**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an effective pest control program to address rodents in resident rooms. The facility census was 172. Review of the facility policy for Pest Control with a revision date of 10/2022 showed: -Purpose: to ensure that the facility is free of exposure to pests to include mice; -The Director of Environmental Services is the designated coordinator for this facility. This person acts as a liaison between the building occupants and the pest management provider; -Regular inspections will be performed by both the Director of Environmental Services/designee and the contracted pest management professional. They will note situations that are conducive to pest populations and recommend repairs, sealing of pest entry entries, clutter reduction, improved sanitation and monitoring procedures; -Proper sanitation will be maintained, and clutter reduced to present food and harborage for pests. Observation on 8/23/24 at 9:50 A.M. showed: -room [ROOM NUMBER] was rodent feces in the three drawer cabinet the second and bottom drawer that contained the resident's clothing; -room [ROOM NUMBER] numerous rodent feces behind the cabinet that housed a television. The cabinet had three drawers with resident clothing in each drawer. Each drawer contained numerous rodent feces with small pieces of what appeared to be a wrapper torn in small pieces scattered throughout the rodent feces; -room [ROOM NUMBER] bathroom with numerous rodent feces around the base of the toilet, on the sink and a two drawer cabinet; -room [ROOM NUMBER] - numerous rodent feces in the nightstand drawers; -room [ROOM NUMBER] the bottom drawer of a three drawer cabinet with numerous rodent feces among resident clothing. There were also rodent feces in the top drawer of the night stand by the head of the resident's bed; -room [ROOM NUMBER] numerous rodent feces in the second drawer of the three drawer cabinet; -room [ROOM NUMBER] the closet floor was covered with rodent feces; -room [ROOM NUMBER] numerous rodent feces in the second drawer of the three drawer cabinet closest to the resident's bed and on the floor of the closet. During an interview on 8/23/24 at 11:15 A.M. Certified Nurse Aide (CNA) A said he/she had seen rodent feces in the resident rooms. During an interview on 8/23/24 at 11:20 A.M. Housekeeper B said: -He/She has seen some mice recently in the glue traps in the utility rooms, resident rooms, and dining rooms; -If he/she see's mouse droppings in the residents' rooms he/she will clean the room; -He/She does not clean the resident cabinet drawers. During an interview on 8/23/24 at 11:30 A.M. Licensed Practical Nurse (LPN) C said: -If a mouse is seen, then a maintenance work order is filled out, the work orders are kept at the front desk; -Housekeeping will sweep and mop the floors, but he/she does not know who was responsible for keeping the resident cabinets and nightstands clean. During an interview on 8/23/24 at 11:40 A.M. the Housekeeping Supervisor said: -She has been told about mice being seen on the halls and in the residents' rooms; -Maintenance has put glue traps out and the contracted pest control has traps set up on the outside. During an interview won 8/23/24 at 11:55 A.M. LPN D said: -He/She has seen mice in the hall ways and has told the maintenance director who will put out glue boards; -He/She has seen some come out of the air conditioning units. Observation on 8/23/24 at 12:15 P.M. of room [ROOM NUMBER] showed a cabinet with a television sat in front of the sliding patio doors. Between the cabinet and the patio doors there were copious rodent feces. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 7/1/24 showed: -Able to make self understood and able to understand others; -Alert and oriented and able to make appropriate decisions. During an interview on 8/23/24 at 1:00 P.M. the resident said: -He/She has had mice in his/her room; -The mice have come out of the air conditioning unit and then run onto his/her bed; -Maintenance will put glue boards in his/her room and the mice will go away for a while, but will come back. 3. During an interview on 8/23/24 at 1:00 P.M. the Maintenance Director said: -He has been dealing with a few rooms on the 200 hall with reports of mice, but not lately; -When he gets a report of mice, he will put down glue boards and notify the contracted pest control company; -There are glue traps set out in each servery in the cabinets; -The contracted pest control company has set out bait boxes on the outside of the facility on areas where the concrete comes up to the facility, but there are no bait boxes where there was only grass; -Rooms 200 through 208 are on the side of the building were there was only grass so there were no outside bait boxes. During an interview on 8/23/24 at 4:30 P.M. the Administrator said: -Staff are reporting when they see a mouse and the maintenance department puts out glue traps; -The staff should be cleaning the resident's rooms to keep the food in closed containers and when they see rodent feces, they should be cleaning it up. MO240812

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three residents (Resident #80 and #403) in a review of 35 sampled residents, were treated in a manner to maintain dignity and respect. The facility census was 149. Review of the facility's undated Residents' Rights policy, showed the following: Dignity and Respect: -Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. You have the right to expect that we will: 1. Treat you as an individual and assist you in getting the most out of the programs and services we offer; 4. Provide safeguards against any kinds of harsh or abusive treatment. 1. Review of Resident #403's care plan, dated 4/29/24, showed the following: -The resident is at risk for falls due to weakness; -The resident has a deficit in mobility related to weakness, current weight bearing status is weight bearing as tolerated, one person transfer; -The resident has a deficit in activities of daily living (ADL) self-care and impaired functional mobility related to hospitalization for stroke; -Provide assistance with ADLS as indicated. Review of the resident's admission Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff), dated 5/3/24, showed the following: -Cognitively intact; -Upper extremity impairment on one side; -Required supervision or touching assistance for toileting hygiene and rolling from left to right; -Always continent of bladder and bowel; -Diagnoses of stroke and diabetes; -Is taking a diuretic. During an interview on 5/7/24 at 3:05 P.M. and 5/10/24 at 1:35 P.M., the resident said the following: -He/She was incontinent and made a mess in the bathroom; -One of the aides (the resident did not know his/her name) came into his/her room; -The aide was mean and yelled at him/her and said, I'm on my lunch break!; -The aide was hateful about having to change him/her and got mad about him/her making a mess in the bathroom; -The aide ripped his/her brief and the blanket off and didn't even tell him/her what he/she was going to do; -He/She doesn't like the way that aide treats him/her. He/She told his/her family member about it the next day; -It really upset him/her and made him/her cry. During an interview on 5/10/24 at 10:15 A.M., the resident's family member said the following: -The resident called him/her earlier this week crying; -The resident said he/she had an accident (went to the bathroom in his/her pants); -The aide came in and was rude and didn't speak to the resident when spoken to ; -It upset him/her when the resident is in the facility and he/she is out of state and the resident called him/her crying; -This is the first time the resident has complained to him/her about treatment by a staff member. During an interview on 5/10/24 at 1:45 P.M., the Director of Nursing (DON) said the following: -The social worker did talk with the resident this week and the resident complained about a night staff member that was rude, but the resident did not know the staff member's name; -She was not aware the resident had a complaint about a staff member on Tuesday. 3. Review of Resident #80's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -No behaviors; -No rejection of care. Review of the resident Physician Order Sheet (POS), dated 5/2024, showed the following: -Diagnoses included Alzheimer's (progressive disease that destroys memory and other important mental functions), age related osteoporosis (condition in which bones become weak and brittle) with current pathological fracture (fracture due to a weakened bone); -Weight bear as tolerated (WBAT). Review of the resident's care plan, last revised 5/4/24, showed the following: -Impaired cognition related to Alzheimer's: Be patient and positive, maintain a calm environment and approach to the resident; -Resident can be physically and verbally abusive: Avoid power struggles with resident, Convey an attitude of acceptance toward the resident; -Activities of Daily Living: Cheerful dialogue with resident while providing care to encourage and maintain self esteem, provide peri-care after each incontinent episode, weight bear as tolerated with two staff assist. Observation on 5/13/24 at 2:30 P.M. showed the following: -Nurse Aide (NA) T and Certified Nurse Assistant (CNA) WW entered the resident's room where he/she sat in the a wheelchair; -They transferred the resident to bed with a sit to stand lift and performed incontinent care; -The resident cried out with cares; -Before exiting the room and within ear shot of the resident, NAT T said to the state surveyor, The resident (called by first name) is a cry baby. He/She likes to cry. During an interview on 5/14/24 at 1:45 P.M , NAT T said staff should not call a resident a cry baby and should treat resident's with dignity and respect. During an interview on 5/14/24 at 12:52 P.M. the DON said she would not expect staff to refer to a resident as a cry baby or state that he/she cried all the time within ear shot of the resident. This would be inappropriate. During a phone interview on 5/22/24 at 1:10 P.M., the administrator said she would expect staff to treat residents with dignity and respect.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #72), a resident with identified history of ingesting non-food items such as Styrofoam, in a review of 35 sampled residents, was served food on Styrofoam. Additionally, the facility failed to ensure staff safely transferred one additional resident, (Resident #306), with a gait belt, when staff assisted and lifted the resident for transfer by placing their hands underneath the resident's arms during the transfer. The facility census was 149. Review of the facility policy for Gait Belt Use, dated 7/2015, showed: -Purpose: to provide control and balance of a resident that required physical assistance for transfers and gait; -Gait belts should be used with all residents that require physical lifting assistance for transfers and/or ambulation; -Wrap the gait belt around the resident's waist and pull the strap through the buckle to tighten; -Make sure you can slide your open (flat) hand between the belt and the resident; -Face the resident when assisting to standing potion and place both hands on the belt; -Once standing, assistant should position dominate hand on the gait belt at the center of the resident's back to assist with mobility. Review of the undated facility policy, Dining Servers: Guidelines for Safe Handling of Tableware, showed Dining Services staff will provide clean, well maintained tableware in a style and configuration comparable with the facilities dining services and in a manner that meets the individual needs of residents. 1. Review of Resident #306's face sheet showed he/she had diagnoses that included stroke with hemiplegia (paralysis on one side of the body), dysphagia (inability to swallow), diabetes and chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's care plan, dated 5/7/24, showed no care plan to direct staff on how the resident transferred or what equipment to use when transferring the resident. Observation on 5/09/24 at 11:11 A.M. showed the following: -Certified Nurse Aide (CNA) MM and CNA NN entered the resident's room. The resident sat in a wheelchair and CNA MM explained to the resident they were going to lay the resident down in the bed; -CNA MM removed a gait belt from around his/her waist, put it around the resident's waist and moved the resident in the wheelchair to the side of the bed; -CNA MM and CNA NN put one hand on the gait belt and one arm under the resident's arms; -The CNA's lifted the resident out of the wheelchair and as they lifted the resident, the resident's shoulders raised up; -Each CNA pulled on the resident's arm to help him/her stand; -The resident had no control on the right side of his/her body and his/her right foot drug the floor as the CNA's pivoted him/her from the chair to the bed; -The CNA's sat the resident on the side of the bed and CNA MM swung the resident's legs onto the bed while CNA NN guided the resident's upper body down to the bed. During an interview on 5/9/24 at 11:30 A.M., CNA MM said if a resident is a two person transfer with a gait belt, each person would put one hand on the gait belt and the other arm/hand under the resident's arm for stability. During an interview on 5/9/24 at 12:30 P.M., CNA NN said the following: -This was the first time he/she had worked with the resident; -He/She did not know how the resident transferred; -He/She should have had both hands on the gait belt to transfer the resident. During an interview on 5/9/24 at 11:45 A.M., Licensed Practical Nurse (LPN) Z said staff should always have their hands on the gait belt when transferring a resident, never under a resident's arms. During an interview on 4/14/24 at 12:52 P.M., the Director of Nursing (DON) said she would expect staff to have both hands on the gait belt when transferring a resident, and never under the resident's arms. 2. Review of Resident #72's face sheet showed the following: -He/She had a diagnosis of Alzheimer's disease (a form of dementia), cognitive communication deficit (difficulty communicating because of injury to the brain that controls the ability to think), unspecified dementia with behavioral disturbance, and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness); -He/She had a legal guardian; -He/She resided on the division unit (an Alzheimer's/dementia unit). Review of the resident's care plan showed the following: -Problem start date: 5/24/21 - The resident has the potential for nutritional deficits related to a recent hospital stay and a regular diet which consists of finger foods; -Approach start date: 5/24/21 - Assess the residents' ability to feed him/herself and provide assistance/supervision as needed; -Problem start date: 12/05/22 - The resident had ingested and/or has the intermittent desire to ingest non-food items (Styrofoam from dinner plates); -Goal target date: 7/29/23 - The resident will not ingest non-food items and/or experience injury from ingestion of non-food items; -Approach start date: 12/05/22: 1. The resident will be observed during meals for any attempts at ingesting non-food items; 3. The resident will not be served meals/drinks on/in Styrofoam plates/cups or be given plastic silverware. Review of the resident's quarterly Minimum Data Set (MDS), (a federally mandated assessment completed by facility staff), dated 8/27/23 and 2/26/24, showed the following: -The Brief Interview for Mental Status (BIMS) (identifies cognition) could not be conducted as the resident is rarely/never understood; -Severely impaired for both short- and long-term memory; -His/Her cognition skills for daily decision making regarding tasks of daily life were severely impaired and he/she never/rarely made decisions; -He/She had behaviors of inattention and disorganized thinking were continuously present and did not fluctuate; -He/She required help with setting up and cleaning up with eating, but could eat without assistance. Review of the resident's physician orders, dated May 2024, showed the following: -The resident's diet was regular and to serve finger foods; -The resident level of orientation was to his/herself. Observation on 5//7/24 at 12:30 P.M. showed the following: -The resident sat a table in the dining room eating; -Staff served the resident his/her drink in a Styrofoam cup. No staff member sat with the resident at his/her table. The resident bit down on a Styrofoam cup he/she was drinking from and staff put on gloves to get the Styrofoam out of his/her mouth. The resident clamped his/her teeth down together making it difficult for staff to retrieve Styrofoam from his/her mouth. LPN DD was able to retrieve a piece of Styrofoam about the size of a dime and the bite mark missing from the Styrofoam cup looked to be about one-half dollar in size. Review of the resident's progress note, dated 5/07/24 at 12:38 P.M., showed staff documented the following: -At lunch, the resident was observed taking a bite out of a Styrofoam cup; -LPN DD immediately attempted to remove the Styrofoam from the resident's mouth; -After comparing the missing piece from the cup, it was determined the resident did ingest some of the Styrofoam; -Call placed to nursing administration, the physician and the guardian. Review of the resident's physician orders, dated 5/07/24, showed a new order to monitor for any adverse reaction due to eating a piece of Styrofoam cup, include findings in progress notes every shift (start 5/07/24). Review of the resident's care plan, revised 5/08/24, showed no additional documentation added to the plan. Review of the facility's division care schedule, a document listing twenty four care areas in a grid format for ease of care for each resident on the unit dated 5/08/24, showed the following: -The care schedule is kept at the division nursing desk; -Keep the resident from wandering around the division dining area during meals because he/she will eat leftovers from other residents. Observation of the resident in the dining room on 5/09/24 at 12:57 P.M., showed staff served the resident grapes in a Styrofoam bowl. The resident ate the grapes from the bowl, no staff member sat with the resident or supervised the resident. Observation of the resident in the dining room on 5/13/24 at 12:30 P.M., showed the resident sat at a table eating his/her noon meal. Staff served the resident fruit in a Styrofoam bowl. The resident picked up the partially fruit filled bowl and used it to move his/her hair out of his/her eyes. While he/she held the Styrofoam bowl, he/she rubbed the bowl on his/her left cheek and then started licking the bowl with his/her tongue and moved the rim of the bowl to his/her mouth. No staff monitored the resident. Review of the facility's, undated, dietary restrictions chart, located in the division 200 servery, when? if on 5/7 before the 12:30 P.M. observation, please move this statement there showed the resident required finger foods and a special cup. (Found at the end of the survey after all of the meals had been served) During an interview on 5/23/24 at 9:17 A.M., the resident's guardian/family member, said the following: -Staff should never serve the resident food in Styrofoam, the resident had ingested a piece of Styrofoam when this had occurred; -He/She would have expected staff serve the resident food in something the resident could not bite through; -The resident would mistake Styrofoam for food because of his/her cognition. During an interview 5/13/24 at 3:07 P.M., Certified Medication Technician (CMT) FF said the following: -He/She did not believe any resident on the division should have been served any food on/in Styrofoam because it was unsafe, even if the dishwasher was not working; -He/She would go off of the dietary restrictions and instructions from the nurse when serving the resident his/her food; -He/She was unaware the resident had eaten a piece of Styrofoam earlier that week. During an interview on 5/07/24 at 12:37 P.M. and 5/22/24 at 9:26 A.M., LPN DD said the following: -The facility dishwasher had been broken for about one week and staff served the residents food in/on Styrofoam; -He/She was not aware the resident's care plan showed he/she was not supposed to be served food on/in Styrofoam; -He/She was not aware the resident had ingested Styrofoam before 5/07/24. During an interview on 5/13/24 at 2:39 P.M. and 5/14/23 at 10:55 A.M., LPN EE said the following: -After receiving report, he/she knew the resident needed to be served food in a plastic cup instead of Styrofoam; -He/She had asked the dietary manager earlier today (5/13/24) to serve the resident's fruit in a plastic cup; -All of the staff should be following the resident care plans; -The aides bring the food to the residents, but it was still the nurse's responsibility to ensure no Styrofoam was given to the resident; -On 5/13/24 and 5/14/24, he/she had instructed all of the aides at the beginning of the shift, there should be no food served in Styrofoam to the resident; -Staff served the resident fruit in a Styrofoam bowl during lunch on 5/13/24; -He/She did not know why the resident had no Styrofoam added to his/her care plan in December 2022. During an interview on 5/13/24 at 2:51 P.M., the dietary manager said the following: -He/She was unaware the resident was not supposed to be served food on Styrofoam; -Dietary staff members prepare fruit in the Styrofoam bowls and delivered it to the division; -If the resident was not supposed to have the Styrofoam, the division staff could empty the food in a plastic cup to be served to the resident. During an interview on 5/14/24 at 12:26, the dietician said he/she would expect a resident to not be served food on Styrofoam if the resident could not safely be served on Styrofoam. There were plastic items the dietary staff could use for food service. During an interview on 5/14/24 at 12:52 P.M., the Director of Nursing (DON), said the following: -She would not expect a resident to be served food on/in Styrofoam if the resident had taken a bite out of a Styrofoam cup the prior day; -She did not feel it was safe for division 200 to be served food on/in Styrofoam even with the dishwasher being out of service; -It was ultimately the division nurses responsibility to ensure the resident was not served food in/on Styrofoam; -Dietary should be notified by the nursing staff as to what a resident should be served food on/in if the resident could not be safely served food on/in Styrofoam. During a phone interview on 5/22/24 at 1:10 P.M., the administrator said the following: -She would not expect a resident to be served food on Styrofoam if they had taken a bite out of a Styrofoam cup the day before unless closely monitored; -She would expect staff to follow a resident's care plan; -She would not expect a resident to be served food on Styrofoam if their care plan from 12/2022 said the resident should not be served food on Styrofoam; -It would be resident specific if it is safe for division 200 to receive food served on/in Styrofoam; -Staff could wash dishes on division 200; they are using some regular dishes even with the dishwasher being broken; -Nursing and or dietary were responsible to ensure the resident would not receive food on/in Styrofoam.