playing cards, social activities, parties, listing to music, and watch television. Review of the resident's individual activity record, dated 02/01/24 through 3/21/24, showed the record did not contain documentation of one on one activity. Observation on 03/20/24 at 10:00 A.M., showed the resident in his/her room asleep in his/her wheelchair. Observation showed the resident did not participate in the scheduled activity. 4. Review of Resident #22's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Very important to do his/her favorite activities; -Somewhat important to have books, newspapers and magazines to read; -Very important to listen to music he/she likes; -Somewhat important to be around animals such as pets; -Somewhat important to do things with groups of people; -Very important to go outside and get fresh air when the weather is good; -Somewhat important to participate in religious services or practices; -Used a wheelchair; -Dependent to wheel the wheelchair -Diagnoses of a Parkinson's disease (a degenerative neurological disease), heart failure, anxiety, and depression. Review of the resident's care plan, revised 02/08/24 showed: -Quality of live is better when able to do things that are most important to him/her. Personal preferences will be honored frequently throughout next review with interventions of: -Likes to talk and hold conversations about my family and old times; -It is important to do his/her favorite activities such as watching television and listening to music; -It is important for him/her to go outside and get fresh air when the weather is good, go outside when the weather is warm, sit in the sun; -It is important for him/her to listen to music, to attend live music performances; -It is important for him/her to participate in religious services or practices; -Provide one-to-one visits as needed. enjoy having the cards and letters, receive in the mail and read to me and sharing stories about my family. Observation on 03/20/24 at 10:00 A.M., showed the resident in his/her room in the wheelchair. The resident did not attend the activity with the therapy dog activity. Observation on 03/21/24 at 10:21 A.M., showed the resident in bed. Staff did not assist the resident to the 10:00 A.M. activity of devotion. During an interview on 03/22/24 at 01:19 P.M., the Assisted Living Activities Director (AD) said the resident enjoys anything with music, and will tap his/her foot and move to music, and also likes staff to talk to him/her one on one. 5. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Very important to do his/her favorite activities; -Somewhat important to have books, newspapers and magazines to read; -Very important to listen to music he/she likes; -Somewhat important to do things with groups of people; -Somewhat important to participate in religious services or practices; -Used a wheelchair; -Diagnoses of non-traumatic brain dysfunction, dementia and depression. Review of the resident's care plan, dated 12/15/23 showed staff are directed as follows: -Dependent for meeting emotional, intellectual, physical and social needs because of cognitive deficits and immobility. Will maintain involvement in cognitive stimulation, social activities as desire with interventions: -Ensure the activities attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed; Compatible with individual needs and abilities and age appropriate; -May need one on one bedside/in-room visits and activities if unable to attend out of room events; -Prefer activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as painting, coloring, watching or listening to music or videos; -Will need assistance/escort to activity functions; -Prove a program of activities that is of interest and empowers him/her by encouraging/allowing choice, self-expression and responsibility. Observation on 03/19/24 at 2:57 P.M., showed the resident in a recliner in the television room, holding a doll. The resident did not attend the scheduled activity. Observation on 03/20/24 at 9:58 A.M. and 10:30 A.M., showed the resident in the hall next to the nursing station. The resident did not attend the scheduled activity. During an interview on 03/22/24 at 01:19 P.M., the Assisted Living AD said the resident enjoys looking at books with animals or vehicles, and also enjoys walking with staff assistance. 6. During an interview on 03/22/24 at 01:11 P.M., the Director of Wellness said at this time there is only one activity director for the entire skilled nursing and assisted living complex. The Director of Wellness said dependent residents should have one on one visits in their rooms and be person-centered based on what the resident's preferences are. He/She said the activity director is instructed to use the residents' care plans to plan the residents' one on ones. He/She said dependent residents should be invited to the group activities if appropriate. During an interview on 03/22/24 at 1:19 P.M., the Assisted Living AD said he/she was helping as much as he/she was able while the activities director position was vacant in the skilled nursing area. The AD said all activities are charted as well as when the resident declines an activity. The resident should have at least one activity per week with staff interaction. During an interview on 3/22/24 at 1:46 P.M., the Director of Nursing (DON) said dependent residents should have at least two activities a week but there is no activities director, and no one is dedicated to providing activities to the dependent residents. During an interview on 3/22/24 at 2:26 P.M., the administrator said dependent residents should be provided with two one on one activities per week and to participate in group activities if appropriate, and all activity participation should be documented.