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide food in a form as ordered by the physician, monitor weights, notify the physician of the refusal of nutritional supplements and weights for two residents with significant weight loss, (Resident #59 and #305), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy for Weight Monitoring, dated 11/2018, showed: -Purpose: to obtain accurate weight of each resident and maintain control of weight changes; -Residents are weighed on admission, weekly for the first four weeks and monthly thereafter, unless otherwise ordered by nursing order or the attending physician; -Residents are weighed upon admission and on a weekly basis for the first four weeks to establish a baseline weight; -Any resident with a weight gain/loss of five pounds will be re-weighed within 24 hours; -Weight reports will be monitored by the Charge Nurses, Registered Dietician (RD)/Dining Services Director and Director of Nursing. The weight management committee will meet monthly to discuss residents with fluctuation; -Significant weight loss is defined as residents with weight loss of five percent (%) or more in the last 30 days, seven and one-half % or more in the last three months or 10% or more in the last six months; -Residents with unplanned weight loss/gain will be weighed weekly or as ordered by the physician. A weight change follow-up event will be completed by the Charge Nurse in the electronic health record (EHR); -The charge nurse is responsible to immediately notify the attending physician, registered dietitian and resident representative of weight loss/gain; -Any significant weight loss or gain is to be noted in the progress notes section in the EHR, as to the reason why the resident has weight loss or gain with any interventions. 1. Review of Resident #59's significant change Minimum Data Set (MDS), (a federally mandated assessment instrument completed by facility staff), dated 10/25/23, showed the following: -Cognitively intact; -Swallowing disorders (holding food, coughing/choking and difficulty/pain with swallowing); -Weight of 158 pounds (lbs); -Mechanically altered diet while a resident; -No weight loss/gain; -Set up only for eating. Review of the resident's weight record for 2024 showed the following: -February weight of 148.4 pounds; -March weight of 43 pounds (5.59 % loss for one month). Review of the resident's April 2024 physician order sheets (POS) showed and order for a mechanical soft diet (12/8/22). Review of the resident's weight record showed staff documented the resident's weight as 135 lbs on 4/12/24. Review of the resident's progress note, dated 4/15/24, and authored by the Registered Dietician (RD), showed the following: -Current body weight 135 lbs, 3/8/24 weight 143 lbs, 1/7/24 weight 153.4 lbs, weight 10/1/23 158 lbs. Weight down 8 lbs/5.6% for one month, 18 lbs/12% for three months and 23 lbs/14.6% for six months. Weight loss is significant at one, three and six months. Body Mass Index (BMI)=23.91 indicating adequate weight/height. On mechanical soft diet. By mouth intakes variable, refuses Glucerna (nutritional supplement) so will try to change to Ensure Clear (nutritional supplement) two times daily to provide 500 kcal and 18 grams protein if consumed. Often refuses care. Eats all meals in bed. On hospice for comfort and support. Resident may continue to lose weight if intake remains poor. Encourage food/fluid intakes as tolerated. Monitor weight, by mouth intakes and skin. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No swallowing disorders; -Weight of 135 pounds; -Mechanically altered diet; -Set up only for meals; -No weight loss/gain. Review of the resident's April 2024 POS showed a new order for Ensure clear two times daily, scheduled for 7:15 A.M. -11:15 A.M. and 3:15 P.M. -6:45 P.M. (order date of 4/15/24). Review of the resident's care plan, last revised 4/16/24 showed the following: -Weight loss; -Monitor need for changing diet consistency to increase ease of eating; -Monitor/record weight weekly for four weeks then monthly (4/16/24); -Upper dentures; -Provide bedtime snack; -Mechanical soft diet; -Assess ability to feed self. Provide assistance/supervision as needed; -Monitor for signs/symptoms of dysphagia (difficulty swallowing), coughing and choking with liquid and/or meal intake; -Ensure Plus (nutritional shake) two times daily. Review of the resident's April 2024 POS showed a new order for weekly weights times four weeks (4/19/24 to 5/17/24). Review of the resident's weight record showed the following: -No documentation to show staff obtained the resident's weight on 4/16/24; no documentation the resident refused; -No documentation to show staff obtained the resident's weight on 4/19/24; no documentation the resident refused; -Staff documented on 4/21/24 that the resident's weight was not taken (no documentation of a reason why); -No documentation to show staff obtained the resident's weight on 4/26/24; no documentation the resident refused. Review of the resident's medication administration record (MAR) dated 4/2024 showed the following: -Resident refused supplements 21 out of the 29 times they were scheduled; -Weights were documented as not taken on 4/21 and 4/28, with no reason why documented. Review of the resident's progress notes from 4/1/24 to 4/30/24, showed no documentation the resident's physician was notified of weight loss, concerns with obtaining weekly weights or supplemental refusals. Review of the resident's POS, dated 5/2024, showed the following: -Mechanical soft diet (12/8/22); -Ensure clear two times daily, scheduled for 7:15 A.M. -11:15 A.M. and 3:15 P.M. -6:45 P.M. (order date of 4/15/24); -Weekly weights times four weeks (4/19/24 to 5/17/24). Review of the resident's May 2024 MAR, from 5/1/24 to 5/6/24, showed one weight attempted on 5/5/24 and the resident refused. Review of the resident's progress notes from 5/1/24 to 5/6/24, showed no documentation staff notified the physician of the resident's refusal to obtain his/her weight. Review of the resident's weight record on 5/7/24 showed no documentation to show staff obtained the resident's weight on 5/3/24 and no documentation about the resident refusing to have his/her weight obtained on 5/5/24. During an interview on 5/7/24 at 12:21 P.M., the resident said staff did not bring desserts with trays and that he/she had to beg for them. Review of the lunch dietary spreadsheet, dated 5/8/24, showed staff was to prepare and serve minestrone soup, #8 ground Italian meat and cheese on hoagie bun, shredded lettuce, diced tomatoes, chopped steamed broccoli and a peach half for a mechanical soft diet order. Observation and interview on 5/8/24 at 1:53 P.M., showed the resident lay in bed with the head of the bed elevated. A Styrofoam plate sat on his/her lap and contained an Italian sub sandwich made up of ham, roast beef, salami and cheese. The meat was not cut up, mechanical soft or ground. The plate also contained a pickle, lettuce, an onion and a tomato (none were cut up or diced) and a cup of chocolate pudding. No peach half was served. The resident said he/she could not chew the food. Review of the supper dietary spreadsheet, dated 5/8/24, showed staff was to prepare and serve #8 diced tomato salad, #8 ground Salisbury steak with mushroom gravy, white rice, Normandy vegetables and canned ambrosia fruit salad for a mechanical soft diet order. Observation and interview on 5/8/24 at 8:14 P.M., showed the resident was in bed with the head elevated and his/her food on a Styrofoam plate which included a formed Salisbury steak (not ground with minimal gravy) and cooked broccoli/carrot vegetable mix and rice. There was no dessert (ambrosia fruit salad), however staff retrieved ice cream for the resident after he/she requested it. He/She had taken a few bites of the steak. The resident said he/she could not eat it as he/she had trouble swallowing the food. Review of the lunch dietary spreadsheet, dated 5/9/24, showed staff was to prepare and serve a green salad/dressing, #8 ground sole with tarter sauce, #8 mashed potatoes, Tuscany vegetables and canned fruit for a mechanical soft diet order. Observation and interview on 5/9/24 at 1:07 P.M. showed the resident in bed and his/her lunch tray in front of him/her. The tray contained a large, whole (not cut or ground) piece of breaded fish (no tarter sauce), a large, whole (not cut) potato wedges (not mashed potatoes), mixed vegetables with greens, coleslaw and no canned fruit (dessert). The resident said he/she could not eat the fish (tapping it with a fork) and requested a cheeseburger. Staff (Nurse Aide in Training (NAT) T ) brought a cheeseburger, whole and not ground, for the resident and exited the room. Review of the diet sheet (posted in the 600 unit servery) dated, 5/10/24 at 8:25 A.M., showed the resident took his/her meals in his/her room and his/her diet was listed as mechanical soft. Review of the resident's MAR, dated 5/2024, showed the following: -The resident refused Ensure Clear (ordered two times daily) 14 times from 5/1/24 to 5/13/24 out of the 26 times it was scheduled; -On 5/12/24, staff documented the resident was not weighed due to condition. Review of the resident's progress notes for May 2024 (through 5/14/24) showed no documentation staff notified the physician of the resident's refusal to obtain his/her weight or consume the ordered nutritional supplement. During an interview on 5/10/24 at 8:22 A.M., Dietary Aide G said the following: -He/She helped plate trays in the 600 unit servery; -They refer to the dietary sheet for diet orders which are updated and printed weekly; -He/She double checked the diet sheet (which sat atop the serving table on each end) to ensure it was correct; -The certified nurse aides (CNA's) stand at the servery door, report the resident name and diet order, and they in turn plate the food and the CNA's deliver the trays. During an interview on 5/9/24 at 3:12 P.M., Nurse Aide in Training (NAT) T said the following: -He/She worked regularly on the resident's unit; -He/She knew residents diets (regular, mechanical soft diet, puree); -Staff serving the resident meals should be aware of the resident's diet; -A mechanical diet should have ground meat; -He/She was not aware that the resident was on a mechanical soft diet; -The resident had said he/she did not like the ground meat; -Staff should cut up meat and other food if chunks were too big; -CNA's served meal trays to residents after telling the servery staff who they needed a tray for and what their diet was; -The servery staff would hand them the meal tray and they would deliver it to the resident either in the dining room or in their room. During an interview on 5/14/24 at 9:55 A.M. Certified Nurse Aide (CNA) II said the following: -He/She believed the resident was on a regular, NCS (no concentrated sweets) as he/she was a diabetic; -He/She was not aware that the resident was on a mechanical soft diet; -If a resident refused their ordered diet, he/she would expect staff to inform him/her; -Staff had not reported to him/her of the resident's refusal to eat his/her ordered diet. 2. Review of Resident #305's undated face sheet showed the following: -The resident admitted to the facility on [DATE]; -Diagnoses included dementia with anxiety, depression, and vitamin deficiency. Review of the resident's progress notes, dated 4/23/24 at 6:15 P.M., showed the resident refused most of his/her meal. He/She left the dining room early at dinner. The resident was yelling out for help as he/she did not know where his/her room was. Staff assisted the resident to his/her room and instructed the resident to wait for assistance to get into bed. Review of the resident's April 2024 POS showed the following: -Regular diet; -Weekly weights on Sundays; -May follow recommendations made by the RD. Review of the resident's weight record, dated 4/23/24, showed the resident weighed 192.2 pounds. Review of the resident's intake record for April 2024 showed the resident ate 26-50 percent (%) of his/her food at breakfast and lunch on 4/24/24. Review of the resident's progress notes, dated 4/24/24 at 4:03 P.M., showed the RD completed an initial nutrition assessment. The resident's current body weight was 192.2 pounds on 4/23/24. The resident was on a regular diet. His/Her oral intake was fair. The resident reported his/her appetite was good, and he/she liked most foods. Staff to encourage food/fluids intake and to monitor the resident's weight and intake. Review of the resident's intake record for April 2024 showed the following: -On 4/25/24, the resident ate 1-25% at breakfast and lunch; -On 4/26/24, the resident ate 1-25% at lunch. Review of the resident's weight record showed no documentation staff obtained a weekly weight as ordered on 4/28/24 (or during the week of 4/28/24 through 5/4/24). Review of the resident's intake record for April 2024 showed the following: -On 4/28/24, staff documented the resident did not eat at lunch; -On 4/29/24, the resident ate 1-25% at breakfast and lunch; -On 5/1/24, the resident ate 1-25% at breakfast and lunch; -No documentation of the resident's meal intakes after 5/1/24. (The RD recommended on 4/24 for staff to monitor the resident's intake.) Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition moderately impaired; -Moderate depression; -Supervision required for eating. -Weight 192 pounds; -No weight loss or gain. Review of the resident's weight record, dated 5/7/24, showed the resident weighed 180.8 pounds (11.4 pound weight loss, 5.9% loss in two weeks). Observation on 5/7/24 at 12:28 P.M. showed staff began to serve the lunch meal out of kitchenette, bringing meals out one meal at a time. The resident received his/her tray at 12:28 P.M. At 12:30 P.M., the resident left the dining room without eating his/her lunch meal. Staff was not in the dining room at this time and did not observe the resident leave. During an interview on 5/7/24 at 2:50 P.M., the resident said he/she did not remember why he/she did not eat lunch. He/She did not eat very much anymore. Review of the resident's progress notes, date 5/8/24 at 10:55 A.M., showed the RD completed a weight note. The resident's current body weight on 5/7/24 was 180.8 pounds. The resident's weight was 192.2 pounds on 4/23/24; weight down 11 pounds in one month, which was significant. The resident was on a regular diet. His/Her intake was generally good. The resident said he/she had a good appetite and ate most of what was on his/her plate. Recommend nutritional supplement every day to provide 350 kilocalories (kcal) and 13 grams (g) of protein. Staff to encourage food/fluid intakes and monitor weight and intakes. Observation on 5/8/24 at 12:36 P.M. showed staff began to serve the lunch meal. Observation on 5/8/24 at 12:59 P.M. showed the following: -The resident left the dining room after only eating a few bites of his/her meal; -Staff was not in the dining room during this time; -No staff observed the resident leave. Review of the resident's care plan, dated 5/8/24, showed the following: -The resident experienced weight loss; -Encourage oral intake of food and fluids; -Monitor need for changing diet consistency to increase ease of eating; -Monitor/record weight weekly for four weeks, then monthly. Notify the physician and family of significant weight change; -Offer available substitutes if resident has problems with the food being served. Review of the resident's May 2024 POS showed an order dated 5/8/24 for nutritional supplement every day with morning medication pass. Review of the resident's MAR, dated May 2024, showed the following: -On 5/9/24, the resident did not receive the nutritional supplement; the administration box said NONE (other days had percentages); -On 5/10/24, the resident did not receive the nutritional supplement; the administration box said NONE. Review of the resident's MAR, dated May 2024, showed the resident did not receive the ordered nutritional supplement on 5/13/24; the administration box said NONE. Review of the resident's weight record, on 5/14/24, showed no documentation staff had obtained the resident's weight on Sunday (per physician order), 5/12/24, and had not obtained a weight since 5/7/24. During an interview on 5/14/24 at 9:55 A.M., CNA II said the following: -Staff weigh the residents once a week on Sunday; -Oral intake comes up on the computer charting system for the CNA to complete for 10 days after admission; -If a resident did not eat his/her meal, he/she would report this to the charge nurse; -CNAs do not give nutritional supplements, only Certified Medication Technicians (CMTs). During interview on 5/14/24 at 12:45 P.M., CNA OO said the following: -Weights that needed to be obtained were placed (written) on the daily assignment sheet (by the nurse) at the nurses station for the CNA to obtain; -If a weight was needed, it was red in the computer charting system; -If a weight was not done the previous week, the CNA could not see it wasn't completed; -Weights are supposed to be documented in the computer. During an interview on 5/14/24 at 9:40 A.M., CMT LL said the following: -CMTs were responsible to give nutritional supplements if a nutritional supplement was ordered; -He/She asks residents (in general) if they wanted the nutritional supplement during the morning medication pass; -If a resident said they did not want a nutritional supplement, he/she would not give the resident one; -If a resident said they wanted a nutritional supplement, he/she would give them one after he/she completed the medication pass; -If a resident refused to take a nutritional supplement, he/she would notify the charge nurse; -If a resident received a nutritional supplement but did not drink it, he/she would notify the charge nurse. During an interview on 5/10/24 at 11:28 A.M., and 5/14/24 at 10:00 A.M., Licensed Practical Nurse (LPN) Z said the following: -Staff did not have to document meal intakes; -CMTs gave nutritional supplements if a nutritional supplement was ordered. During interview on 5/14/24 at 10:08 A.M., the Director of Nursing (DON) said the following: -Nursing administration entered new admission orders into the computer charting system; -Weight orders were put in with admission orders, and tasked to the CNAs for documentation; -Nurses would not see if the CNA completed the task; (obtaining weights as ordered); -Oral intake was recorded for seven days after admission; -CMTs were responsible for monitoring nutritional supplements. During an interview on 5/14/24 at 12:22 P.M., the RD said the following: -She would expect diet orders to be followed; -She would not expect a resident with an order for a mechanical soft diet to be served a regular diet; -A resident on a mechanical soft diet should not be served fish, potato wedges, Salisbury steak or Italian hoagies unless it was ground; -If a resident refused an ordered diet, he/she would expect staff to take the tray to the nurse, ensuring she was made aware and could then notify the physician; -CNA's and servers should be aware of diet orders. They should also refer to the list; -She could not say if Resident #59 being served the wrong diet was directly related to the weight loss as the resident's eating was variable; -They could speak with hospice regarding comfort foods for Resident #59; -Staff entered a standard order for weekly weights for the first four weeks and then monthly thereafter into the computer system on admission; -She looked at oral intakes but she also liked to observe the residents during meal times; (there was no documentation in the RD's notes to indicate observations had been made of either resident); -She met with the interdisciplinary team and gave her suggestions; -CMTs made him/her aware if a resident did not take their supplements. During an interview on 5/22/24 at 1:10 P.M., the Administrator said the following: -She would expect staff to follow orders; -Nursing who care for the residents should be aware of their diet orders (regular vs mechanical soft); -If a diet was refused he/she would expect staff to notify the family and physician; -The physician would be the one to decide if the diet was changed.

Based on observation and interview, the facility failed to ensure equipment was maintained in good repair and safe operating condition so as not present a hazard to staff, residents, or visitors. The facility census was 149. Observation on 5/8/24 at 10:44 A.M., in the kitchen, showed the power cord of the food processor was frayed at the connection to the machine and was missing part of the cord's protective coating in an approximate one-inch long section. Observation on 5/7/24 at 12:54 P.M., in the 700 servery, showed the refrigerator compartment of a combination refrigerator/freezer unit was not working. The temperature on the unit read 105 degrees Fahrenheit. The door opened freely and felt warm inside the compartment. No food items were located in the compartment and there was no sign posted on the unit indicating the compartment was not working nor instructing staff, residents, or visitors to not put food items in the compartment for cooling. During an interview on 5/7/24 at 12:54 P.M., Dietary Aide I, confirmed the refrigerator compartment of the 700 servery combination refrigerator/freezer unit did not work. The unit was moved from a different part of the facility and the refrigerator portion had not worked for awhile. The bottom freezer portion still worked and was used for frozen food and ice storage. During an interview on 5/8/24 at 3:14 P.M., the director of environmental services said the following: -The refrigerator portion of the 700 servery combination refrigerator/freezer unit did not work and he made the decision not to repair it due to being told the parts were unavailable to fix it; -The dietary manager wanted the non-working refrigerator portion of the unit to be screwed shut; -He was unaware of the frayed cord on the food processor in the kitchen and he expected staff to report needed repairs to the maintenance department. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said the following: -Equipment should be maintained in good repair and safe operating condition; -She was unaware of the frayed cord found on the food processor. She expected staff to let her know when an item needed repair so she could submit a work order to maintenance staff; -She was aware of the non-working refrigerator compartment in the servery and planned to have the maintenance staff screw the compartment shut. During an interview on 5/9/24 at 3:37 P.M., the administrator said she was unaware of the non-functioning refrigerator compartment in the 700 servery and of the frayed cord on the food processor in the kitchen. She expected staff to notify the maintenance staff of items needing attention so they could be repaired, replaced, or locked-out/tagged-out as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for five residents (Resident #78, Resident #26, Resident #140, Resident #87, and Resident #43) in a review of 35 sampled residents when call lights were not accessible at all times to the residents. The facility also failed to accommodate one resident's (Resident #121's) need for assistance, including assistance with toileting, which resulted in incontinence. The facility census was 149. Review of the facility policy, Call Lights, last reviewed 6/21, showed the following: -Purpose was to get to the resident when he/she calls for assistance and to assist the nurse in meeting the resident's requests; -Check to see that the resident's call light is within reach; -Go to the resident as soon as he/she calls. Answer within 5-15 minutes. Emergency lights should be responded to immediately to prevent injury. 1. Review of Resident #78's Continuity of Care document (CCD) showed the resident's diagnoses included malignant neoplasm of lungs and brain (cancer), difficulty in walking, and lower extremity contracture (condition that prevents normal movement of a joint or other body part) of right foot and right ankle. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/24, showed the following: -Moderately impaired cognition; -Dependent on staff for transfers and toileting; -Always incontinent of bowel and bladder; -Dependent on staff for manual wheelchair mobility. Review of the resident's care plan, revised 4/12/24, showed the following: -Incontinent of bowel and bladder; -Staff to give reminders to use call light and wait for assistance; -Ensure call light is in reach and educate on the use of call light, if indicated. Observation on 5/8/24 at 7:25 P.M. showed the following: -The resident sat near the end of his/her bed, in his/her geri chair (high back chair that the sitter is not able to self-propel in) with foot pedals in place; -The call light lay across the bedside table at the end of the bed; -The call light was not within reach for the resident's use. During an interview on 5/7/24 at 12:55 P.M., the resident said he/she used to self propel to get around, but now he/she has these foot pedals that prevent him/her from being able to get around. During an interview on 5/8/24 at 7:25 P.M., the resident said the following: -He/She asked a staff member walking by his/her room to change him/her about 15 minutes ago and no one returned; -He/She had been incontinent of bowel and bladder and needed his/her brief changed; -His/Her call light was not within reach, so he/she had to ask someone walking by the room for help. Observation on 5/8/24 at 9:06 P.M. showed the following: -Certified Nurse Aide (CNA) RR and CNA SS entered the resident's room with a mechanical lift to transfer the resident, change the resident and provide incontinence care; -The resident's peri area was red and irritated all the way to the thigh area with a small superficial opening on the left upper thigh area just below the crease of the thigh; -Following cares, CNA SS placed the call light within reach after the resident requested the call light. During an interview on 5/8/24 at 9:25 P.M., the resident said he/she asked staff for his/her call light to be in place before leaving the room because he/she had been without it and had been sitting for a while waiting to be changed. As a result of waiting, he/she now has skin irritation between his/her legs. Observation on 5/9/24 at 10:45 A.M. showed the following: -The resident asleep in his/her wheelchair in his/her room; -The call light was on the floor near the wall on the other side of the bed and not within reach for the resident to use. Observation on 5/10/24 at 10:06 A.M. showed the following: -The resident was asleep in his/her wheelchair in his/her room; -The call light was on the side of the bed near the wall hanging to the floor and not within reach for the resident to use. 2. Review of Resident #121's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Mobility device: wheelchair; -Required substantial/maximal assistance for toileting hygiene; -Dependent on staff for sit-to-stand and toilet transfers; -Urinary and bowel continence not marked; -Diagnoses of cancer, anxiety and depression; -Taking a diuretic medication. Review of the resident's care plan, dated 5/1/24, showed the following: -Resident is at risk for falls due to weakness; -Resident has a deficit in mobility related to weakness; -Current weight bearing status is weight bearing as tolerated, two person transfer Sara lift (a powered sit-to-stand lift designed for active transfers, balance, stepping and gait training); -Resident has a deficit in activities of daily living (ADL) self-care and impaired functional mobility related to weakness; -Provide assistance with ADLs as indicated. During an interview on 5/7/24 at 4:23 P.M., the resident said the following: -He/She requires use of the sit to stand lift in/out of bed and assistance of two staff; -He/She has waited for 40 minutes to go to the bathroom; -He/She has had several urinary tract infections (UTIs) and when he/she has to go there's not much time to get there; -He/She ended up having an accident (was incontinent) and went down to the head nurse after 35 minutes and the nurse had to find the aide to assist him/her; -He/She just hates it when he/she urinates in his/her pants, it upsets him/her; -One agency aide told him/her that he/she was helping someone else and he/she would just have to hold it. 3. Review of Resident #26's CCD showed the resident's diagnoses included muscle weakness, difficulty in walking, Parkinson's disease (a disease affecting the nervous system), and neuromuscular dysfunction of bladder. Review of the resident's annual MDS, dated [DATE] showed the following: -Intact cognition; -Dependent on staff for toileting and transferring. Review of the resident's care plan, revised 5/8/24, showed the following: -Incontinent of bowel and bladder; -Ensure call light in place prior to leaving room. Observation on 5/8/24 at 9:20 A.M. showed the following: -The resident sat in bed and ate his/her breakfast from the bedside table that was positioned over his/her lap; -The call light was near the foot of the bed on top of the upright mattress against the wall and not accessible to the resident. During an interview on 5/8/24 at 9:20 A.M., the resident said he/she normally hits the call light if he/she needs assistance from staff, but he/she was unable to locate it and he/she needed assistance with eating. Observation on 5/9/24 at 10:55 A.M. showed the following: -The resident was asleep in his/her bed; -His/Her call light lay near the end of the bed and not within the resident's reach. 4. Review of Resident #140's CCD showed the resident's diagnoses included multiple sclerosis (disease causing muscle weakness), restlessness and agitation, and fracture of right femur (leg fracture). Review of the resident's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for transfers and toileting; -Always incontinent of bowel and bladder. Review of the progress note, dated 3/20/24 at 5:25 P.M. showed the following: -The resident required assist of two or more staff members; -The resident required a mechanical lift for transfers; -The resident required a broda chair (specialized wheelchair) with assistance for mobility. Review of the resident's care plan, revised 3/4/24, directed to ensure call light is in reach and educate on the use of the call light, if indicated. Observation on 5/8/24 at 7:35 P.M. showed the following: -The resident was awake and sat in a wheelchair next to his/her bed; -His/Her call light was near the foot of the bed next to the wall and not within reach. During an interview on 5/8/24 at 7:35 P.M., the resident said he/she wasn't sure where his/her call light was, but was able to use it if he/she had it and needed something. Observation on 5/9/24 at 10:50 A.M. showed the following: -The resident was awake and sat in his/her wheelchair next to his/her bed; -His/Her call light lay across the bed, and not within his/her reach. 5. Review of Resident #43's CCD showed the resident's diagnoses included speech and language deficits, stroke, muscle weakness, difficulty in walking, and insulin dependent diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Dependent on staff for transfers, dressing, personal hygiene and bathing. Review of the resident's care plan, revised 4/3/24 , showed the following: -Always incontinent of urine; -Keep call light in reach at all times; -Respond to call light requesting to get up in a timely manner. During an interview on 5/7/24 at 12:55 P.M., the resident said that he/she was able to use a call light. Observation on 5/8/24 at 8:00 P.M. showed the following: -The resident was asleep in his/her bed; -His/Her call light was on the floor next to the wall and not accessible to the resident. Observation on 5/9/24 at 10:50 A.M. showed the following: -The resident was awake in a broda chair; -His/Her call light was on the bed, and not accessible to the resident. 6. Review of Resident #87's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Minimal depression; -Scheduled and as needed pain medication; -Partial to moderate assist for transfers and toileting; -Manual wheelchair (dependent for mobility). Review of the resident's POS dated 5/2024 showed the following: -Diagnoses included chronic diastolic heart failure (condition that causes shortness of breath and exercise intolerance); -Hospice (3/25/24). Review of the resident's care plan, last revised 4/19/24, showed the following: -Deficit in mobility related to weakness; -Required assist of one staff with transfers and toileting; -Keep call light in easy reach, encourage the use of call light for assistance; -Respond to call light requesting to get up in a timely manner. Observation on 5/13/24 at 11:00 A.M. showed the resident sat in his/her wheelchair in his/her room. The call light was out of the resident's reach on the over-the-bed table. Observation on 5/14/24 at 10:30 A.M. showed the resident lay in his/her bed. The call light was on the over-the-bed table out of the resident's reach. During an interview with the Director of Nursing (DON) on 5/14/24 at 12:55 P.M., she said the following: -She would expect call lights to be within reach for all residents; -She would expect call lights to be within reach when the resident is in bed and when the resident is out of bed. During a phone interview on 5/22/24 at 1:10 P.M., the administrator said the following: -She would expect staff to have call light within reach for all residents; -She would expect staff to answer call lights and respond to resident's needs within a timely fashion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for three residents (Resident #307, #309 and #403) in a review of 35 sampled residents. The facility census was 149. Review of the facility policy for Following Physician Orders, dated 7/29/21, showed: -It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurses (RN), Licensed Practical Nurses (LPN)) and other Healthcare Professionals, follow Physician Orders in accordance to State, Federal regulations and their respective practice acts; -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; -If an order is questionable according to the seven Rights of Medication Administration, a clarification order will be obtained; -All physician or other health care professional's verbal, telephone or written orders will be immediately entered in the Electronic Health Record (EHR) by the nurse obtaining the order. Review of the facility policy for Weight Monitoring, dated 11/18/2018, showed residents are weighed on admission, weekly for the first four weeks and monthly thereafter, unless other wise ordered by nursing order or the attending physician. Review of the facility policy, Thickened Liquids/nothing by mouth (NPO), reviewed 5/2021, showed the following: Purpose: -To decrease the risk of aspiration and increase functional ability of swallowing; -A resident's physician's order for thickened liquids describing the consistency as nectar, honey or pudding will be communicated to the nursing, dining services, and other appropriate staff; -Assure the resident is receiving the appropriately thickened liquids. 1. Review of Resident #403's care plan, dated 4/29/24, showed the following: -Mechanical soft diet with nectar thick (where an agent is added to a liquid to make it of the ordered consistency to decrease the risk of choking) liquids; -Monitor for signs and symptoms of dysphagia (difficulty swallowing), coughing and choking with liquids and/or meal intake. Review of the resident's May 2024 physician's orders showed an order for mechanical soft diet with nectar thick liquids (start date 4/29/24). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/3/24 showed the following: -Cognitively intact; -Upper extremity impairment on one side; -Required set up or clean up assistance for eating; -Diagnoses of stroke and diabetes. Observation on 5/13/24 at 12:35 P.M., in the dining room, showed the following: -The resident sat at the dining room table; -The resident had a glass of thin (not thickened) water and glass of thin (not thickened) lemonade; -The resident took a sip of the water and said I can't have that; -The resident then took a sip of the lemonade and said that isn't nectar thick. During an interview 5/13/24 at 12:35 P.M., the resident said the following: -He/She has had an order for nectar thick liquids since April; -He/She had a stroke and has difficulties swallowing; -More than once, staff have brought him/her regular liquids and he/she can't have them. During an interview on 5/13/24 at 12:40 P.M., Certified Nurse Aide (CNA) ZZ said the following: -He/She may have given the resident his/her liquids at lunch today, but he/she didn't know for sure; -He/She knew the resident had an order for nectar thick liquids. During an interview on 5/14/24 at 10:25 A.M., Licensed Practical Nurse (LPN) V said the following: -CNA staff can access diet orders in the kiosk (electronic point of care charting); -Diet orders and thickened liquids are also on the condensed care plan sheet; -Nursing staff are responsible for and should serve thickened liquids to residents with orders for thickened liquids. During an interview on 5/14/24 at 12:53 P.M. the Director of Nursing (DON) said she would expect for staff to serve nectar thick liquids to residents with orders for nectar thick liquids. 2. Review of Resident #307's Face sheet showed the resident admitted to the facility on [DATE]. He/She resided on the rehab unit. Review of the resident's care plan for nutrition, dated 4/23/24, showed: -Resident has the potential for nutritional deficits related to recent hospital stay; -Goal: will provide balanced nutritional diet and prevent unintended weight loss: -Interventions: Monitor weekly weight for four weeks after admission. Review of the resident's POS, dated May 2024, showed an order dated 4/23/24 for weekly weight to be done on Sundays. Review of the resident's comprehensive MDS, dated [DATE], showed: -admitted to the facility on [DATE]; -Weight of 208 pounds (lbs). Review of the resident's weights in the EHR on 5/13/24 showed the following: -4/22/24 weight of 208 lbs; -4/23/24 weight of 222.4 lbs; -No weekly weight documented on Sunday, 4/28/24 or for 4/29/24 or 4/30/24 (a week from the previous weights); -The facility had not obtained the resident's weight weekly per physician orders or as their policy or the resident's care plan instructed. 3. Review of Resident #309's face sheet showed the resident admitted on [DATE]. He/She resided on the rehab unit. Review of the resident's care plan for Nutrition, dated 5/4/24, showed the following: -Resident has the potential for nutritional deficits related to recent hospital stay; -Goal: Will provide balanced nutritional diet and prevent unintended weight loss; -Intervention: monitor weekly weight for four weeks after admission. Review of the resident's POS, dated May 2024, showed an order dated 5/4/24 for a weekly weight on Sunday. Review of the resident's weights documented in the EHR on 5/13/24 showed the following: -Weight on 5/2/24 of 139.4 lbs; -No other weights were documented; -No weekly weight documented on Sunday, 5/5/24; -No weekly weight documented on Sunday, 5/12/24. -There was no documented weight after the resident's admission weight. The facility had not obtained the resident's weight weekly per physician orders or as their policy or the resident's care plan instructed. During an interview on 5/14/24 at 10:00 A.M., CNA II said the following: -Residents on the Rehab hall are weighed every Sunday; -On the CNA charting screen, only the day that is being charted can be seen; you cannot go back to see if something was charted the previous days; -There was no way to tell if a resident had or had not been weighed. During an interview on 5/13/24 at 2:00 P.M., LPN Z said the following: -Residents who reside on the rehab unit are weighed every Sunday, regardless of their admission date; -Aides take the weights and log them in the point of care (POC) system for charting. POC will populate on the nurses Sunday notes that weights are to be done; this is how the nurses monitor weights. If the order is not entered correctly, and they put it under the Activities of Daily Living (ADL) section of the nurse aide charting, then it will not show up on the nurses screen to be monitored; -Residents #307's orders for weekly weight were entered incorrectly in the computer, so the order does not show up on the nurses screen. Resident #306 did not get an order entered to have the weight done weekly. During an interview on 5/15/24 at 9:15 A.M. LPN JJ said the following: -He/She worked on 5/12/24 on the Rehab hall; -He/She could not remember which residents were to be weighed; -He/She would have written on the daily assignment sheet which residents were indicated on the nurses screen to be weighed. During an interview on 5/14/24 at 12:23 P.M., the Registered Dietician said the facility has a standing order for new admissions to be weighed weekly for four weeks. During an interview on 5/14/24 at 12:52 P.M., the Director of Nursing (DON) said the following: -Residents on the rehab hall should be weighed upon admission then every Sunday for four weeks; -Depending on how the order was entered into the EHR, was how the order will populate for the CNA's and nurses to chart; -Resident #307's order was entered incorrectly and the nurses were not aware that the weight was not done; -Resident #306 did not have the order entered; -She would expect the nurses to be monitoring if a resident has been weighed, as every resident on the Rehab hall was weighed on Sunday. During an interview on 5/22/24 at 1:10 P.M., the administrator said she would expect staff to follow physicians orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided eight residents (Resident #11, #89, #80, #83, #78, #306, #307 and #311) in a review of 35 sampled residents and one additional resident (Resident #120), activities of daily living (ADL) care, including showers, nail care, shaving, oral care, incontinence care and assistance at meal time. The facility census was 149. Review of the facility policy titled Shaving, dated 5/2021, showed the following: Purpose: -To remove excessive hair from the face; -To provide cleanliness; -To improve resident morale and appearance. Review of the facility policy titled Nails, Care of (Finger and Toe), dated 5/2021, showed the following: Purpose: -To provide cleanliness; -To prevent spread of infection; -For comfort; -To prevent skin problems; -NOTE: Fingernails of diabetic residents are to be cut by the nurse. Review of the facility policy for Perineal Care, dated 3/2021 showed: -Purpose: to establish routine practices for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection and prevent odors; -All residents will receive perineal care, as needed, in the morning before breakfast, every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent. -Procedure: Wash hands, gather equipment, put on gloves. Remove the resident's brief, remove gloves, wash hands and apply new gloves; -Position resident on their back and separate resident's legs; -Make a mitten with the wash cloth, wet and apply soap or peri-wash; -Wash front peri area with soap and water or use disposable peri-wipes. Wash inner thighs and all exposed areas with soap and water or disposable peri-wipes; -Rinse wash cloth in basin if using soap or gram warm wash cloth from plastic bag -Rinse all cleansed areas if using soap and water, and dry thoroughly; -Apply protective ointment to front peri area; -Remove gloves, wash hands and apply clean gloves; -Turn resident on side away from you; -Lather wash cloth and wash rectal area and buttocks if using soap and water, otherwise use disposable peri-wipes; -Rinse all cleansed areas where soap and water was used, and dry thoroughly; -Remove gloves and wash hands; -Put on clean gloves; -Apply lotion, or moisture barrier to buttocks and rectal area if indicated; -Position resident for comfort; -Remove gloves and wash hands. Review of the facility policy, Bathing, dated 6/2021, showed the following: -Purpose was to cleanse the skin of micro-organisms thus preventing infections and preserving the integrity of the skin, to provide comfort and relaxation, stimulate circulation, encourage passive and active range of motion and improve self-esteem through improved appearance; -Policy for bath days and the type of bath to be given will be assigned by the charge nurse according to the resident's preference. Review of the facility policy, Oral Hygiene, dated 5/2021, showed the following: -Purpose was to ensure cleanliness, prevent odor, improve appetite, prevent cavities, tartar buildup, and gum disease, and to stimulate circulation of blood in the gums; -Frequency: every morning and bedtime, at least every two hours from residents that are nothing by mouth (NPO); -Oral care refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues. This involves not only activities such as brushing of teeth or oral appliances, but also maintenance of oral mucosa. 