Based on observation, interview, and record review, facility staff failed to ensure multi-dose medications were dated when opened, including inhalers, insulin pens, and a nose spray. The facility census was 54. 1. Review of the facility's Storage of Medication policy, dated 01/12/07, showed facility staff were directed as follows: -Insulin (helps your body turn food into energy and manages your blood sugar levels) products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Opened insulin pens must be stored at room temperature; -Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal; -Medications for nasal inhalation are stored in the dispensed containers following manufacturer guidelines for positioning and priming. The following information is provided as general guidelines for proper storage of specific nasal inhaler products and is not meant to be all-inclusive. Review of the facility's PharMerica List of Medications with Shortened Expiration Dates, updated December 2023 showed: -Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy; -A drug product's beyond use date is the manufacturer supplied expiration date or the shortened date after opening whichever comes first; -These in-use medications should be labeled such that the date opened is noted, clearly visible and securely attached to a part of the package to not be discarded; -Humulin pen (insulin) good for 28 days after first use; -Basaglar pen (insulin) good for 28 days after first use; -Combivent inhaler (used to open airways) good for 3 months after first actuation; -Lantoprost (eye drops to treat glaucoma) good for 42 days after opening or moving to room temperature from the refrigerator; -Generally all other eye drops/ointments are good for 60 days after opening unless individual products package insert state otherwise. 2. Observation on 3/22/24 at 08:46 A.M., showed the 400 hall medication cart contained: -An undated, open bottle of prescription flucortisone nasal spray (used for allergies); -An undated, open Humulin (insulin) pen; -An undated, open Basiglar pen; -Three undated, open bottles of lantoprost eye drops (used for glaucoma); -An undated, open bottle of dorzolamide eye drops (used for glaucoma); -Four bottles of undated, open artificial tear eye drops (used for dry eye and allergies); -One undated, open tube of artificial tears eye ointment (used for dry eye and allergies); -One undated, open, unlabeled with a resident name bottle of artificial tears; -One undated, open bottle of sodium chloride eye drops (used to draw water out of the eye); -Two undated, open albuterol inhalers (used to ease breathing). During an interview on 03/21/24 at 08:40 A.M., Certified Medication Technician (CMT) D said nose sprays are good for six weeks. During an interview on 03/22/24 at 09:00 A.M., CMT E said he/she uses the expiration dates labeled on the box or bottles to determine when something is expired. He/She said eye drops are good for 30 days, inhalers are good until the expiration date on the box/bag it comes in, and insulin is good for 28 days once put into use. He/She did not know why there were undated open medications in the cart. CMT E said giving medications that are expired could cause the resident to get the wrong dose. During an interview on 3/22/24 at 01:10 P.M., the Director of Nursing (DON) said eye drops are good for as long at the expiration date is on the packaging, insulin is good for 28 days and nasal sprays are good until the give by date. He/She said if insulin is not dated, he/she would expect staff to discard the medication and obtain a new pen and to not use medications that are not dated. He/She said the night shift staff are responsible to do medication cart checks either every night or weekly. The DON said if staff are unsure of the dates, they are to call the physician to obtain clarification and guidance on what to do. He/She did not know and is not sure why the items in the cart were not dated. During an interview on 3/22/24 at 02:25 P.M., the administrator said medications are good for 30 days when opened and put into use. If medication is not dated, then staff are to throw it away and obtain a new medication. He/She said the DON and Assistant Director of Nursing (ADON) do all medication cart checks along with the pharmacy who checks monthly for expired medications. He/She said giving medication outside of the expiration date could potentially change the dose received. During an interview on 3/25/24 at 03:48 P.M., the pharmacy nurse consultant said staff should be dating the bottles of medications including insulins, eye drops, inhalers and nasal sprays to ensure the correct dosing and stability of medication when opened. He/She said the facility should have a copy of the pharmacies short expiration dates medication list to use as a guideline to medication expirations and if there is no guidance on a specific medication such as artificial tears, he/she would expect staff to follow the package insert for guidance.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to four of four residents (Residents #11, #18, #27 and #42) who received pureed diets. The facility census was 54. 1. Review of the facility provided policies and procedures, showed the records did not contain policies and procedures for resident food service. Review of meal tray tickets for Residents #11, #18, #27 and #42, showed the tickets directed staff to serve the residents a pureed diet. Review of the facility lunch menus and recipes dated 03/19/24 (Week 3, Day 17), showed the facility staff were directed to provide the residents who received pureed diets with: -A #8 (four ounce) scoop of pureed orange-rosemary pork loin or pureed lemon pepper tilapia; -A #8 scoop of mashed potatoes with two ounces of gravy; -Four ounces of pureed green beans or a #12 (2.6 ounce) scoop of pureed sauteed zucchini and squash; -A #12 scoop of pureed apple slaw or pureed diced tomato salad; -A #16 (two ounce) scoop of pureed corn muffin; -A #8 scoop of pureed bread pudding with vanilla sauce. Observation on 03/19/24 during the lunch meal service, which began at 12:00 P.M., showed along with the mashed potatoes with gravy and pureed vegetable, the Kitchen Supervisor served residents #11, #18, #27 and #42 a #12 scoop of pureed orange-rosemary pork loin (1.4 ounces less than directed by the menus). Review showed the staff did not prepare or serve the pureed apple slaw or diced tomato salad, pureed corn muffin, and pureed bread pudding with vanilla sauce as directed by the menus. During an interview on 03/19/24 at 12:11 P.M., the Kitchen Supervisor said the facility did not have menus with portion sizes for modified diets and the kitchen staff are directed to use the serving sizes from the recipes. The kitchen supervisor said he/she did not review the recipes for the portion sizes to be served for the pureed food items. The Kitchen Supervisor said the other pureed food items were not made, because they are to be made by the baker and the facility did not have a baker on duty that day. Review of the facility lunch menus dated 03/20/34 (Week 3, Day 18), showed the facility staff were directed to provide the residents who received pureed diets with: -A #8 scoop of pureed hamburger on bun or a #6 (5.3 ounce) scoop of pureed cheese manicotti with marinara; -A #8 scoop of mashed potatoes with two ounces of gravy; -A #12 scoop of winter vegetables or four ounces of pureed Caesar salad; -One slice of pureed bread; -A #16 scoop of pureed chocolate chess pie. Observation on 03/20/24 during the lunch meal service, which began at 12:08 P.M., showed along with the mashed potatoes and gravy, [NAME] F served residents #11, #18, #27 and #42 a #8 scoop of pureed cheese manicotti (1.3 ounces less than directed by the menus), four ounces of pureed winter vegetables (1.4 ounces more than directed by the menus), and a #10 (3.2 ounce) scoop of pureed pie (1.2 ounces more than directed by the menus). Observation showed the staff did not prepare or serve the pureed bread as directed by the menus. During an interview on 03/20/24 at 12:32 P.M., [NAME] F said staff are to serve the meals in accordance with the planned menus and the baker is responsible to make the pureed bread, but the baker arrived late to work that day. The cook said in the absence of the baker, the cook is responsible to ensure all food items are prepared so that residents receive full meals. The cook said he/she reviewed the menus prior to the meal, but missed that purees were supposed to get bread. The cook said he/she did not realize that he/she had the wrong scoop sizes for the pureed food items. During an interview on 03/20/24 at 3:01 P.M., the Certified Dietary Manager (CDM) said staff are trained and expected to serve meals in accordance with the planned menus. The CDM said the facility does have menus with portion sizes for modified diets in the dining room and staff should review those menus prior to service to ensure all items are prepared and served accordingly. The CDM said the baker does make some of the pureed food items, but the cook is responsible to ensure that all food items are made. During an interview on 03/20/24 at 3:34 P.M., the administrator said the facility does have menus with portion sizes for modified diets, the dietary staff should have all menus and recipes needed available to them in the kitchen, and they are expected to serve meals in accordance with the planned recipes and menus. The administrator said he/she did not know that the menus with portion sizes for modified diets were not available in the kitchen and staff did not serve the meals in accordance with the menus for residents who received pureed diets.