1. Review of Resident #83's care plan, revised 2/2/24, showed staff was to provide assistance with activities of daily living (ADLs) as indicated and to document as required. (Review showed no documentation specifically related to showers, shaving or nail care.) Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/20/24, showed the following: -Intact cognition; -Required substantial/maximal assistance from staff for personal hygiene, dressing and shower/bathing; -Rejected care one to three days for the seven day lookback period. Observation on 5/7/24 at 12:30 P.M. showed the resident sat in the dining room with long, dirty finger nails. The resident's hair was greasy and disheveled, and he/she had facial stubble. During an interview on 5/7/24 at 12:30 P.M., the resident said the following: -He/She preferred to be clean shaven; -His/Her nails needed to be cut; -He/She required staff assistance to shower, shave and provide nail care. Review of the facility shower schedule showed the resident was to receive showers twice a week on Wednesdays and Saturdays. Review of the shower sheets for April 2024 showed the following: -No documentation a shower was offered, received or refused 4/1/24 through 4/9/24 (nine days); -The resident received a shower on 4/10/24; -No documentation a shower was offered, received or refused 4/11/24 through 4/16/24 (six days); -The resident received a shower on the 4/17/24, 4/21/24 and 4/24/24; -No documentation a shower was offered, received or refused 4/25/24 through 4/30/24 (six days). Review of the shower sheets on 5/9/24 for May 2024 showed the following: -No documentation a shower was offered, received or refused on 5/1/24 through 5/7/24; -The resident received a shower on 5/8/24 (14 days after his/her last documented shower on 4/24/24). Observation on 5/8/24 at 8:10 P.M. showed the resident sat in his/her wheelchair in his/her room with long, dirty finger nails. The resident's hair was greasy and disheveled and he/she had facial stubble. During an interview on 5/14/24 at 12:15 P.M., Certified Nurses Aide (CNA) O said the following: -The resident would only allow certain staff to give him/her a shower or shave him/her; -The resident often refused showers; -If a resident refused, he/she would offer again later and if they continue to refuse, he/she would inform the charge nurse; -He/She did not clip the resident's nails with every shower. The resident's nails were hard to keep clean because he/she ate snacks all of the time and food got under them; -If the resident refused a shower, there would still be a shower sheet filled out that said refused. 2. Review of Resident #78's Significant Change MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for transfers and toileting; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 4/12/24, showed the following: -The resident was incontinent of bowel and bladder; -Provide incontinence care after each incontinent episode. During an interview on 5/8/24 at 7:25 P.M., the resident said he/she told staff (name unknown) walking by about 15 minutes prior that he/she was incontinent of bowel and bladder and needed to be changed. Observation on 5/8/24 at 9:06 P.M. showed the following: -The resident sat in his/her high back wheelchair in his/her room; (he/she had still been awaiting care from asking as the resident interview from 7:25 P.M. showed); -CNA RR, CNA SS and Licensed Practical Nurse (LPN) TT entered the resident's room; -Staff transferred the resident to bed and provided incontinence care; -The resident's incontinence brief was soaked with urine and he/she had dried feces on his/her skin; -The resident's peri area was red and irritated all the way to the thigh area with a small superficial opening on the left upper thigh area just below the crease of the thigh. -LPN TT discovered a skin tear in the resident's gluteal cleft. During an interview on 5/8/24 at 9:25 P.M., the resident said the following: -He/She had been sitting for a while waiting to be changed; -He/She felt so irritated between his/her legs. During an interview on 5/14/24 at 12:55 P.M., the Director of Nurses (DON) said the following: -It was not appropriate for a resident to wait 30 minutes or more for assistance from staff; -She expected staff to respond immediately if a resident told them he/she was incontinent. 3. Review of Resident #307 face sheet showed his/her diagnoses included stroke with hemiplegia (paralysis on one side of the body). Review of the resident's care plan for Nutritional Status, dated 4/23/24, showed the following: -Resident has the potential for nutritional deficits; -Goal: will provide balanced nutritional diet and prevent unintended weight loss; -Interventions: Assess ability to feed self. Provide assistance/supervision as needed. Review of the resident's comprehensive MDS, dated [DATE], showed the following: -Sometimes understands and sometimes able to make self understood; -Able to make some decisions; -Independent with eating after staff sets up the tray; -Impairment of right side extremities. Observation of the dining room on 5/8/24 at 12:10 P.M. showed the following: -Nursing staff served the noon meal to the residents; -The meal consisted of minestrone soup, cold sandwich (Italian club on hoagie), broccoli salad, pickles in a cup, mayonnaise in a cup, lettuce and onion slice on the side of the plate, chocolate pudding served in a bowl and the silverware was in a sealed plastic wrapper; -No staff assisted the residents with eating; -The resident had difficulty when opening the silverware packet. He/She got the knife out of the package and began to eat the soup with the knife; -The resident spilled the soup on the plate and onto the brace that was on his/her right hand and arm. The resident tried to clean the soup off the brace with a fork then used his/her shirt to wipe the brace; -He/She picked up the bowl of soup and drank from the bowl; -Several staff members walked by the resident as they served other residents their food; -No one stopped to assist the resident. During an interview on 5/13/24 at 3:15 P.M., LPN KK said the following: -There was a staff member assigned to the dining room who was responsible to monitor and to provide assistance as needed; -Any staff member could assist in the dining room and should help when a resident needed help opening an item or cutting up food. During an interview on 5/14/24 at 12:52 P.M., the DON said the following: -A CNA should be in the dining room for all meals providing assistance as needed; -She expected a CNA to help with the opening silverware as needed and assist if a resident needed help with eating. 4. Review of Resident #311's face sheet showed his/her diagnoses included fracture of the vertebrae. Review of the resident's care plan for dentures, dated 4/29/24, showed the following: -The resident wears dentures; -The resident will have comfortable, proper-fitting dentures; -Instruct resident in proper care, handling and storage of dentures. Observation on 5/08/24 at 2:55 P.M. showed a partial denture plate on the sink in the resident's bathroom. A denture cup, containing dirty water, sat next to the partial denture plate. During an interview on 5/8/24 at 2:55 P.M., the resident said the following: -He/She had a partial set of dentures; -He/She did not get help with putting them in, taking them out or putting them in the denture cup; -Staff did not assist with brushing his/her teeth or with the dentures. During an interview on 5/13/24 at 3:15 P.M., LPN KK said the following: -The aides and the nurses can help with oral care and ensure that residents have their dentures in their mouths; -The aides should put dentures in a resident's mouth in the morning when they get the residents up. During an interview on 5/14/24 at 12:52 P.M., the DON said she expected staff to assist the residents with dentures, brushing their teeth, and caring for their dentures. 5. Review of Resident #120's admission MDS, dated [DATE], showed the following: -Able to make self understood and understood others; -Some difficulty in making decisions; -Dependent on staff for toileting and hygiene; -Continent of bowel and bladder. Observation on 5/8/24 at 8:23 P.M. showed the following: -The resident lay in his/her bed; -CNA AAA and LPN Z entered the resident's room to provide incontinent care and to change the resident's dressing; -LPN Z removed the resident's urine soiled incontinence brief, and wiped the resident's buttock with a disposable wipe. He/She wiped down the center of the buttocks; -LPN Z retrieved treatment supplies and placed a clean dressing on the wound; -CNA AAA stood at the resident's bedside while LPN Z retrieved the wound supplies; -LPN Z then placed a clean brief under the resident, and with the assistance of CNA AAA, rolled the resident to his/her back and fastened the brief; -Neither CNA AAA or LPN Z performed frontal pericare for the resident. During an interview on 5/8/24 at 9:20 P.M., CNA AAA said he/she thought LPN Z cleaned the front of the resident when he/she was cleaning the resident's back. During an interview on 5/8/24 at 9:00 P.M., LPN Z said he/she did not wipe the front of the resident as he/she thought CNA AAA did that while he/she was getting treatment supplies. 6. Review of Resident #306's care plan for incontinence, dated 5/7/24, showed the following: -Resident experiences incontinence; -The resident will not exhibit skin breakdown, urinary tract infections, or impaired social interactions, lowered self esteem secondary to incontinence; -Provide incontinence care after each incontinent episode. Observation of the resident on 5/9/24 at 11:11 A.M. showed the following: -CNA MM and CNA NN transferred the resident to his/her bed and removed the resident's urine and feces soiled incontinence brief; -With the resident on his/her side, CNA MM wiped feces from the resident's rectum and buttocks. He/She put his/her hand between the resident's legs and wiped the resident's peri-area from front to back; -CNA NN placed a clean incontinence brief under the resident; -CNA MM rolled the resident onto his/her back, and with out cleansing the resident's groin area that had come into contact with urine, fastened the clean brief around the resident. During an interview on 5/9/24 at 11:30 A.M., CNA MM said the following: -The resident did not have a lot of urine in the brief, so he/she wiped the buttocks where the urine would have touched; -He/She was able to cleanse the front of the resident when he/she wiped the resident from behind. During an interview on 5/9/24 at 12:30 P.M., CNA NN said the following: -He/She did not help with incontinence care; -Staff should clean any area of skin that came into contact with urine or feces. Staff need to place the resident on their back to clean the front of the resident. 7. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Required substantial to maximal assistance with personal hygiene. Review of the resident's care plan, dated 5/8/24, showed the following: -The resident had deficit in ADL self-care and impaired functional mobility related to weakness/again/new environment; -Provide assistance with ADLs as indicated. Observation on 5/8/24 at 8:35 A.M. showed the following: -The resident lay in bed eating breakfast; -His/her face was covered with hair stubble; -His/Her fingernails were long and had brown debris under them. Observation on 5/10/24 at 12:10 P.M. showed the following: -The resident lay in bed; -His/Her face was covered with facial hair approximate ½ inch in length; -The resident's fingernails were long and had brown debris under them. During an interview on 5/10/24 at 12:10 P.M., the resident said the following: -Staff forgot to shave him/her with his/her bed bath yesterday; -All this facial hair made him/her itch; -His/Her nails were so long they break off. 8. Review of Resident #89's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment on one side both upper and lower extremities; -Required substantial/maximal assistance from staff for personal hygiene; -Diagnosis of stroke. Review of the resident's care plan, dated 5/8/24, showed the resident had a deficit in ADL self-care and impaired functional mobility. Observation on 5/10/24 at 12:15 P.M. in the main dining room showed the following: -The resident sat in his/her wheelchair at the table; -The resident's fingernails on his/her left hand were long; -There was black debris under the fingernails on his/her right hand. Observation on 5/13/24 at 12:30 P.M. showed the following: -The resident sat in his/her wheelchair; -He/She had brown debris under his/her fingernails. During an interview on 5/10/24 at 12:15 P.M., the resident said his/her nails were dirty. During an interview on 5/10/24 at 1:48 P.M., CNA EEE said the following: -Staff should provide nail care and shaving two times a week with showers; -He/She didn't get Resident #89's nails trimmed and cleaned yesterday, it should have been done with his/her shower. During an interview on 5/10/24 at 12:37 P.M., Registered Nurse (RN) Q said CNA staff should trim and clean nails and shave residents on shower days and as needed. 9. Review of Resident #80's admission MDS, dated [DATE] showed the following: -Moderately impaired cognition; -Did not reject care; -Upper extremity impairment on one side; -Substantial to maximum assist with personal hygiene. Review of the resident's care plan, last revised 5/1/24, showed the following: -Deficit in ADL self care due to impaired functional mobility; -Provide set-up/cueing/assistance as needed with ADLs. Observation on 5/7/24 at 1:10 P.M. showed the resident sat in his/her wheelchair in his/her room eating lunch. The resident had whitish/gray facial hair on his/her face and neck. Observation on 5/9/24 at 10:16 A.M. showed the resident sat in his/her wheelchair just outside of his/her room. The resident had facial hair covering his/her face. Observation on 5/10/24 at 8:20 A.M. showed the resident sat in his/her wheelchair in the dining room. The resident had whitish/gray facial hair covering his/her face. During an interview on 5/7/24 at 1:10 P.M., the resident said he/she was not sure if staff helped him/her to shave. During an interview on 5/9/24 at 10:30 A.M., the resident's family member said the resident was very particular about his/her appearance. During an interview on 5/14/24 at 12:55 P.M., and 5/22/24 at 1:10 P.M., the DON said the following: -She expected the CNAs to clean and clip resident's nails during showers, but would prefer the nurse to use the clippers or put the resident on the podiatry list to be seen; she would also expect staff to provide nail care when needed, not necessarily with every shower; -She expected residents to receive a shower two times a week; -She expected staff to offer the shower again if the resident refused. If the resident refused more than once, the staff should talk to the charge nurse; -She expected staff to shave the residents who want to be shaved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate care of a urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) for three residents (Resident #58, #20 and #11), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy, Catheter Care, revised 3/2021, showed the following: Purpose: -To keep indwelling catheter free of discharge and/or crusting which can cause infections; -Attach bag to bed frame only; -Never lift bag above bladder level (source of infection). 1. Review of Resident #58's continuity of care document (CCD) showed the resident had diagnoses that included personal history of UTIs, neuromuscular dysfunction of bladder (when the nerves and the muscles in the bladder don't communicate properly with the brain), and retention of urine (when the bladder does not completely empty of urine). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 2/23/24, showed the following: -Dependent on two or more staff for hygiene and toileting hygiene; -Had indwelling catheter; -Occasionally incontinent of bowel. Review of the resident's care plan, revised 4/17/24, showed the following: -The resident was at risk for contracting a multi-drug resistant organism (MDRO) due to an indwelling device that requires the use of personal protective equipment during high contact activities; -The resident had potential for recurrent UTI's related to history of UTI's; -If the resident was incontinent, provide peri care as soon as possible after incontinent episode, per facility policy, being sure to cleanse well and cleanse from front to back; -Use principles of infection control and universal/standard precautions. Observation on 5/8/24 at 8:25 P.M., showed the following: -Certified nurse aide (CNA) UU, walked into the resident's room, donned gloves, picked up trash (candy wrappers, used plastic ware and Styrofoam cups) from the room and held the trash can with his/her gloved hands. With soiled gloves, he/she grabbed a graduate container (container used to measure a volume of liquid) from the resident's bathroom and emptied the resident's urine filled catheter bag by removing the drainage tube from the holder, (touching the drainage tube with his/her soiled gloves), and emptied the collection bag into the graduate container. With soiled gloves, CNA UU then touched the drainage tube and placed it back in the holder. Observation of CNA VV on 5/9/24 at 12:00 P.M. showed the following: -CNA VV put on gloves upon entering the resident's room, grabbed the trash (candy wrappers, Styrofoam cups) from around the room and bedside table and placed them in the trash can and cleaned spilled soda from the resident's bedside table; -Without doffing his/her soiled gloves, hand sanitizing or washing his/her hands with soap and water and donning new gloves, CNA VV went into the bathroom and wet some washcloths (one with soap and one with water); -With the soapy washcloths and soiled gloves, CNA VV wiped down the right side of the resident's leg, wiped down the left side of the resident's leg, then with the same wash cloth, cleaned the catheter tube from the insertion site down the tube; -Still wearing the same soiled gloves, CNA VV repeated another swipe down the catheter tubing with the soiled wet washcloth; -CNA VV did not perform proper catheter care. 2. Review of Resident #20's significant change MDS), dated [DATE], showed the following: -Indwelling catheter; -Diagnoses of heart failure, diabetes, and dementia; -UTI in the last 30 days; -Hospice care. Review of the resident's care plan, dated 4/17/24, showed the following: -Resident requires an indwelling urinary catheter related to retention; -Position bag below the level of bladder; -Resident has deficit in activities of daily living (ADL) self-care and impaired functional mobility. Observation in the resident's room on 5/9/24 at 2:25 P.M., showed the following: -The resident sat in his/her Broda chair (a type of chair that provides the ability to tilt and recline) with a urinary bedside drainage bag hanging on the lower bar under the Broda chair; -CNA CCC and CNA ZZ entered the resident's room and applied gowns and gloves; -CNA CCC removed the bedside drainage bag from the lower bar under the Broda chair and held it above the level of the resident's bladder; -The urine in the tubing was cloudy yellow with mucous, and as CNA CCC held the bag at that level, urine backed up in the catheter tubing. 3. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -Required substantial to maximal assistance with toileting and personal hygiene; -Indwelling catheter; -Diagnoses of cancer, neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), septicemia (blood poisoning by bacteria), and diabetes; -Dependent on staff for chair/bed to chair transfer. Review of the resident's care plan, dated 5/8/24, showed the following: -Resident has a potential for recurrent UTIs related to history of UTI; -Resident requires an indwelling urinary catheter related to urinary retention/neurogenic bladder; -Position bag below level of bladder; -Provide catheter care every shift and as needed; -Weight bear as tolerated, two person mechanical lift transfer. Observation on 5/8/24 at 10:20 A.M., in the resident's room, showed the following: -CNA EEE and CNA ZZ entered the resident's room; -The resident lay in bed; -CNA EEE and CNA ZZ hooked the resident up to the mechanical lift; -CNA EEE hooked the resident's urine collection bag on a loop of the sling (above the level of the resident's bladder); -The urine in the tubing was yellow with mucous and had a strong smell; -CNA EEE and CNA ZZ transferred the resident to his/her wheelchair; -CNA EEE removed the urinary collection bag from the loop of the sling and placed it under the resident's wheelchair. During an interview on 5/10/24 at 1:48 P.M., CNA EEE said the following: -Catheter bags should be off the floor; -The catheter bag should always be below the level of the bladder. During an interview on 5/28/24 at 9:00 A.M., LPN W said the following: -The catheter bag should be below the level of the bladder at all times; -The catheter bag should be off the floor at all times. During an interview on 5/10/24 at 12:37 P.M., Registered Nurse (RN) Q said the BSDB should be kept off the floor and below the level of the bladder. During an interview on 5/14/24 at 12:53 P.M. the Director of Nursing said the following: -She would expect the catheter drainage bag to be off the floor; -She would expect the catheter drainage bag to be below the level of the bladder at all times.

Based on observation, interview and record review, the facility failed to ensure three additional residents (Resident # 39, #51, #109), who received insulin injections, were free from significant medication errors. Staff failed to prime (remove the air from the needle and cartridge) the Humalog Kwik pen (prefilled pen of fast acting insulin (medication injected under the skin used to treat diabetes)) needle as instructed by the manufacturer prior to administration of the medication, resulting in administration of less, or more than the ordered dose of Humalog. Staff failed to hold the needle against the resident's skin for the manufacturer's suggested time after the administration of the medication. The facility census was 149. Review of the facility policy, Insulin Administration, dated 05/2021, showed the following: -Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual; -Insulin pen needles are also intended only for a single person; -Explain the procedure to the resident; -Provide privacy; -Wash hands; -Put on gloves; -Check the label on the pen and make sure it is the correct ordered insulin for the resident; -Check the expiration date; -Remove the pen cap and cleanse the rubber stopper with an alcohol wipe. Attach pen needle to device. Do not use a syringe to draw insulin out of the pen; -Select an approved site for insulin administration; -Cleanse the area with an alcohol wipe; -Prime the pen immediately before injection. Priming is dialing up two units of insulin and pressing the button on the pen to shoot some insulin into the air. You should see a drop of insulin at the end of the needle. More than one prime may be required for a new pen; -Dial up the dose on the pen as indicated on the order. Verify that insulin is being given at the correct time in relation to meals; -Administer insulin to cleansed area using a subcutaneous method. The inserted needle should remain in the tissue for 10 seconds after the pen gets back down to zero to ensure proper absorption; -Dispose of needle in a sharps container. Please note that needles are one time use only; -Cover resident and ensure his/her comfort. Place call light within reach; -Document dose given on eMAR. Review of the Humalog Kwik pen package insert showed the following in part: -Humalog Kwik Pen was a disposable single-patient-use prefilled pen containing 300 units of Humalog insulin. Each turn (click) of the dose knob dialed one unit of insulin. You could give from one to 60 units in a single injection; -Pull the pen cap off, wipe the rubber seal with alcohol swab, check the liquid in the pen and ensure the liquid is clear. Select a new needle, remove the paper tab from the outer needle shield, push the capped needle straight onto the pen and twist the needle on until tight. Pull off the outer needle shield and remove the inner needle shield; -Prime. If you do not prime before each injection you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle; -Turn the dose knob and select the number of units you need to inject and administer the medication; -Choose your injection site. Humalog is injected subcutaneously (under the skin) in your stomach area, buttocks, upper legs, upper arms; -Wipe skin with an alcohol swab and let the skin dry before you inject your dose; -Insert the needle into the skin. Push the dose knob all the way in; -Continue to hold the dose knob in and slowly count to five before removing the needle. 1. Review of Resident #51's May 2024 Physician Order Sheets (POS) showed the following: -Diagnosis of type 2 diabetes mellitus; -Humalog Kwik Pen Insulin (insulin Lispro) 100 units/milliliter (ml) subcutaneous (sub-q) (tissue just below the skin) inject 30 units with lunch; -Accucheck (blood glucose test) four times daily and at bedtime; -Humalog KwikPen Insulin (insulin Lispro) insulin pen, 100 units/ml; amount per sliding scale (a dose amount to be determined based on the accucheck); if blood sugar is 150 to 200 give two units, if blood sugar is 201 to 250 give four units, if blood sugar is 251 to 300 give six units, if blood sugar is 301 to 350 give seven units, if blood sugar is 351 to 400 give 10 units, if blood sugar is greater than 400 give 12 units subcutaneous. Observation on 5/9/24 at 11:45 A.M. showed the following: -Licensed Practical Nurse (LPN) W obtained the resident's blood sugar level with results of 289 milligrams per deciliter (mg/dL) and determined Humalog sliding scale Insulin dose was to be six units; -LPN W obtained the resident's Humalog flex pen from the top medication cart drawer, removed the lid, cleansed the tip with an alcohol pad and attached a new sterile needle; -LPN W did not prime the insulin pen; -LPN W dialed 36 units of Humalog insulin (Humalog 30 units scheduled and six units sliding scale) and administered the medication in the resident's subcutaneous tissue of the abdomen; -LPN W did not hold the dose knob in for five seconds before removing the needle. 2. Review of Resident # 39's May 2024 POS showed the following: -Diagnosis of type 2 diabetes mellitus; -Humalog Kwik Pen Insulin (insulin Lispro) 100 u/ml sub-q, inject 16 units with lunch; -Accucheck four times daily; -Humalog KwikPen Insulin (insulin Lispro) insulin pen; 100 u/ml; amount per sliding scale; if blood sugar is 200 to 250 give two units, if blood sugar is 251 to 300 give four units, if blood sugar is 301 to 350 give six units, if blood sugar is 351 to 400 give eight units, if blood sugar is greater than 400 give nine units subcutaneous. Observation on 5/9//24 at 12:03 P.M showed the following; -LPN W obtained the resident's blood glucose level with a blood glucose reading of 187 mg/dL and determined that sliding scale insulin was not needed; -LPN W obtained the resident's Humalog Kwik pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new sterile needle; -LPN W did not prime the insulin pen; -LPN W dialed up 16 units of Humalog insulin and administered the medication in the resident's subcutaneous tissue of the abdomen; -LPN W did not hold the dose knob in for five seconds before removing the needle. 3. Review of the Resident #109's May 2024 POS showed the following: -Diagnosis of type 2 diabetes with hyperglycemia (elevated blood sugar); -Accucheck before meals and at bedtime; -Humalog Kwik Pen Insulin (insulin Lispro) 100 u/ml sub-q, inject eight units with lunch; -Humalog KwikPen Insulin (insulin Lispro) insulin pen, 100 units/ml; amount per sliding scale ( a dose amount to be determined based on the amount of sugar in the blood); if blood sugar is 70 to 140 give zero units, if blood sugar is 141 to 180 give three units, if blood sugar is 181 to 220 give six units, if blood sugar is 221 to 260 give nine units, if blood sugar is 261 to 300 give 12 units, if blood sugar is 301 to 350 give 15 units if blood sugar is greater than 350 call MD. Observation on 5/9/24 at 12:10 P.M. showed the following: -LPN W obtained the resident's blood sugar level with results of 195 mg/dL and determined Humalog insulin sliding scale dose was to be six units; -LPN W obtained the resident's Humalog Kwik pen from the medication cart, cleaned the tip with an alcohol pad and attached a new sterile needle; -LPN W did not prime the insulin pen; -LPN W dialed up 14 units of Humalog insulin (Humalog eight units scheduled and six units sliding scale), cleansed the site and administered the medication in the subcutaneous tissue of the abdomen; -LPN W did not hold the dose knob in for five seconds before removing the needle. During an interview on 5/28/24 at 09:00 A.M. LPN W said the following: -Insulin pens should be primed; -Insulin pen should be held in place on the residents skin for five to six seconds according to manufacturer's recommendations. During an interview on 05/14/24 at 1:00 P.M., the Director of Nursing said the following: -She expected staff to prime insulin needles; -She expected staff to hold following administration; -She expected staff to administer insulin in accordance with facility policy, physician orders, and manufacturer guidelines. During an interview on 5/22/24 at 1:10 P.M., the administrator said she would expect nursing staff to prime and administer insulin pens as recommended by the manufacturers recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use disposal methods for controlled medications that involved a secure and safe method to prevent diversion and/or accidental exposure. The facility failed to keep discontinued/outdated Schedule II medications (narcotic medications with a high potential for abuse) stored in containers or cabinets and under double lock in the medication room. The facility failed to ensure staff kept medications locked up or secured when staff left medications unattended and not within sight on the medication cart and at the nursing desk and left the medication cart unlocked. The facility census was 149. Review of the facility's policy, Disposal of drugs, revised 12/2020 showed the following: -Medications not authorized for release to a resident by the physician at discharge and any expired medications must be destroyed on site by two professionals. Record of disposal shall be retained by the facility for at least seven years in the resident's chart. The policy did not address how staff were to dispose of drugs. Review of the facility's policy, Storage of drugs, revised 05/2013 showed the following: -Schedule II drugs are stored in containers or cabinets under double lock in the medication room. Only the charge nurse or medication nurse has access to the narcotics keys. The key to the narcotic compartment or cabinet is not the same as the medication room or medication cart key. - No discontinued, outdated, or deteriorated drugs or medications are stored in the facility over thirty days; -Compartment and areas containing drugs are locked when not in use or when left unattended. Such areas include drawers, cabinets, rooms, refrigerators, carts and boxes. Review of the facility's policy, returns/refusals revised 03/2017 showed the following: -All drugs which are discontinued or remain after a resident expires, or is discharged , shall be returned to the issuing pharmacy or destroyed; -No controlled drugs may be returned to the pharmacy, but must be destroyed on site, by two licensed nurses or a pharmacist and a licensed nurse by the end of shift; -Medications in the facility which are beyond their date of expiration shall be removed and destroyed by two nurses/Certified Medication Technicians (CMT's) and indicated on the resident's medication destruction record; -The policy did not address how drugs were to be disposed of. 1. Observation on 5/9/24 at 3:00 P.M. in the locked medication room at the 500 hall nurses' station, showed a small, opened sharps container on the counter that was three fourths full of medication tablets; water was not visible (the medications were not under double lock in the medication room as the policy instructed). During an interview on 5/9/24 at 3:00 P.M. Licensed Practical Nurse (LPN) V said the small biohazard container on the counter contained controlled medications to be destroyed. The process for destruction of controlled medications was to have two nurses put the medications in a small biohazard container with a small amount of water, fill out the medication destruction log, fill out the destruction log in Mediprocity (part of the electronic medical records for pharmacy) and when the small sharps container is full, it is put in the biohazard to be picked up. The small sharps container contains the controlled medications. 2. Observation on 5/10/24 at 1:00 P.M. in the locked medication room at the 100 hall nurses' station showed a small sharps container on the counter that was half full of medication tablets; there was no water visible in the container. The medications were not under double lock in the medication room as the policy required. During an interview on 5/10/24 at 1:00 P.M. Registered Nurse (RN) Q said to destroy controlled medications, it takes two nurses that put medications in the small sharps container with a small amount of water, fill out the medication destruction log on paper and in Mediprocity (a secure messaging system) and when the sharps container is full, it goes to the biohazard to be picked up. During an interview on 5/13/24, at 11:55 A.M., LPN R to destroy controlled medications two nurses pop the medications out of the medication cards and put in the small sharps container with water to dissolve; the medications are signed out as destroyed on the medication destruction log and in Mediprocity and when the container is full, it goes to the biohazard to be picked up. During an interview on 5/14/24 at 1:00 P.M., the Director of Nursing said the following: -To destroy medications two nurses pop out the medications and put them in the sharps containers; -Small sharps container are used for controlled medications; -The nurses fill out the paper destruction log and one in Mediprocity; -Water or some sort of liquid is added to the sharps containers to dissolve the tablets and when the container is full, it will be sent with the biohazard company. 3. Review of Resident #84's Physician Orders, dated 5/08/24, showed the following: -Macrobid (antibiotic) 100 milligrams (MG), give one capsule two times daily for urinary tract infection (UTI), start 5/08/24; -Florastor (probiotic) 250 mg. capsule, give one capsule two times daily for UTI, start date 5/08/24. Review of Resident #135's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/07/24, showed the following: -Diagnoses included Alzheimer's disease (the most common type of dementia) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities); -The resident had severe cognitive impairment. Observation on 5/08/24 at 8:14 P.M., showed the following: - medication card containing 14 Macrobid 100 mg capsules sat on the nurses desk unattended; -Medication card containing 20 Florastor 250 MG capsules sat on the nurses desk unattended; -No staff was in sight; -Resident #135 sat at the nurses' desk, on the opposite side as the medications, rolling ace wrap bandages. During an interview on 5/08/24 at 8:17 P.M., LPN AA said the medications were delivered from the pharmacy. He/She had signed for the medications, but had not had the opportunity to lock them up. He/She was responsible for the medications. Medications were not supposed to be left on the nurses desk unattended. During an interview on 5/08/24 at 8:19 P.M., the Administrator said medications are expected to be locked in a medication cart and not left on the nurses' desk. Medications should not be left unattended on a nurses' desk with a resident sitting on the other side of the desk. 4. Review of Resident #800's face sheet showed his/her diagnoses included chronic diastolic (congestive) heart failure (a condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), essential hypertension (high blood pressure), pulmonary hypertension (a type of high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and pain. Review of the resident's physician orders, dated May 2024 showed the following: -Amlodipine (anti hypertensive) 10 mg give one tablet a day; -Carvedilol (heart failure) 12.5 mg give one tablet twice daily; -Citalopram (anti depressant) 20 mg give one tablet a day; -Gabapentin (pain) 100 mg capsule, give 200 mg three times a day. Observation on 5/10/24 at 11:25 A.M., showed the following: -A medication cart sat in the hallway near the resident's room; -The medication cart was unlocked and unattended; -The following medications sat on top of the unattended, unlocked medication cart: -A medication card containing eight amlodipine 10 mg. tablets; -A medication card containing 18 carvedilol 12.5 mg. tablets; -A medication card containing seven citalopram 20 mg. tablets; -A medication card containing 14 capsules of gabapentin 100 mg; -LPN BB sat in the resident's room; the medication cart was not in sight; -Two staff members and one visitor walked by the unattended, unlocked medication cart. During an interview on 5/10/24 at 11:29 A.M., LPN BB said the medication cart should not be left unlocked and unattended in the hallway. The medications which were on top of the cart should not have been left unattended and should have been put up before going to the resident's room to administer medication. 5. Observation on 5/9/24 from 10:17 A.M. to 10:19 A.M. in the hallway outside room [ROOM NUMBER] showed the following: -An unlocked medication cart sat in the hallway outside room [ROOM NUMBER]; -LPN XX stood in the resident's room with his/her back to the door and to the medication cart; -LPN XX administered the resident's medications and gave him/her a drink of water; -The medication cart was not in line of sight of LPN XX; -The top drawer of the medication cart was open approximately two inches; -An opened bottle of polyethylene glycol (laxative) sat on top of the cart; -A resident propelled past the opened medication cart in his/her power chair; -An activity staff member pushed another resident in a wheelchair down the hallway and past the cart. During an interview on 5/9/24 at 10:19 A.M. LPN XX said the following: -He/She usually locks the medication cart when he/she enters a resident's room; -He/She didn't lock the medication cart today, he/she did not know why; -He/She usually tried to park the medication cart closer to the resident's room; -The medication cart contains multiple residents' medications. During an interview on 5/14/24 at 12:52 P.M., the Director of Nursing (DON) said all medication carts needed to be locked if they were unattended. She expected all medications to be locked in the medication carts and expected no medications to be left out of a medication cart unattended. During an interview on 5/22/24 at 1:10 P.M. , the Administrator said the following: -She would not expect medications to be left on top of a medication cart sitting in 100 hallway unattended; -She would not expect that same medication cart to be left unlocked in 100 hallway when two staff members and one visitor passed by and staff were out of sight of the cart; -She would expect the medication cart to be locked if unattended on division 200 when resident was standing right next to the cart.