Based on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary, using approved techniques to prevent cross-contamination. The facility census was 54. 1. Review of the facility supplied policies and procedures, showed the records did not contain a food service hand hygiene policy. Observation on 03/19/24 at 10:00 A.M., showed dietary aide (DA) G washed soiled dishes in the mechanical dishwashing station and then, without performing hand hygiene, the DA put away sanitized dishes from the clean side of the station. Observation on 03/19/24 at 10:32 A.M., showed DA G washed soiled dishes in the mechanical dishwashing station. Observation showed after the DA loaded the soiled the dishes into the dishwasher, he/she rinsed his/her hands with water from the water spray nozzle located on the dirty side of the station and then, without performing hand hygiene, put away sanitized food service trays from the clean side of the station. During an interview on 03/19/24 at 10:33 A.M., DA G said he/she had worked at the facility for 25 years and he/she had been trained on hand hygiene procedures. The DA said staff should wash their after they touch dirty dishes, before they touch clean dishes and he/she just got in a hurry and did not do so. Observation on 03/20/24 from 2:10 P.M. to 2:18 P.M., showed [NAME] F washed his/her hands at the handwashing sink and scrubbed his/her hands with soap for five seconds. Observation showed after the cook washed his/her hands, he/she used his/her bare hand to lift the trash can lid to dispose of a paper towel, obtained a box of gloves from the office, donned a pair of gloves from the box, and then used his/her gloved hands to place leftover hamburger patties into plastic resalable bags and put the bags in refrigerator. Observation showed the cook then removed his/her gloves and washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap for three seconds. During an interview on 03/20/24 at 2:18 P.M., [NAME] F said he/she had worked at the facility for nine years and staff trained him/her on hand hygiene upon hire, but not since then. The cook said staff should scrub their hands with soap long enough to sing the alphabet when they wash their hands. The cook said he/she did not know how long it should take to sing alphabet song and it depended on how fast I want to be. The cook said he/she could not say how long he/she thought he/she just washed his/her hands for but it was probably not long enough. The cook said trash cans would be considered dirty and staff should wash their hands after touch anything dirty, but he/she just did not think about it. Observations on 03/20/24 at 2:27 P.M. and 2:51 P.M., showed DA H washed soiled dishes in the mechanical dishwashing station and then, without performing hand hygiene, the DA put away sanitized dishes from the clean side of the station. During an interview on 03/20/24 at 2:52 P.M., DA H said he/she had worked at the facility for one year and he/she did not get trained on hand hygiene upon hire. The DA said staff should wash their hands before they start to wash dishes and before they put away clean dishes. DA H said he/she did not know why he/she did not wash his/her hands. During an interview on 03/20/24 at 2:57 P.M., the Certified Dietary Manager (CDM) said staff should should wash their hands between the dirty and clean dishes, before and after glove use and anytime they touch anything dirty, which would include the trash cans. The CDM said staff should scrub their hands with soap for 30 seconds when they wash their hands and staff have been trained on proper hand hygiene procedures. During an interview on 03/20/24 at 3:34 P.M., the administrator said staff should wash their hands any time they go from a dirty task to a clean task and after they remove their gloves. The administrator said trash can lids would be considered dirty and staff should wash their hands if they touch the trash can with their bare hands. The administrator said staff are trained on hand hygiene procedures upon hire and at least six times a year. The administrator said the CDM is responsible to monitor his/her staff's hand hygiene practices, but the director of nursing also makes six random hand hygiene observations every month and staff are reeducated as needed based on those observations.

Based on interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure all residents were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs, when staff failed to ensure a two-step Mantoux test (a skin test to determine whether a person in infected with determining whether a person is infected with tuberculosis) was completed and documented in accordance with their policy for three (#4, #6, and #9) out of six sampled residents. The facility census was 54. 1. Review of the facility's Tuberculosis Testing for Residents, Employees, and Volunteers policy, dated 11/22/23 showed: -The facility will screen residents, employee and volunteers for tuberculosis using established protocols from the Missouri Department of Health and Senior Services; -The facility will ensure that all test results are completed, and that documentation is maintained for all residents, employees, and volunteers; -The facility will work collaborative with the Missouri Department of Health on managing any suspicious concerns regarding tuberculosis; -The facility will screen their residents, employees and volunteers for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit (5TU) test; -The infection preventionist or designee will ensure that all test results are completed, and that documentation is maintained for all residents, employees, and volunteers; -Within one month prior or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD two-step tuberculin test; -If the initial test is negative, zero to nine millimeters (0-9 mm), the second test, which can be given after admission, should be given one to three (1-3) weeks later; -Documentation of chest x-ray evidence ruling out tuberculosis disease within one month prior to admission, along with an evaluation to rule out signs and symptoms compatible with infectious tuberculosis, may be accepted by the facility on an interim basis until the Mantoux PPD two-step test is completed; -Residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. 2. Review of the Resident #4's medical record showed: -An admission date of 11/06/20; -Did not contain documentation an annual evaluation to rule out signs and symptoms of TB. 3. Review of the Resident #6's medical record showed: -An admission date of 10/27/16; -Did not contain documentation an annual evaluation to rule out signs and symptoms of TB. 4. Review of the Resident #4's medical record showed: -An admission date of 11/26/23 -Did not contain documentation the resident received the Mantoux PPD two-step tuberculin test. 5. During an interview on 03/21/24 at 11:00 A.M., the Infection Preventionist said all residents are given the two-step TB test and the results are documented in the resident's electronic medical record (EMR). He/She did not know why the documentation was missing in the charts. During an interview on 03/22/24 at 2:26 P.M., the Director of Nursing (DON) said he/she did not know why the residents' TB tests were missing in the EMR. The DON said the information may have not been pushed into the EMR when the software used was recently switched. He/She said an order should be generated for the TB tests and reading of the TB tests, and to document in the resident's chart all of the information regarding the TB test.