Based on observation, interview, and record review, the facility failed to ensure meals were served to meet the needs of the residents when staff failed to prepare and serve all items listed on the menu, failed to serve food items for each diet type according to the menu, and failed to serve the correct serving sizes per the menu. The facility census was 149. 1. Review of the diet spreadsheet menu for the lunch meal on 5/8/24 showed the following: -Staff was to serve fruit garnish (2 ounces) to residents with a regular, finger foods, low sodium, and no concentrated sweets (NCS) diet; -Staff was to serve a peach half (2 ounces) to residents with a mechanical soft diet; -Staff was to serve pureed peach (2 ounces) and pureed tomato (2 ounces) to residents with a pureed diet. Review of the resident diet roster for the 500/600 division, obtained on 5/7/24 from the dietary manager, showed the following: -Eleven residents were on a mechanical soft diet; -One resident was on a pureed diet with one additional resident who could receive pureed items upon request. Observation on 5/8/24 from 12:30 P.M. to 1:37 P.M., in the 500/600 division servery, showed no fruit garnish, peach half, pureed tomato, or pureed peach arrived in the food items delivered from the kitchen nor did staff serve any of these items to residents during the lunch meal service. During an interview on 5/9/24 at 8:44 A.M., Dietary Aide H said he/she was unaware the fruit garnish, peach half, pureed tomato, or pureed peach were to be served during the lunch meal and confirmed he/she did not prepare these items. He/She referred to the weekly at-a-glance menu rather than the diet spreadsheet menu and must have missed these items. Review of the weekly at-a-glance menu showed fruit garnish was listed for the lunch meal on 5/8/24. The peach half, pureed tomato, and pureed peach were not listed on the weekly menu. During an interview on 5/9/24 at 12:37 P.M., Dietary Aide I said he/she went to the kitchen to pick up food items to serve in his/her respective servery. If the kitchen staff did not prepare a food item for a meal, he/she only served what was prepared. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said she expected staff to follow, prepare, and serve all items listed on the diet spreadsheet menu. 2. Review of the diet spreadsheet menu for the lunch meal on 5/8/24 showed staff was to serve sugar-free chocolate pudding to residents with a no concentrated sweets (NCS) diet and low-sodium soup to residents on a low sodium (LS) diet. Review of the facility-wide resident diet order report, obtained on 5/7/24 from the dietary manager, showed 32 residents had a physician's order for a NCS diet and seven residents had a physician's order for a LS diet. Review of the resident diet roster for the 500/600 division, obtained on 5/7/24 from the dietary manager, showed the following: -Fifteen residents were on a NCS diet; -One resident was on a LS diet. Observation 5/8/24 from 12:30 P.M. to 1:37 P.M., during the lunch meal service in the 500/600 division servery, showed the following: -The facility's dietitian and Dietary Aide G served minestrone soup to residents. No soup identified as low-sodium was served to residents; -Various staff aides obtained individual bowls of pre-portioned pudding from the servery's cooler and served the pudding to residents. None of the bowls were marked or indicated as being sugar-free pudding. During an interview on 5/8/24 at 1:39 P.M., the facility's dietitian said the food items served from the 500/600 division servery were delivered from the kitchen. She confirmed no sugar-free pudding or low-sodium soup food items were brought from the kitchen nor were these items served to residents during the 5/8/24 lunch meal service. During an interview on 5/9/24 at 8:44 A.M., Dietary Aide H confirmed he/she scooped regular chocolate pudding into individual bowls that was served in the main dining room and all the facility's serveries for the lunch meal service on 5/8/24. He/She was unaware residents with a NCS diet were to receive sugar-free pudding for the meal. He/She didn't think the facility even had sugar-free pudding and confirmed this by looking for the item in the dry storage room with negative findings. During an interview on 5/9/24 at 8:48 A.M., [NAME] A said he/she prepared regular minestrone soup for the 5/8/24 lunch meal service and did not prepare a separate low-sodium soup. The soup was served in the main dining room and all the facility division serveries. He/She did not add salt to the pre-packaged soup and usually only made a low-sodium option if it there was a cream-based soup on the menu. Review of the recipe for minestrone soup showed the sodium content was 239 milligrams per six-ounce serving. During an interview on 5/24/24 at 3:37 P.M., the facility's corporate dietitian said the following: -She expected staff to follow the diet spreadsheet menu and residents' physician diet orders; -If a low-sodium food item, such as low-sodium soup, was indicated on the spreadsheet menu to be served to residents with a low-sodium diet, she expected staff to prepare and serve that item to those residents; -A resident with a low-sodium diet order should consume under 2,500-3,000 milligrams of sodium daily (total for all food items); -Diet rosters that listed residents and their associated orders were available for staff to utilize; -Staff serving food to residents were responsible to ensure residents were served the correct diet order; -She expected staff who brought residents' food trays from the servery to double-check that the residents were receiving the correct food for their diet type. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said she expected staff to follow the diet spreadsheet menu and resident's physician diet orders. 3. Record review of the facility's undated policy, Portion Variations, showed the following: -The menu diet spreadsheets will indicate specific portions to be served at each meal to meet the dietary reference intakes and specific state and federal guidelines if required; -Residents requiring portion variations will be served according to the information listed on their diet sheet or diet spreadsheet; -Information on the meal card will be used to guide serving sizes that are different from the diet spreadsheet. Review of the diet spreadsheet menu for the lunch meal on 5/8/24 showed staff was to serve 4 ounces of chocolate pudding to residents on regular, mechanical soft, pureed and low sodium diets. Observation on 5/8/24 at 10:49 A.M. showed Dietary Aide H used a 3-ounce scoop to serve chocolate pudding into individual bowls for the lunch meal. Observation 5/8/24 from 12:30 P.M. to 1:37 P.M., during the lunch meal service, at the 500/600 division servery, showed staff served the individual bowls of pre-portioned (3 ounces) pudding to residents. During an interview on 5/9/24 at 8:44 A.M., Dietary Aide H confirmed he/she used a 3-ounce scoop to serve pudding into bowls for the lunch meal. He/She normally used that size scoop for serving pudding and was unaware the diet spreadsheet menu indicated the pudding was to be served at a 4-ounce portion size. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said she expected staff to serve correct portion sizes by following the diet spreadsheet menu.

Based on observation, interview and record review, the facility failed to prepare and serve food at a safe and appetizing temperature and to conserve the flavor of food items. The facility census was 149. 1. Review of the facility's undated policy, Monitoring Food Temperatures for Meal Service, showed the following: -Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures; -The temperature for each food item will be recorded on the Food Temperature Log. Foods that required corrective action (such as reheating), will have the new temperature recorded with a circle around it next to the original temperature; -If the serving/holding temperature of a hot food is not at 135 degrees Fahrenheit (F) or higher when checked prior to meal service, the item will be reheated to at least 165 degrees F for a minimum of 15 seconds; -If the serving/holding temperature of a cold food item or beverage is not at 41 degrees F or below (for less than four hours in duration) when checked prior to meal service, the item will be chilled on ice or in the freezer until it reaches 41 degrees F or less before service; -Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees F or greater to promote palatability for the resident; -Any complaint regarding food temperatures by residents will be documented on the food temperature log. Complaints will be investigated by conducting a test tray for that meal to determine if foods are remaining above 120 degrees F. The investigation is recommended to be completed within 72 hours of the complaint; -All room trays are sent to the room with a tray ID. The ID will list the resident's name, diet, room number. Review of the following recipes and manufacturer label showed the following: -Pureed broccoli salad, hold or serve cold food at or below 41 degrees F; -Mechanical soft broccoli salad, hold or serve cold food at or below 40 degrees F; -Pureed Italian club on hoagie roll, hold or serve cold food at or below 41 degrees F; -Turkey on hoagie roll, hold or serve cold food at or below 40 degrees F; -Mayonnaise, refrigerate after opening. Review of the 500/600 servery binder temperature log, for the lunch meal on 5/8/24, showed the following entries: -Entrée, 40 degrees F; -Starch, 38 degrees F; -No temperature entries recorded for cold item, mechanical entrée, puree entrée, puree starch, and vegetable. Observation 5/8/24 from 12:30 P.M. to 1:37 P.M., in the 500/600 division servery, showed staff served pureed broccoli salad, mechanical soft broccoli salad, pureed Italian club on hoagie roll, French fries, and turkey on hoagie roll (with mayonnaise) to residents in the associated dining rooms and halls during the lunch meal service. Mayonnaise, located in individual condiment cups, sat on a cart and was not on ice. Observation on 5/8/24 at 1:42 P.M. of the lunch meal test tray obtained after all residents had been served on the 500/600 division, showed the following (temperatures of food items obtained using a calibrated probe-style thermometer): -The temperature of the pureed broccoli salad was 51.4 degrees F; it tasted warm and was not cool to taste; -The temperature of the mechanical soft broccoli salad was 53.1 degrees F; it tasted warm and was not cool to taste; -The temperature of the pureed Italian club was 59.2 degrees F; it tasted lukewarm and was not cool to taste; -The temperature of the turkey on hoagie roll was 52.7 degrees F and tasted warm; -The temperature of the mayonnaise was 78.3 degrees F and tasted lukewarm; -The temperature of the French fries (alternate food item) was 95.4 degrees F and were very cool to taste. During an interview on 5/9/24 at 12:37 P.M., Dietary Aide I said the following: -Hot food items should be 160 to 170 degrees F at the steam table and close to that temperature when residents receive their food; -Cold foods should be at least 40 degrees F or below and should be held on ice. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said the following: -She expected hot foods to be served hot and cold foods to be served cold; -Hot food items should be held at 140 degrees F and served at 130 degrees F on the halls; -Cold food items should be held and served at or below 40 degrees F; -Each servery had a temperature log book for staff to record temperatures of food items at each meal. 2. Review of the diet spreadsheet menu, for the lunch meal on 5/8/24, showed staff were to serve a mechanical soft ground Italian meat and cheese on hoagie sandwich to residents on a mechanical soft diet. Review of the weekly at-a-glance menu, for the lunch meal on 5/8/24, showed cheeseburgers were an alternate daily food item available to residents. Review of the recipe for mechanical soft ground Italian meat and cheese on hoagie bun showed the following preparation instructions: 1. Slice buns in half lengthwise; 2. Spread each roll half with Italian dressing (one teaspoon) and mayonnaise (one teaspoon); 3. Measured desired number of servings of meat into food processor. Grind to appropriate consistency. If needed, add gravy or broth to moisten meat; 4. Place a #10 scoop of meat on bun along with half slice of cheese. Top with second half of bun and slice sandwich in half. Observation on 5/8/24 at 1:42 P.M. of the lunch meal test tray obtained after all residents had been served on the 500/600 division, showed the following: -No mayonnaise was spread on the bun for the mechanical soft ground Italian meat and cheese on hoagie bun. The meat mixture tasted overwhelmingly of mayonnaise; -The French fries (alternate food item) tasted very dry and bland; -The cheeseburger lacked flavor. During an interview on 5/9/24 at 8:44 A.M., Dietary Aide H said the following: -He/She prepared the meat for the mechanical soft ground Italian meat and cheese on hoagie sandwich by adding mayonnaise, rather than broth, to the ground meat mixture when he/she processed the meat in the food processor; -He/She did not refer to a recipe but thought mayonnaise was an appropriate item to use in moistening the mechanical soft meat. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said the following: -Food served to residents should taste good; -Staff should follow recipes for food items and recipes should be readily available to staff; -Recipes were kept in a binder in the food preparation area and, if a recipe was not in the book, staff should ask her for the food item's recipe; -She started working for the facility approximately eight weeks ago and had not yet conducted a test tray to evaluate food taste or temperature.