Based on observation, interview, and record review staff failed to implement procedures to ensure schedule IV (drugs with a low potential for abuse and low risk of dependence) medications were monitored for one resident (Resident #4) and failed to ensure medications were stored in a safe and effective manner. The facility census was 48. 1. Review of the facility policies showed staff did not provide a policy for controlled medication monitoring. 2. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 12/15/22, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Diagnosis of dementia, and seizure disorder/epilepsy. Observation on 3/1/23 at 10:10 A.M., showed a vial of Ativan (anti-anxiety medication), 3 milligram (mg)/milliliter (ml), in a locked box in a refrigerator in the medication storage room. Further observation of the vial's label showed the resident's name and a date a fill date of 9/8/21. Review of the resident's POS, dated 2/2023, showed the record did not contain an order for Ativan. Review of the resident's Medication Administration Record (MAR), dated 2/2023, showed the record did not contain an order for Ativan. Review of the facility medication records showed the record did not contain documentation staff monitored or counted the amount left in the vial of Ativan. During an interview on 3/3/23 at 4:05 P.M., the Licensed Practical Nurse (LPN) A said if a resident has a medication but there is no order then staff would need to call the doctor. LPN A said the Ativan is kept on hand for the resident in case he/she has a seizure. He/She said the facility recently changed owners so the Electronic Medical Record changed, however he/she knows there was an order for the medication at one time, but is unsure what happened or how it got missed. LPN A said there should be an order for any medication before it's given to a resident, especially this type of medication. 3. Observation on 3/1/23 at 9:40 A.M., showed the medication cart on the back of 400 hall contained: -One large loose orange tablet with KC10 stamped on it; -Two small loose yellow tablets with 458 stamped on it; -One loose oval pink tablet with 457 stamped into it. During an interview on 3/1/23 9:55 A.M., Certified Medication Technician (CMT) K said medication technicians and nurses are responsible for checking carts for loose pills, and expired medications. CMT K said if he/she found a loose pill she would let the charge nurse know. CMT K said he/she typically checks his/her cart, but it sometimes just happens when the cards are moved around. He/She said if a resident is discharged the medications go with them. If the medications are expired they are destroyed. CMT K said medications not given or found loose should be destroyed. During an interview on 3/3/23 at 1:50 P.M., the DON and administrator said if loose pills are found in the mediation cart, pills that are expired, or pills found in a resident's room the pills should be destroyed. If there is a medication remaining without current orders, the facility disposes of the medication and discontinues the order. The nurse or the CMT is responsible for destroying medications in a timely manner, as long as the medication is not a narcotic. This task should be completed at least weekly. The nurse are responsible for checking the medication rooms and the refrigerator in the medication room. During an interview on 3/3/23 at 4:05 P.M., LPN A said he/she does not know who is responsible for checking medications or cleaning the medication room.

Based on interview and record review, the facility staff failed to complete the Employee Disqualification List (EDL) check, the Family Care Safety Registry (FCSR), and/or Criminal Background Check (CBC) upon hire for two current employees (Employee O and Licensed Practical Nurse (LPN) N) as directed in their policy and failed to periodically check the employee disqualification list for one of ten sampled current employees (Housekeeper M). In addition, the facility failed to complete the required Certified Nurse Aide (CNA) Registry checks upon hire for two of the ten sampled employees (Employee O and LPN N). The facility census was 48. 1. Review of the facility's Background Checks Policy and Procedure, undated, showed the following: Policy: The facility has a responsibility to ensure the safety of our residents. To comply with this responsibility, any and all owners, directors, officers, clinical staff, employees, vendors, independent contractors, volunteers, consultants and others working for the facility (Associates) that come into contact with residents are required to submit to criminal background checks. -Offers of acceptance to work in the Facility are made as conditional offers. Applicants may be denied admittance if the background screenings are returned with felony convictions. A current Associate who comes into contact with residents who refuses to authorize testing or whose background check returns with felony convictions may not be allowed to continue working for the Facility. Procedure: -Associates shall be checked against the Missouri Family Care Safety Registry (FSCR). This registry helps ensure that persons who care for children, the elderly, and the physically or mentally disabled can easily be screened as required by Missouri law. -Associates shall also be checked against the Missouri Highway Patrol, the Missouri Department of Health and Senior Services (sanction list) and any agency thereof, the FBI and any other law enforcement agency of and state of the United States, the Office of Inspector General sanction list and the General Services Administration sanction list if necessary as well as any other background screenings that may be required by federal or state laws or regulations. The policy did not direct staff to check the Certified Nurse Aide registry. 2. Review of Employee O's employee file showed: -Date of hire 12/26/22; -The file did not contain documentation the EDL had been checked; -The file did not contain documentation the CBC had been checked; -The file did not contain documentation the FCSR had been checked; -The file did not contain documentation the CNA registry was checked. 3. Review of LPN N's employee file showed: -Date of hire 12/5/22; -The file did not contain documentation the EDL had been checked; -The file did not contain documentation the CBC had been checked; -The file did not contain documentation the FCSR had been checked; -The file did not contain documentation the CNA registry was checked. 4. Review of Housekeeper M's employee file showed: -Date of hire 3/15/22; -The file did not contain documentation the EDL had been checked periodically since hire. 5. During an interview on 03/02/2023 at 12:45 P.M., the director of human resources said he/she knows since October 2022 there has not been an EDL check been done on employees. During an interview on 3/3/23 at 1:50 P.M., the Director of Nursing (DON) and administrator said some records for employee background checks were lost in the ownership transition and the required background checks should be completed on every new employee, and the EDL should be checked periodically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain professional standards of care by not following physician's orders for four residents (Resident #3, #20, #24, and #39). The facility census was 48. 1. Review of the facility's policies, showed staff did not provide a policy for following or obtaining physician's orders. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/10/23, showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from staff for mobility, transfers, and toileting; -Always incontinent of urine; -Frequently incontinent of bowel; -At risk for developing pressure ulcers. Review of the resident's Physician Order Sheet (POS), dated 2/2023, showed an order dated 2/21/23 for Triad Hydrophilic wound dressing three times a day (TID) and PRN for open area to inner left buttock until healed. Review of the resident's Treatment Administration Record (TAR), dated 2/21/2023 through 3/2/23, showed staff did not document they provided the wound treatment on the following dates and time: -On 2/22/23 morning treatment; -On 2/23/23 morning treatment; -On 2/24/23 morning treatment; -On 2/27/23 morning treatment; -On 3/1/23 morning treatment. 3. Review of Resident #20's significant change MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Always incontinent of bowel; -At risk for developing pressure ulcers; -Diagnosed with an unstageable coccyx (tailbone) pressure ulcer. Review of the resident's POS, dated 1/2023 to 2/2023, showed the an order dated 1/14/23 to clean area around G-Tube (gastric tube- tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food) with mild soap and warm water daily, Replace split gauze daily every day shift. Review of the resident's TAR, dated 1/2023 to 2/2023, showed staff did not document they provided the G-tube treatment on the following dates: -G-Tube treatment on 1/19/23; -G-Tube treatment on 2/2/23; -G-Tube treatment on 2/6/23; -G-Tube treatment on 2/12/23; -G-Tube treatment on 2/16/23; -G-Tube treatment on 2/23/23; -G-Tube treatment on 2/26/23. Review of the resident's POS, dated 2/2023, showed they following: -An order dated 2/10/23 for: Coccyx: Cleanse with wound cleanser, apply Collagen powder, medihoney, cover with dry dressing, change daily and prn every day shift; -An order dated 2/17/23 for: Coccyx: Cleanse with Normal Saline (NS), apply damp gauze with Betadine solution, cover with foam dressing, change daily and prn every day shift for wound care. Review of the resident's TAR, dated 2/2023, showed staff did not document they provided the following: -Coccyx treatment on 2/12/23; -Coccyx treatment on 2/14/23; -Coccyx treatment on 2/19/23; -Coccyx treatment on 2/23/23; -Coccyx treatment on 2/24/23. 4. Review of Resident #24's significant change MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on staff for mobility, transfers, and toileting; -Always incontinent of urine and bowel; -At risk for developing pressure ulcers; -Diagnoses of a left heel arterial wound and a left hip stage 3 pressure ulcer. Review of the resident's POS, dated 2/2023, showed an order dated on 12/6/22 for MedHoney wound/burn gel; Apply to left buttock topically one time a day for open area of the left buttock. Review of the resident's TAR, dated 12/2022, showed staff did not document they provided wound treatment on the following: -Wound treatment on 12/6/22; -Wound treatment on 12/7/22. Review of the resident's POS, dated 12/22-1/23, showed an order dated on 12/15/22 for the left heel: Discontinue current treatment. Cleanse with normal saline, apply MedHoney Hydrogel (50/50 mix), cover with gauze then wrap to change daily and as needed. Review of the resident's TAR, dated 12/2022, showed staff did not document they provided wound treatment on the following: -Wound treatment on 12/15/22; -Wound treatment on 12/16/22; -Wound treatment on 12/17/22; -Wound treatment on 12/18/22; -Wound treatment on 12/19/22; -Wound treatment on 12/20/22; -Wound treatment on 12/21/22; -Wound treatment on 12/22/22; -Wound treatment on 12/23/22; -Wound treatment on 12/24/22; -Wound treatment on 12/25/22; -Wound treatment on 12/26/22; -Wound treatment on 12/27/22; -Wound treatment on 12/28/22; -Wound treatment on 12/29/22; -Wound treatment on 12/30/22; -Wound treatment on 12/31/22; -Wound treatment on 1/24/23. 5. Review of Resident #39's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -At risk for pressure ulcer; -Diagnosis of rectal fistula (is a small, infected passageway that can develop between the end of the bowel and the skin surrounding the anus) and anal abscess (collection of pus, usually caused by a bacterial infection). Review of the resident's POS, showed an order on 12/7/22 to provide wound care twice a day and PRN for left buttock and anal tunneling fistula. Review of the resident's TAR showed staff did not document they provided the wound treatment on the following dates: -On 12/9/22; -On 12/11/22; -On 12/24/22 -On 12/28/22; -On 1/1/23; -On 1/14/23; -On 1/16/23; -On 1/3023; -On 2/15/23. During an interview on 3/3/23 at 3:53 P.M., Licensed Practical Nurse (LPN) A said he/she knows what types of treatments or medications to give based on physician orders that are located in the resident's electronic medical record (eMAR). He/She said staff must always follow the physician orders. He/She said staff must have an order for anything they need to give or put on a resident, even a band aide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for three residents (Resident #11, #25, and #40). The facility census was 46. 1. Review of the facility's Medication Administration Safety Program (MASP) -High Alert Medications, not dated, showed antipsychotics may be used with appropriate supporting diagnosis. 2. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff, dated 12/22/22, showed facility staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors directed towards others; -Did not reject care; -Received antipsychotic, antidepressant, and antianxiety medications 7 out of 7 days in the look back period (7 day period of time before the assessment is completed to capture the status of a resident); -Diagnosis of Dementia (for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and Anxiety disorder (feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities. Review of the resident's Physician Order Sheets (POS), dated March 2023, showed an order on 9/28/20 for Risperidone (antipsychotic) 0.25 Milligrams (mg) tablet, give 0.5 mg in the evening for unspecified dementia. Review of the resident's medical record showed the record did not contain an appropriate diagnosis. 3. Review of Resident #25's quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognitively Intact; -No behaviors directed towards others; -Did not reject care; -Received antipsychotic, antidepressant, and antianxiety medications 7 out of 7 days in the look back period; -Diagnosis of anxiety disorder, and dementia. Review of the resident's POS dated March 2023, showed an order on 12/1/22 for Fluoxetine HCl (antidepressant) 20 mg daily for mood disturbance. Review of the resident's medical record showed the record did not contain an appropriate diagnosis. 4. Review of Resident #40's quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors directed towards others; -Did not reject care; -Received antipsychotic, antidepressant, and antianxiety medications 7 out of 7 days in the look back period; -Diagnosis of Alzheimer's (a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), Dementia, and Anxiety disorder. Review of the resident's POS, dated March 2023, showed an order dated 12/1/22 for Seroquel (Quetiapine-antipsychotic) 25mg, give 37.5mg by mouth two times a day related to for dementia. Review of the resident's medical record showed the record did not contain an appropriate diagnosis. 5. During an interview on 3/3/23 at 1:50 P.M., the DON and administrator said upon admissions, the pharmacist reviews resident medications and diagnoses and can make recommendations; the quality assurance team monitors all initial and subsequent pharmacist recommendations and follow through with the physician for changes recommended. During an interview on 3/3/23 at 3:53 P.M., Licensed Practical Nurse (LPN) A said the doctors are responsible for providing the diagnosis on resident medications. Once a month the Pharmacist reviews the medications and then gives recommendations.

Based on observation, interviews, and record review, the facility staff failed to ensure the ice bin drained through an air gap, to maintain the kitchen environment in a clean and sanitary manner, to perform hand hygiene as often as necessary, and to properly store open food to prevent cross contamination and outdated usage. This had the potential to affect all facility occupants. The census was 48. 1. Review of the facility's policies showed the facility did not have a policy for the ice machine. Observation on 3/1/23 at 10:40 A.M., showed the ice machine, located in the kitchen, did not drain through an air gap, and the bottom ¼ inch of the drain pipe contained a black substance. Further observation showed staff used the ice machine for resident meal service. During an interview on 3/1/23 at 2:54 P.M., the dietary director (DD) and the dietary manager (DM) said an outside company inspected the ice machine last week, and they did not mention the air gap. They said the ice machine is used for the residents' meals, and it should drain through an air gap. The DD and DM said the facility did not have a policy for the ice machine. During an interview on 3/1/23 at 3:22 P.M., the administrator said the DD and the DM are responsible to ensure the ice machine is inspected and maintained according to code. She said the ice machine is used for the residents, but she was not aware it should drain through an air gap. The administrator said the facility did not have a policy for the ice machine. 2. Review of the facility's Weekly Tasks policy, undated, showed the policy did not address cleaning of the ceiling, light fixtures, and sprinkler heads. Observation on 3/1/23 at 10:50 A.M., showed the ceiling, light fixtures, and sprinkler heads throughout the kitchen visibly dirty with dust. Further observation showed staff prepared residents' lunch under the dusty items. During an interview on 3/1/23 at 2:54 P.M., the dietary director (DD) and the dietary manager (DM) said dietary staff clean their work areas daily, but no one cleans the ceilings, light fixtures, or sprinkler heads. The DD and the DM said they did not know how to clean these areas. During an interview on 3/1/23 at 3:22 P.M., the administrator said the DD and the DM are responsible to ensure the kitchen is cleaned and maintained in a sanitary manner. She said dietary staff clean the kitchen daily, and it is expected the ceiling, light fixtures, and sprinkler heads would be included on the cleaning schedule. 3. Review of the facility's Handwashing and Glove Usage policy, undated, showed: - Before food preparation or handling, staff are to wash hands thoroughly; - Once hands are properly washed, gloves must be n prior to contact with food items; - If employee touches any other item, person, or themselves, they are to dispose of soiled gloves, wash hands, and put on fresh gloves. Observation on 3/1/23 at 10:57 A.M., shows [NAME] F entered the kitchen and touched food items in the reach-in refrigerator. He/she walked in and out the walk-in refrigerators, touched the door handles, and other food items. [NAME] F did not perform hand hygiene when entering the kitchen. Observation on 3/1/23 at 11:04 A.M., showed [NAME] G poured French fries onto a baking sheet, discarded the bag into the trash can, and touched the trash can lid with the side of his/her hand. The cook continued to prepare the residents' lunch. [NAME] G did not perform hand hygiene after touching the trash can lid. Observation on 3/1/23 at 11:12 A.M., showed [NAME] H took medication by mouth. Further observation showed [NAME] H did not perform hand hygiene after he/she took the medication and before he/she touched food related items. Observation on 3/1/23 at 11:15 A.M., showed Dietary I entered the kitchen and wore gloves on both hands. The cook touched the kitchen door, the refrigerator doors, and two pies for resident lunch service. Dietary I did not remove gloves and perform hand hygiene when he/she entered the kitchen and before touching food and food related equipment. Observation on 3/1/23 at 11:20 A.M., showed [NAME] H wore gloves and prepared residents' lunch meal. Further observation showed the cook touched a foot stool with his/her gloved hands and continued to prepare the residents' lunch meal. [NAME] H did not remove his/her gloves and perform hand hygiene before or after touching the foot stool and before touching resident food items. Observation on 3/1/23 at 11:26 A.M., showed [NAME] J touched his/her face mask with his/her bare hand to the front of the mask. The cook did not perform hand hygiene after touching his/her face mask and before touching clean dishes. Observation on 3/1/23 at 11:44 A.M., showed dietary aide (DA) K touched his/her face mask with his/her bare hand to the front of the face mask. The DA picked up a resident lunch plate, with his/her fingers on the food surface. DA K did not perform hand hygiene after touching his/her face mask and before touching food related items. Observation on 3/1/23 at 11:55 A.M., showed DA L touched his/her face mask with his/her bare hand to the front of the face mask. The DA touched an ice cream scoop, resident cups, and resident plates. DA L did not perform hand hygiene after touching his/her face mask and before touching food related items. During an interview on 3/1/23 at 2:54 P.M., the dietary director (DD) and the dietary manager (DM) said dietary staff should perform hand washing when they enter the kitchen, when they put on or take off gloves, when moving from a dirty to a clean task, after touching their face masks, and after taking medication. They said staff should remove gloves and perform hand washing after each task. They said the facility has a policy on hand washing and glove use, and all staff have been trained on the policy. During an interview on 3/1/23 at 3:22 P.M., the administrator said the DD and the DM are responsible to ensure the kitchen staff use gloves and perform hand washing according to policy. She said it is expected dietary staff perform hand washing when they enter the kitchen, when they put on or take off gloves, when moving from a dirty to a clean task, after touching their face masks, and after taking medication. 