Based on observation, interview, and record review, the facility failed to ensure residents, including those with a physician's order for a mechanical soft diet, received food items with the proper texture to allow for foods to be easily swallowed. The facility census was 149. 1. Review of the facility policy, admission Diet Orders, effective June 2021, showed the following: -Purpose: To ensure each resident has a diet order prescribed by the physician and documented in the medical health record. The safest diet for each resident will be ordered; -All diet orders will be reviewed upon admission by the charge nurse to assure that they conform to the language of the facility offered diets; -If there is a particular dysphagia diet that is not offered by the facility, the diet should be downgraded to a diet used in the community until a speech therapist can evaluate the resident; -A speech therapist consult should be initiated for all residents on texture modified diets for the evaluation of the appropriate diet for safe consumption by the resident; -Samples of appropriate diet modifications: minced and moist - pureed, soft and bite size - pureed, easy to chew - mechanical soft; -The diet recommended by the speech therapist should be brought to the attention of nursing, approved by the physician, and entered into the electronic health record. Review of the facility's Diet Manual, 2024 edition, showed the following: -Summary of Diets: Mechanical Soft Diet - This consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. The diet follows the Regular Diet planned and provides foods that can be more successfully and easily chewed. The diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. Review of the facility-wide resident diet order report, obtained on 5/7/24 from the dietary manager, showed the following: -24 residents had a physician's order for a mechanical soft diet; -133 residents had a physician's order for a regular texture (including those with finger foods) diet. Review of the diet spreadsheet menu, for the lunch meal on 5/8/24, showed staff was to serve chopped steamed broccoli to residents on a mechanical soft diet. Review of the weekly at-a-glance menu, for the lunch meal on 5/8/24, showed a cheeseburger was a daily alternate food item available to residents. During an interview on 5/9/24 at 8:44 A.M., Dietary Aide H said he/she made mechanical soft broccoli salad for the lunch meal on 5/8/24. He/She had [NAME] A steam the broccoli so it wasn't so hard then he/she added mayonnaise and cheese to it to make the salad. Observation 5/8/24 from 12:30 P.M. to 1:37 P.M., during the lunch meal service, at the 500/600 division servery, showed staff served mechanical soft broccoli salad (instead of chopped steamed broccoli) to residents with a mechanical soft diet. Observation on 5/8/24 at 1:42 P.M. of the lunch meal test tray obtained after all residents had been served on the 500/600 division, showed the following: -Mechanical soft broccoli salad - numerous edges of the broccoli pieces were hard and the softness was in between cooked and raw broccoli. The salad contained large-sized chunks of broccoli measuring approximately one-quarter inch, and was difficult to chew and swallow; -French fries (alternate item) had hard edges that were difficult to chew; -The bottom bun of the cheeseburger was very hard and tough especially around the edges and was difficult to chew. 2. Observation on 5/9/24 at 12:45 P.M. in the 100 hall dining room showed the following: -Resident #11 sat at the dining room table; -Staff served the resident fried fish; -The crust on the fish was dark brown and appeared crispy; -The resident attempted to cut the fish with the plastic fork and could not; -The resident took his/her fork, poked it into the piece of fish and held the piece of fish up; -The resident said he/she couldn't cut the fish, it was too tough. Observation on 5/9/24 at 12:50 P.M. in the 100 hall dining room showed the following: -Resident #47 sat at the dining room table; -Staff served the resident fried fish; -The crust on the fish was dark brown and appeared crispy; -The resident tried to cut his/her fish and could not; -The resident said he/she was trying to cut his/her fish but the fish was too hard to cut. Observation on 5/9/24 at 12:51 P.M. in the 100 hall dining room showed the following: -Resident #20 sat at the dining room table; -The Restorative Aide served the resident a plate of fried fish; -The Restorative Aide attempted to cut the fish into bite sized pieces; it took the RA several minutes to cut up the fish; -The RA dipped a piece of fish into the tartar sauce and gave the resident a bite; -The resident had no teeth; -The resident chewed and chewed for several minutes and eventually swallowed the fish. During an interview on 5/9/24 at 2:02 P.M. Resident #20 said he/she couldn't eat the regular piece of fish so staff gave him/her softer fish as he/she had no teeth. Observation on 5/9/24 at 1:00 P.M. of a test tray showed the outer breading was crunchy and the fish was hard to chew. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said food served to residents should be prepared at the correct texture and should not be tough or difficult to chew.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to follow appropriate infection control and prevention procedures while providing care to 12 residents, (Resident #11, 58, 59, 74, 77, 78, 87, 89, 120, 121, 309 and 606), in a review of 35 sampled residents. Staff failed to use appropriate hand washing and gloving techniques while providing care, failed to wear appropriate personal protective equipment (PPE), failed to utilize enhanced barrier precautions (EBP) during care and failed to ensure proper infection control was utilized for respiratory care supplies. The facility census was 149. Review of the facility policy, Enhanced Barrier Precautions (EBP), revised 3/2024, showed the following: -Purpose was to reduce the spread of multi-drug resistant organisms (MDRO); -EBP was indicated for residents with any of the following: Infection or colonization with a Centers for Disease Control (CDC)-targeted MDRO when contact precautions do not otherwise apply; or, wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Procedure: -Residents with colonization of MDRO and/or with indwelling medical devices (central lines (an intravenous line placed in a large vein like the neck or near the heart to administer medications or draw blood), gastrostomy tubes (G-tubes) (surgically inserted tube that provides direct access to the stomach for nutrition, hydration or medicine), foley catheters (flexible tube inserted into the bladder to drain urine) ) will be placed on EBP; -Signage will be placed outside of their rooms to alert staff that personal protective equipment (PPE) is needed; -PPE including gowns and gloves, will be available immediately outside of the resident room; -PPE should be worn during high-contact resident care activities: dressing, bathing/showering, transferring (not needed when transferring in common areas), providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing, chronic wound examples include pressure injuries, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers (a wound on the leg or ankle caused by abnormal or damaged veins); -Trash can will be placed inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room; -Private room is not required; -Resident may participate in communal activities and dining. Review of the facility policy, Gloves, revised 6/21, showed the following: -Purpose: To prevent the spread of infection and disease to residents and employees, to protect wounds from contamination, to protect hands from potentially infectious matter, and to prevent exposure to blood borne pathogens; -Procedure: Gloves are to be used when touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin, when employee's hands have any cuts, scrapes, wounds, dermatitis, etc, when cleaning up spills or splashes of body fluids, when it is likely that hands will come into contact with blood, body fluids, or other potentially infectious material, whenever in doubt; -When gloves are indicated, disposable single-use gloves are to be worn; -After use, remove gloves in the following manner: using one hand, pull the cuff down over the opposite hand turning the glove inside out, discard the glove into the waste can inside the resident's room, with the un-gloved hand, pull the cuff down over the opposite hand turning the glove inside out; again, discard in waste can in resident's room; -Wash hands after removing gloves, gloves do not replace hand washing; -Reminder: do not wear gloves in the hallway; dispose of in resident's room. Review of the facility policy, Hand Washing, revised 1/21, showed the following: -Purpose: to provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections; -Procedure: Check for adequate paper towels before starting the handwashing procedure, wet hands with water, apply two squirts of soap, using friction, rub hands together, cleaning under nails and between fingers thoroughly, wash up to your wrist as well, do this for at least 20 seconds, rinse hands well without touching the inside of the sink or the faucet (these are always considered soiled), leave water running, dry hands well, when finished, turn off faucet with a clean paper towel, discarded the towel in an appropriate trash container; -When to wash hands (at a minimum): when reporting to work and before going home, before eating and drinking, before and after using the toilet, after sneezing, coughing, or blowing your nose, after touching your hair, face, etc., after smoking cigarettes, before and after each resident contact, after touching a resident or handling his or her belongings, whenever hands are obviously soiled, after contact with any body fluids, after handling any contaminated items (lines, soiled diapers, garbage, etc.), after caring for residents with active clostridium difficile (a type of bacteria that can cause colitis (a serious inflammation of the colon)), before and after caring for residents with active Coronavirus Disease 2019 (COVID-19) (infectious disease) infection; -Procedure for using alcohol based hand rub (ABHR): the hands should be free of dirt and organic material, apply enough alcohol-based hand sanitizer to cover the entire surface of the hands and fingers, or a drop about the size of a nickel, rub the solution vigorously until dry, the ABHR may be used routinely for hand hygiene, unless hands are visible soiled; then soap-and-water handwashing is required, always wash hands with soap and water after blood or body fluid exposure; -When to use alcohol hand sanitizer: Only when visible soil is absent, after contact with residents' intact skin (as in taking a pulse, blood pressure or repositioning a resident). Review of the facility policy, Continuous Positive Airway Pressure (CPAP) (machine that uses mild air pressure to keep breathing airways open while you sleep)/Bi-Level Respiratory Care (non-invasive ventilation that helps one breathe) revised 7/2021 showed the following: Purpose: -Obstructive sleep apnea is a sleep disorder that occurs when the airway is obstructed or blocked and as a result, no air moves into or out of the lungs; -The obstruction may be due to a variety of factors including loss of muscle control over the tongue which may cause the tongue to fall back against the airway and/or the collapse of the soft palate over the airway; 4. Cleaning: a. DAILY: Wash mask with warm washcloth or CPAP mask wipes; NOTE: masks/cannula should be stored in mesh or comparable ventilated bag when not in use; Review of the policy did not include any direction to staff regarding storage of nebulizer masks when not in use. Review of the facility's Catheter Care Policy, revised 3/2021, showed the following: -Purpose: To keep indwelling catheter free of discharge and/or crusting which can cause infections; -Observation and Reporting: 4. Check tubing for positioning. Coil on bed; 5. Attach the urine collection bag to the bed frame only; 6. Never lift the bag above bladder level (source of infection); -No documentation showing were the urinary collection bag should be attached on a wheelchair, or that the bag should no be sitting on the floor or dragged on the floor when placed under a wheelchair. 1. Review of Resident #78's continuity of care document (CCD) showed he/she had diagnoses that included malignant neoplasm of lungs and brain (cancer), difficulty in walking, functional diarrhea and lower extremity contracture (tightening or shortening of muscle, tendons, skin or other tissue that can limit movement in a joint or body part) of right foot and right ankle. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/24, showed the following: -Dependent on staff for transfers and toileting; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 4/12/24 showed the following: -Incontinent of bowel and bladder; -Resident is at risk for skin breakdown related to limited mobility and incontinence; -Assess resident for presence of risk factors; treat, reduce, and eliminate risk factors to extent possible; -Provide incontinence care after each incontinent episode. Observation on 5/8/24 at 9:06 P.M. showed the following: -Certified Nurse Aide (CNA) RR and CNA SS came into the resident's room with a mechanical lift to provide incontinence care and get the resident ready for bed; staff donned gloves but did not use hand sanitizer or wash hands with soap and water prior to donning gloves; -Licensed Practical Nurse (LPN) TT came in to assist, donned gloves, but did not use hand sanitizer or wash hands with soap and water prior to donning gloves; -CNA RR used a disposable wipe to wipe down one side of the inner leg, folded the cloth, wiped down the other side of the inner leg, folded the cloth, wiped down the center genitalia from front to back and repeated with a clean disposable wipe; -LPN TT dried the front peri area with a washcloth and assessed the resident's skin; -CNA RR cleaned the resident's buttock of dried feces with disposable wipes; -LPN TT took a wash cloth to the bathroom sink to get it wet and then cleaned the resident's buttocks with the wet wash cloth; -LPN TT used a towel to dry the resident's buttock and doffed gloves; he/she did not wash hands with soap and water and donned new gloves, opened the new package of briefs, removed a clean brief, handed it to CNA SS, grabbed a tube of zinc cream and gave it to CNA SS to apply to the resident's buttock; -CNA SS applied cream to the resident's buttock and with soiled gloves, helped CNA RR put a clean brief on the resident; he/she then doffed gloves, placed dirty linens in a clear bag, tied it up then washed hands; -CNA RR doffed gloves, washed hands, donned new gloves and a put a new gown on the resident, doffed gloves and washed hands; -LPN TT doffed gloves and left the resident's room without hand washing or hand sanitizing. During an interview on 5/8/24 at 8:50 P.M., LPN TT said handwashing should be done before and after care. 2. Review of Resident #58's CCD showed he/she had diagnoses that included urinary tract infection (UTI), personal history of urinary tract infections, neuromuscular dysfunction of bladder (when the brain, spinal cord or nerves that control bladder function are damaged), and retention of urine (difficulty completely emptying the bladder). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Dependent on two or more staff for transfers, hygiene, dressing, showering/bathing, and toileting hygiene; -Has an indwelling catheter; -Occasionally incontinent of bowel. Review of the resident's care plan, revised 4/17/24 showed the following: -The resident was at risk for contracting a multi-drug resistant organism (MDRO) due to an indwelling device that requires the use of personal protective equipment during high contact activities; -The resident is on Enhanced Barrier Precautions (EBP); -Staff must perform hand hygiene before and after providing care; -Staff to wear gloves and gowns when providing high contact activities; -The resident had potential for recurrent UTI's related to history of UTI's; -Ensure meticulous personal hygiene, especially after elimination, keep perineal area clean and dry, use a front to back wiping technique; -If the resident was incontinent, provide peri care as soon as possible after incontinent episode, per facility policy, being sure to cleanse well and cleanse from front to back; -Use principles of infection control and universal/standard precautions. Review of the resident's physician order sheet (POS), dated 4/17/24, showed the following: -Gloves and gowns for all high contact tasks; -Wear eye protection if splash anticipated. Observation of the area outside the resident's room and of CNA UU on 5/8/24 at 8:25 P.M. showed the following: -A precaution sign outside the resident's room that instructed everyone must clean hands before entering and after leaving the room and wear gloves and gown for high contact resident care activities, additional personal protective equipment may be required for standard precautions; -Personal Protective Equipment (PPE), including gowns, gloves, trash bags and hand sanitizer was outside the resident's room; -CNA UU walked into the resident's EBP room without gowning or washing hands with soap and water or sanitizing hands. He/She donned gloves, grabbed the graduate container (a container to measure the amount of liquids) from the resident's bathroom and emptied the resident's urine from the urine collection catheter bag into the graduate container, emptied the urine into the toilet, rinsed the graduate container out with water from the bathroom sink and dumped it into the toilet. CNA UU did not wear goggles or a face shield. CNA UU doffed gloves, and without washing his/her hands with soap and water or using hand sanitizer, touched the resident's candy from the bedside table with his/her bare hands and handed it to the resident; -He/She exited the room without hand sanitizing or hand washing and walked down the hallway to the clean utility room, got a roll of trash bags, took the trash bags back into the resident's room (without gowning or hand sanitizing or hand washing), donned gloves, emptied the trash, doffed gloves and left the room without hand sanitizing or washing hands. During an interview on 5/8/24 at 8:25 P.M., CNA UU said the following: -He/She was not sure what the precaution sign and PPE was for on the door; -The hand sanitizer on the wall in the hallway was always empty; -He/She didn't even notice there were supplies on the door. During an interview on 5/8/24, at 8:50 P.M., LPN TT said the following: -The PPE and EBP is for resident's that are more susceptible to infections and germs such as residents with a g-tube, compromised skin/wounds, catheters, etc; -Staff should gown and glove when entering the room and remove them before leaving the room; -Staff should wash hands before and after care and/or use the hand sanitizer that is on the door with the PPE supplies. 3. Review of Resident #74's annual MDS, dated [DATE], showed the following: -Dependent on staff for mobility, toileting hygiene and dressing; -Always incontinent of bowel. Review of the resident's care plan, revised 4/24/24, showed the following: -The resident was incontinent of bowel and/or bladder and needed assist with toileting; -The staff would provide incontinence care; -The staff would monitor the resident for incontinent episodes and provide peri care after each episode; -The resident had a deficit in activities of daily living (ADL) self-care and impaired functional mobility related to weakness; -The staff needed to provide assistance with ADL's. Observation on 5/08/24 at 7:55 P.M., showed the following: -CNA GG propelled the resident to his/her room; -CNA GG and Certified Medication Technician (CMT) HH entered the resident's room and donned gloves without washing their hands with soap and water or using hand sanitizer; -CNA GG and CMT HH used a mechanical lift to transfer the resident from his/her wheelchair to his/her bed; -The resident lay in his/her bed on his/her back; -CNA GG took off the resident's pants and with CMT HH's assistance, rolled the resident to his/her left side; -CNA GG took down the resident's brief and pushed it through his/her legs; -When CMT HH removed the resident's brief, the resident had been incontinent of feces; -CMT HH used wipes to complete perineal care for the resident. Without changing gloves and washing hands with soap and water, CMT HH applied a barrier cream to the resident's buttock. With soiled gloves, he/she then used his/her left hand on the resident's left side and pulled a clean brief up between the resident's legs. CNA GG helped to roll the resident to his/her back; -CNA GG used wipes to clean feces from inside of the resident's legs. Without changing gloves and washing hands with soap and water, CNA GG pulled the clean brief up and fastened the brief, pulled down the resident's gown and covered the resident up with his/her sheet and blanket. During an interview on 5/08/24 at 8:23 P.M., CMT HH said he/she should change his/her gloves when perineal care was completed. He/She washed his/her hands as soon as possible after perineal care was finished. He/She did not take his/her gloves off because he/she was not thinking. During an interview on 5/08/24 at 9:11 P.M., CNA GG said he/she was supposed to change his/her gloves when they were exposed to (feces) or when doing perineal care between the front and the back of a resident. He/She did not change his/her gloves when they became soiled with (feces) because he/she was moving too fast and not paying attention. He/She knew the reason for changing gloves was to prevent the transfer of germs. 