4. Review of the facility's Food Safety policy, undated, showed: - Guarantee food is dated and labeled; indicate an expiration date for all items; - Food must be stored in airtight containers; - Employ safe food handling and infection control practices at all times to avoid cross-contamination. Observation on 3/1/23 at 1:34 P.M., of the pantry, showed: - Three open bags of penne pasta undated; - One open bag of pasta undated; - Two open bags of macaroni undated; - One open bag of brown macaroni undated; - One open bag of brown penne pasta undated; - Two open bags of brown spaghetti undated; - One package of taco seasoning unprotected; - One package of oatmeal undated; - One package of pancake mix undated; - One package of tortillas undated; - One package of tortilla chips undated; - One open package buttermilk biscuit mix dated 5/17/21; - One unopened package buttermilk biscuit mix dated 5/17/22. Further observation showed an expiration date on the package 4/8/22. During an interview on 3/1/23 at 2:54 P.M., the dietary director (DD) and the dietary manager (DM) said dietary staff label, date, and seal all food in the pantry. They said the facility has a supply specialist who checks the panty two times weekly. The DD and the DM said it is expected food would be discarded after the expiration date on the package. They said the facility has a policy on food storage and all staff have been trained on the policy. During an interview on 3/1/23 at 3:22 P.M., the administrator said the DD and the DM are responsible to ensure food items are stored according to policy. She said it is expected dietary staff label and date all food and discard outdated and expired food. The administrator said all food items should be sealed to prevent contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care and communication between the facility and two local hospice providers (Hospice A and Hospice B) for four residents (Resident #3, #24 #36, and #40) receiving Hospice services. The facility census was 48. 1. Review of the facility's Hospice A Hospice and Respite Care Service Agreement, dated 1/26/23, showed: -Plan of Care: a written plan prepared for each Hospice patient, containing an assessment of the patient's needs, identification of services to be provided, and a detailed description of the scope and frequency of services needed to meet the patient's and his or her family's needs; -Hospice will furnish a copy of each Hospice patient's Plan of Care to the facility at the time of the resident's admission into Hospice program; -Quality Improvement: The Hospice and Facility representatives shall document and keep written records of all such communications and shall document that the services provided are furnished in accordance with the terms of this agreement. -Medical Record: Facility shall prepare and maintain medical records for each hospice patent receiving services pursuant to the is agreement in accordance with all applicable federal and state laws, rules, and regulations and generally accepted medical record practices and shall complete such records in the same timely manner as required by the staff personnel of Hospice. The medical records shall consist of at least progress notes and clinical notes describing all services and events. Review of the facility's Inpatient Care Services Agreement for Hospice B, dated 11/20/19, showed: -Hospice shall communicate to Skilled Nursing Facility (SNF) any changes in condition of patients which require updating the Plan of Care for each patient, and provide SNF with the updated Plan of Care, if applicable. -Manner of Communication: All communications between the Hospice and SNF pertaining to the care and services provided to the Patient shall be documented in the Patient's clinical record. 2. Review of Resident's #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/10/23, showed: -The resident is on Hospice; -The resident has a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 2/28/23, showed the resident was listed as currently receiving hospice services. Review of the resident's Progress Note, dated 2/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 2/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. 3. Review of Resident #24's significant change MDS, dated [DATE], showed: -The resident is on Hospice; -The resident has a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 2/28/23, showed the resident was listed as currently receiving hospice services. Review of the resident's Progress Notes, dated 2/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 2/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. 4. Review of Resident #36's quarterly MDS, dated [DATE], showed: -The resident is on hospice; -The resident has a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 2/28/23, showed the resident was listed as currently receiving hospice services. Review of the resident's Progress Notes, dated 2/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 2/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. 5. Review of Resident's #40's MDS, dated [DATE], showed: -The resident is on Hospice; -The resident has a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 2/28/23, showed the resident was listed as currently receiving hospice services. Review of the resident's Progress Notes, dated 2/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 2/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. During an interview on 3/3/23 at 1:50 P.M., the Director of Nursing (DON) and administrator said charting is done about hospice residents by exception (a method of medical notation in which nurses only provide notes if there are deviations from a patient's expected disease process or baseline). A hospice nurse reports to the charge nurse and the charge nurse would enter the documentation. Regular information is passed verbally from hospice to nursing and the families and the facility does not have written documentation of this information or communication. The administrator and DON said there was no particular Hospice plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to maintain proper infection control practices for two resident's (Resident #5 and #12) catheters, failed to perform hand hygiene and change soiled gloves during incontinent care and/or care for three residents (Resident #5, #17, and #39), and failed to clean wound care equipment for one resident (Resident #39). Additionally, the facility failed to ensure all employees were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step Mantoux test (a skin test to determine whether a person in infected with determining whether a person is infected with tuberculosis) was completed and documented in accordance with their policy for two out of ten sampled employees. The facility census was 48. 1. Review of the Center for Disease Control's Catheter-Associated Urinary Tract Infections, reviewed November 5, 2015, Proper Techniques for Urinary Catheter Maintenance showed staff are directed as follows: -Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. -Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Review of the facility's Hand Hygiene Policy, revised October 2018, showed staff are directed as follows: Some of the times when hand hygiene is to be performed include the following (Even if gloves are used): -Before and after contact with the resident; -After removing personal protective equipment (e.g., gloves, gown, facemask); -Before and after assisting the resident with personal care; -Before and after changing a dressing; -Before and after assisting a resident with toileting; -After handling soiled or used linens, dressings, bedpans, catheters and urinals; -After removing gloves and/or aprons; Additional Instructions: -Gloves are not a substitution for hand hygiene. Review of the facility's Resident Peri-Care Policy, dated October 1, 2022, showed staff are directed to thoroughly wash hands and apply gloves before beginning peri-care regimen. Review of the Facility's Peri-care with Catheter Competency check off Sheet, not dated, showed staff are checked off on the following; -Wash hands and put on gloves; -Catheter should be placed below the hip level; -Remove gloves and dispose of appropriately. 2. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 1/13/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive, two or more persons physical assistance for bed mobility, transfers, dressing, personal hygiene and toileting; -Had an indwelling catheter; -Always incontinent of bowel. Observation on 3/1/23 at 2:10 P.M., showed Certified Nursing Assistant (CNA) B and Certified Medication Technician (CMT) C entered the resident's room to provide incontinence care. CMT C leaned behind the resident's wheelchair, unhooked the catheter bag from the wheelchair and tossed the catheter bag on the floor in front of the resident's wheelchair. CMT C held the catheter bag above the height of the resident's waist when he/she moved the resident from the wheelchair to the bed. The CMT did not change his/her gloves or perform hand hygiene after he/she removed the resident's pants, brief, provided catheter and incontinence care or before he/she placed a clean brief under the resident. CMT C applied barrier cream on the resident's back side and used a wipe to clean the barrier cream off the gloves. He/She positioned the resident and attached the brief with the same gloves. The CMT did not perform hand hygiene in between glove changes, before he/she changed out the resident's catheter bag. 3. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Required limited physical assistance for dressing, supervision for personal hygiene and dressing, and independent with bed mobility and transfers; -Had an indwelling catheter; -Occasionally incontinent of bowel; -Diagnoses of Alzheimer's Disease, traumatic brain injury, and obstructive uropathy (a condition where the flow of urine is blocked). Review of the resident's Progress notes, dated 2/19/23 showed the resident was diagnosed and treated for a urinary tract infection on 2/19/23 and subsequently admitted to the hospital on [DATE] and diagnosed with sepsis (a body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death). Observation on 2/28/23 at 2:23 P.M., showed the resident in bed with his/her catheter bag on the floor. 4. Review of resident #17's quarterly MDS, dated [DATE], showed staff assessed the assessed the resident as follows: -Moderate cognitive impairment; -Totally dependent on staff for toileting and bathing; -Lower extremity impairment on both sides; -Always incontinent of bowel and bladder; -Diagnosis of dementia. Observation on 3/1/23 at 2:20 P.M., showed CNA I and CNA J in the resident's room, the resident was in the process of being sat on the toilet. CNA I did not change his/her gloves after he/she removed the resident's soiled brief and sat the resident on the toilet or before he/she cleaned the resident's perineal area with wipes, applied a clean brief, and pulled up the resident's pants. During an interview on 3/1/23 at 2:45 P.M., CNA I said he/she should have changed his/her gloves after providing care and before he/she put on the resident's clean brief. 5. Review of Resident #39's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Had an ostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); -Diagnosis of rectal fistula (is a small, infected passageway that can develop between the end of the bowel and the skin surrounding the anus) and anal abscess (collection of pus, usually caused by a bacterial infection). Observation on 3/1/23 at 2:49 P.M., showed Licensed Practical Nurse (LPN) D and the Director of Nursing (DON) entered the resident's room to perform wound care. DON and LPN D did not perform hand hygiene before they applied gloves. LPN D placed a barrier and the DON placed wound care supplies on the barrier. The DON removed the wound packing from the bottle and LPN D reached into his/her pocket and pulled out scissors. The DON cut the wound packing with the scissors and did not clean the scissors first. LPN D used the same scissors to cut the dressing tape. 6. During an interview on 3/3/23 at 3:53 P.M., LPN A said catheter bags should never be on the floor due to risk of contamination. He/She said the catheter bag height should remain below waste level at all times. Staff should wash hands when they are soiled, after providing care to residents, after taking off gloves, before touching food, and should sanitize before walking into a resident's room. He/She said gloves should be changed when going from a dirty to clean procedure, after every resident, and after touching bodily fluids. Gloves are one use only and should never be wiped off instead of changed. He/She said scissors from your pocket should not be used to cut wound dressings or packing. He/She said the scissors should be cleaned before using and not kept in staff member's pockets to reduce the spread of bacteria. During an interview on 3/3/23 at 4:00 P.M., CNA F said when you provide care for a resident, you enter the room, wash your hands and put on gloves. CNA F said after you finish a dirty task, you should change your gloves and wash or sanitize hands before doing the clean task. The CNA said you should wash your hands before you leave the resident's room. During an interview on 3/3/23 at 1:50 P.M., the DON and administrator said hand hygiene should occur every time a person enters and exits a resident room, and any time providing care staff should have on gloves. If staff move hands from a dirty area to a cleaner area, gloves should be removed, hands sanitized, and new gloves put on before the cleaner area is touched. Catheter bags should not be placed on the floor. Catheter bags should be below the height of the resident's waist. 7. Review of the facility's Pre-Employment Medical Policy, undated, showed: A physical examination within 30 days including a Mantoux test, is required following an offer of employment. The Mantoux test results must be read prior to the first day of work. If there is no documented history of a negative Mantoux in the last 12 months the two-step method will be used. Review of LPN G, a current employee, employee file showed: -Hire date 1/19/22; -First PPD not administered until 3/9/22 and read on 3/11/22. Review of Housekeeper H, a current employee, employee file showed: -Hire date of 2/17/23; -Review showed staff did not document they administered a Mantoux test or the employee had a negative Mantoux in the last 12 months. During an interview on 3/3/23 at 1:50 P.M., the DON and administrator said new employees are screened for TB within one month and once a year thereafter.