4. Review of Resident #606's face sheet showed he/she had diagnoses that included hematuria (blood in urine) and benign prostatic hyperplasia (BPH) (a condition in which the prostate gland is enlarged). Review of the resident's physician orders, dated May 2024, showed the following: -Diagnosis for use of indwelling catheter: Urinary retention (inability of the bladder to completely empty) with a start date of 5/09/24; -Insert 16 french (size of tube diameter) urinary catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body) with 30 cubic centimeter (cc) balloon; to be changed per Centers for Disease Control and Prevention (CDC) guidelines; -Catheter was inserted on 5/9/24 with a start date of 5/9/24. Review of the resident's care plan, dated 5/9/24, showed staff was to ensure tubing or any part of the drainage system did not touch the floor. Observation on 5/13/24 at 11:12 A.M., 12:12 P.M., and 2:25 P.M., showed the resident sat in the common area in his/her wheelchair and his/her catheter bag sat directly on the floor underneath his/her wheelchair. Observation on 5/13/24 at 2:32 P.M. showed CMT FF pushed the resident down the hallway and his/her catheter bag dragged the floor underneath his/her wheelchair. During an interview on 5/13/24 at 2:30 P.M., CMT FF said the catheter bag should not be touching the floor. The catheter bag should be kept up off the floor to prevent infection. During an interview on 5/13/24 at 2:39 P.M., LPN EE said a catheter bag should not be touching the floor. A catheter bag should be kept off the floor to prevent infection. 5. Review of Resident #89's quarterly MDS, dated [DATE], showed the following: -Dependent on staff for toileting; -Indwelling catheter; -Diagnoses of stroke, neurogenic bladder (a urinary tract condition that occurs when the bladder doesn't empty properly due to a neurological condition or spinal cord injury), obstructive uropathy (urinary tract disorder that occurs when urine flow is blocked and causes the urine to back up into the kidneys) and diabetes. Review of the resident's care plan, dated 5/8/24, showed the following: -The resident requires an indwelling urinary catheter related to obstructive and reflux uropathy and retention; -Do not allow tubing or any part of the drainage system to touch the floor. Observation of the resident's room on 5/9/24 at 10:28 A.M., showed the following: -The resident lay in bed; -The resident's urinary collection bag sat directly on the carpeted floor; -The resident's urine was pink tinged with mucous and sediment in the tubing (normal urine is usually clear or cloudy, with a pale yellow to amber color and should not contain sediment). During an interview on 5/9/24 at 10:28 A.M., the resident said he/she has had urinary tract infections (UTIs) in the past. 6. Review of Resident #309's face sheet showed his/her diagnoses included fractured left and right femur. Review of the resident's care plan for Infection, dated 5/4/24, showed: -Resident is at risk for contracting an MDRO due to wounds that require the use of PPE during high contact activities; -Goal: resident risk for contracting an MDRO will be decreased; -Interventions: resident is on EBP; staff must perform hand hygiene before and after providing care and staff are to wear gloves and gowns when providing high contact activities. Resident can participate in communal and dining as long as excretions and secretions are contained. Discontinue EBP once wounds are healed or indwelling device is discontinued. Observation of the area outside the resident's room and of staff on 5/8/24 at 7:37 P.M. showed the following: -A sign on the door for EBP indicating that a gown and gloves should be worn; -A storage container with disposable gowns hung over the door; -CNA BBB entered the resident's room and the resident told the aide that he/she was uncomfortable and wanted to be repositioned; -CNA BBB washed his/her hands and donned a pair of gloves but did not put on a gown; -He/She then removed the pillows from the resident's head, fluffed the pillows and put the pillows back under the resident's head. Then removed the pillows from under the resident's legs and placed one pillow on the right side and then the left side; -He/She removed his/her gloves and washed his/her hands and left the room; -The resident had incisions to both hips and there were no dressing to the incisions on either hip. During an interview on 5/8/24 at 7:50 P.M., CNA BBB said the following: -He/She was not aware of what EBP meant; he/she was told that it had to do with residents who had an indwelling catheter or a wound; -He/She was not aware that a gown had to be worn when taking care of the resident. 7. Review of Resident #120's admission MDS, dated [DATE], showed the following: -Dependent upon staff for toileting and hygiene; -Continent of bowel and bladder; -Diagnoses of cancer and arthritis. Observation of staff on 05/08/24 at 8:23 P.M. showed: -LPN Z and CNA AAA entered the resident's room to change the dressing to the resident's wound on his/her coccyx (tailbone); -LPN Z and CNA AAA washed their hands and applied gloves; -LPN Z brought in a dressing in a package and a tube of medication and placed them on the sheet at the foot of the bed (used no barrier); -LPN Z rolled the resident to the right side and removed the resident's brief, the resident had been incontinent of urine; -LPN Z took a wipe and wiped each buttock with one wipe, then, with the same soiled gloves, took a clean wipe and patted the pressure ulcer that was on the resident's coccyx; -LPN Z removed his/her gloves, and without washing his/her hands with soap and water, went to the treatment cart that was outside of the resident's door and took several dressing supplies and a bottle of wound cleanser out of the cart and brought them back into the resident's room placing them on top of the wound dressing package; -Without washing his/her hands with soap and water, LPN Z put on a pair of gloves, took several of the gauze dressings, sprayed the wound cleanser directly on the pressure ulcer and dabbed the wound with the gauze dressings; -With soiled gloves, he/she removed the dressing from the package, placed the dressing on top of the opened package, opened the tube of ointment and put a quarter size amount of ointment on the dressing and placed the dressing on the pressure ulcer on the resident's coccyx; -Wearing the same gloves, LPN Z picked up the tube of ointment and left the room; -LPN Z returned to the room wearing the same soiled gloves, and he/she and CNA AAA removed the resident's blouse and helped place a gown on the resident. During an interview on 5/8/24 at 8:15 P.M., LPN Z said the following: -Gloves should be changed when visibly soiled or going from dirty to clean tasks and before and after wound care; -He/She should have changed his/her gloves when he/she had cleaned the wound and before he/she applied the new dressing; -Dressing supplies should have been put on a clean field, the sheets on the resident's bed would not have been a clean field. 8. Review of Resident #77's quarterly MDS, dated [DATE], showed the following: -Dependent on staff for toileting hygiene; -Continence: blank; -Diagnoses of cancer and diabetes. Review of the resident's care plan, dated 4/29/24, showed the following: -Resident requires an indwelling urinary catheter related to urinary retention; -Resident is at risk for skin breakdown related to decreased mobility and incontinence; -Provide incontinence care after each incontinent episode; -Provide assist with ADLs as indicated. Observation in the resident's room on 5/8/24 at 8:20 P.M. showed the following: -The resident lay awake in bed; -CNA DDD and LPN W entered the resident's room; -CNA DDD and LPN W applied gowns and gloves; -With gloved hands, LPN W unfastened the resident's brief and provided front pericare; -The resident was having a bowel movement which LPN W provided care for; there was visible feces on the disposable wipe; -Without changing gloves or washing his/her hands with soap and water, LPN W assisted CNA DDD with applying a clean brief with the soiled gloves; -With the same soiled gloved hands, LPN W folded the blanket at the end of the bed; -LPN W removed his/her gown and gloves and washed his/her hands; -CNA DDD and LPN W exited the room. Observation in the resident's room on 5/8/24 at 8:40 P.M. showed the following: -CNA DDD and LPN W entered the resident's room; -CNA DDD and LPN W applied gowns and gloves; -The resident was incontinent of a medium soft bowel movement; -CNA DDD and LPN W rolled the resident to his/her right side; -LPN W provided rectal pericare; -With the same gloved hands, LPN W picked up a package of wipes and pulled a clean brief out of the package; -With the same gloved hands, LPN W tucked the soiled brief under the resident's hips and placed a clean brief under the resident's hips; -With the same gloved hands, LPN W applied barrier cream to the resident's buttocks; -LPN W removed his/her gloves and without washing his/her hands with soap and water or using hand sanitizer, LPN W applied clean gloves; -LPN W administered a Dulcolax (laxative) suppository into the resident's rectum; -LPN W removed his/her gloves, and without washing his/her hands with soap and water or using hand sanitizer, applied clean gloves; -LPN W and CNA DDD rolled the resident side to side in bed and CNA DDD removed the soiled brief; -LPN W fastened the tabs on the new brief. During an interview on 5/28/24 at 9:00 A.M., LPN W said the following: -Hands should be washed before cares, before and after gloving; -Hands should be washed prior to applying gloves; -Hands should be washed or hand sanitizer use with each glove change; -Gloves should be changed and hand hygiene completed after touching soiled items or performing pericare prior to touching clean items. 9. Review of Resident #121's physician's orders, dated May 2024, showed the following: -Ipratropium-Albuterol solution (inhaled lung medication) 0.5 milligrams (mg)-3 mg/3 milliliter (ml) one vial inhalation: inhale contents of one vial via nebulizer (machine used to administer nebulized medications) every six hours as needed for shortness of breath/cough (start date 1/26/24); -No order regarding the storage of the nebulizer mask when not in use. Review of the resident's care plan, dated 5/1/24, showed no documentation regarding the use of as needed nebulizer treatments. Observation in the resident's room on 5/7/24 at 4:23 P.M. showed the resident's nebulizer mask lay directly on the bedside table and not in a bag. Observation in the resident's room on 5/13/24 at 11:22 A.M. showed the following: -The resident sat in his/her power chair doing bead work; -The resident's nebulizer mask lay directly on the bedside table and not in a bag. 10. Review of Resident #11's care plan, dated 5/8/24, showed the following: -The resident requires a CPAP mask; -Wash mask, tubing, head gear, humidifier chamber with warm soapy water and air dry. Observation in the resident's room on 5/8/24 at 10:00 A.M., showed the resident's CPAP mask lay directly on the bedside table, and was not stored in a bag or container per policy. There was no visible mesh or comparable ventilated bag in the room to use for storage of the mask. Observation in the resident's room on 5/9/24 at 10:23 A.M. showed the resident's CPAP mask lay directly on the bedside table, and was not stored in a bag or container per policy. There was no visible mesh or comparable ventilated bag in the room to use for storage of the mask. Observation in the resident's room on 5/13/24 at 11:40 A.M. showed the resident's CPAP mask lay directly on the bedside table, and was not stored in a bag or container per policy. There was no visible mesh or comparable ventilated bag in the room to use for storage of the mask. During an interview on 5/13/24 at 11:40 A.M., the resident said the following: -He/She wears his/her CPAP most nights; -Staff have to help him/her put on and take off the mask as he/she can't reach the machine or bedside table. During an interview on 5/13/24 at 11:45 A.M., CNA EEE said the following: -Sometimes he/she takes the CPAP off the resident when he/she comes in in the morning but sometimes the mask was already off; -He/She did not know anything about the mask being stored in something when not in use; -He/She has never seen the CPAP masks stored in a bag when not in use. During an interview on 5/13/24 at 12:50 P.M., LPN YY said the following: -There was no designated staff member responsible for the CPAP and nebulizer masks; -There were no orders to place the masks in a bag when not in use and he/she had not seen a bag for the masks used consistently; -Placing the mask in a bag would probably be a good idea. 11. Review of Resident #87's care plan, last revised 4/19/24, showed no documentation or instruction for storing the nebulizer system (mask, tubing and medication reservoir). Review of the resident's POS, dated 5/2024, showed the following: -Diagnoses included chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe); -Ipratropium-albuterol solution for nebulizer 0.5 mg-3 mg (2.5 mg base)/3 ml: one vial per inhalation four times daily as needed (PRN); -No instructions for the storage of the nebulizer system. Observations of the resident's room showed the following: -On 5/7/24 at 12:17 P.M. the resident lay in his/her bed with the nebulizer mask on, attached to the nebulizer machine and administering a treatment; -On 5/7/24 at 3:35 P.M., the resident's nebulizer system lay on the over-the-bed table (unbagged) ; -On 5/8/24 at 12:54 P.M. and 8:00 P.M., the resident's nebulizer system lay on the over-the-bed table (unbagged); -On 5/9/24 at 1:34 P.M., the resident's nebulizer system lay on the over-the-bed table (unbagged); -On 5/13/24 at 11:00 A.M., resident's nebulizer system lay on the over-the-bed table (unbagged);

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for three residents (Residents #26, #94 and #403), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy Pneumococcal Vaccination of Residents dated 2/2022 showed the following: Purpose: -To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP); Policy: -Upon admission, residents will be assessed for need of pneumococcal vaccination. ACIP recommends a single dose of PCV20 (Prevnar 20) for adults aged > 65 years who have not previously received the pneumococcal conjugate vaccine or whose vaccination history is unknown. For adults aged 19-64 years with certain underlying medical conditions or risk factors* who have not previously received the pneumococcal conjugate vaccine or who vaccination history is unknown, ACIP recommends a single dose of PCV 20; *The underlying medication conditions or risk factors warranting a dose of PCV20 in adults 19-[AGE] years old are: alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies; Special situations: -Adults who have previously received only PPSV23 (Pneumovax) may receive a dose of PCV20 > 1 year after their last PPSV23 dose. Shared clinical decision making between the resident and physician is recommended; -Adults aged > 65 years who have previously received PCV13 (Prevnar 13) should receive a dose of PPSV23 > 1 year after their dose of PCV13 (or > 8 weeks after PCV13 dose if immunocompromised). It should also be at least 5 years since a prior dose of PPSV23, if applicable; -Adults who have received PCV15 (Vaxneuvance) should receive a dose of PPSV23 > 1 year later (or > 8 weeks later if immunocompromised). Review of the CDC Pneumococcal Vaccination: Summary of Who and When to Vaccinate, reviewed 9/22/23, showed the following: -Adults 19 through [AGE] years old with any of these conditions or risk factors: 1. Alcoholism or cigarette smoking; 2. Cerebrospinal fluid leak; 3. Chronic heart disease, including congestive heart failure and cardiomyopathies, excluding hypertension; 4. Chronic liver disease; 5. Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma; 6. Cochlear implant; 7. Diabetes mellitus 8. Decreased immune function from disease or drugs (i.e., immunocompromising conditions); 9. Immunocompromising conditions include: a. Chronic renal failure or nephrotic syndrome; b. Congenital or acquired asplenia, or splenic dysfunction; c. Congenital or acquired immunodeficiency; d. Diseases or conditions treated with immunosuppressive drugs or radiation therapy; e. HIV infection; f. Sickle cell disease or other hemoglobinopathies; -Adults 19 through [AGE] years old who never received any Pneumococcal Vaccine, regardless of risk condition: 1. Give 1 dose of PCV15 or PCV20; 2. When PCV15 is used, it should be followed by a dose of PPSV23 at least one year later. The minimum interval (8 weeks) can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. Their vaccines will then be complete; 3. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete; -Adults 19 through [AGE] years old who only Received PPSV23, regardless of risk condition: 1. Give 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination; 2. Regardless of vaccine given, an additional dose of PPSV23 is not recommended since they already received it. Their vaccines are then complete. -Adults 19 through [AGE] years old who only received PCV13, who have a risk condition (see above) other than an immunocompromising condition: 1. Give 1 dose of PCV20 or PPSV23; 2. The PCV20 dose should be given at least 1 year after PCV13. When PCV20 is used, their vaccines are then complete; 3. The PPSV23 dose should be given at least 8 weeks after PCV13 for those with a cochlear implant or cerebrospinal fluid leak. The PPSV23 dose should be given at least 1 year after PCV13 for any of the other chronic health conditions. When PPSV23 is used, no additional pneumococcal vaccines are recommended until at least age [AGE] years; -Adults 19 through [AGE] years old who have an immunocompromising condition: 1. Give 1 dose of PCV20 or PPSV23; 2. The PCV20 dose should be given at least 1 year after PCV13. When PCV20 is used, their vaccines are then complete; 3. The PPSV23 dose should be given at least 8 weeks after PCV13. When PPSV23 is used, they need another pneumococcal vaccine at least 5 years later. At that time, give either 1 dose of PCV20 or a second dose of PPSV23. When PCV20 is used, their vaccines will then be complete. When a second PPSV23 dose is used, no additional pneumococcal vaccines are recommended until at least age [AGE] years; -Adults 19 through [AGE] years old who have received PCV13 and 1 Dose of PPSV23 and who have an immunocompromising condition: 1. Give 1 dose of PCV20 or a second PPSV23 dose; 2. The PCV20 dose should be given at least 5 years after the last pneumococcal vaccine. Their vaccines are then complete; 3. The second dose of PPSV23 should be given at least 8 weeks after PCV13 and 5 years after PPSV23. No additional pneumococcal vaccines are recommended until at least age [AGE] years; -Adults 65 years or older who have never received any pneumococcal vaccine and don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: 1. Give 1 dose of PCV15 or PCV20; 2. When PCV15 is used, it should be followed by a dose of PPSV23 at least one year later. Their vaccines will then be complete; 3. When PCV20 is used, it does not need to be followed by a dose of PPSV23. The vaccines are then complete; Adults 65 years or older who have never received any pneumococcal vaccine and have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: 1. Give 1 dose of PCV15 or PCV20; 2. When PCV15 is used, it should be followed by a dose of PPSV23 at least 8 weeks later. Their vaccines will then be complete; 3. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete. -Adults 65 years or older who have only received the PPSV23 regardless of risk condition; 1. Give 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination. 2. Regardless of vaccine given, an additional dose of PPSV23 is not recommended since they have already received it. Their vaccines are then complete. -Adult 65 years or older who have only received the PCV13 and don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak; 1. Give 1 dose of PCV 20 or PPSV23, at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. -Adults 65 years or older who have only received the PCV13 and have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak; 1. Give 1 dose of PCV20 or PPSV23. Regardless of vaccine used, their vaccines are then complete; 2. The PCV20 dose should be given at least 1 year after PCV13. 3. The PPSV23 dose should be given at least 8 weeks after PCV13. -Adults 65 years and older who have received PCV13 at any age and PPSV23 before age [AGE] and don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak; 1. Give 1 dose of PCV20 of PPSv23. Regardless of vaccine used, their vaccines are then complete. 2. The PCV20 dose should be given at least 5 years after the last pneumococcal vaccine; 3. The PPSV23 dose should be given at least 5 years after the last PPSV23 dose. It should also be given at least 1 year after the PCV13 dose. -Adults 65 years and older who have received PCV13 at any age and PPSV23 before age [AGE] who have an immunocompromising condition, cochlear implant or cerebrospinal fluid leak; 1. Give 1 dose of PCV20 or PPSV23. Regardless of vaccine used their vaccines are then complete; 2. The PCV20 dose should be given at least 5 years after the last pneumococcal vaccine; 3. The PPSV23 dose should be given at least 5 years after the last PPSV23 dose. It should also be given at least 8 weeks after the PCV13 dose. -Adults 65 years or older who have received the PCV13 at any age and the PPSV23 after the age of 65; 1. Use shared clinical decision-making to decide whether to administer PCV20. 2. If so the dose of PCV20 should be administered at least 5 years after the last pneumococcal vaccine. -Adult 65 years or older who have only received PPSV23: 1. Give 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination; 2. Regardless of vaccine given, an additional dose of PPSV23 is not recommended since they already received it. Their vaccines are then complete. 1 Review of Resident #26's Continuity of Care Document (CCD) showed the following: -admission date 2/25/21; -The resident was his/her own responsible party; -Diagnoses included 2019 nCov acute respiratory disease (COVID-19) (an infectious disease that can affect the upper and lower respiratory tract); -The resident was greater than [AGE] years of age. Review of the resident's Vaccination Consent Form, signed and dated 2/26/21, showed the resident wanted to receive the Pneumococcal Polysaccharide Vaccine (PPSV23). Review of the resident's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/10/24, showed the following: -Intact cognition; -The resident's pneumococcal vaccine was not up to date; -The resident was not offered the pneumococcal vaccine. Review of the resident's electronic health record (EHR) showed the following: -No documentation the resident had received any pneumococcal vaccine prior to admission; -No documentation the resident was offered, received or refused any pneumococcal vaccine; -The resident was not up to date on thepneumococcall vaccination per CDC recommendations. During an interview on 5/8/24 at 9:20 A.M., the resident said he/she believed his/her vaccines were up to date. -He/She could not recall the facility giving him/her the PPSV23; -He/She could not recall getting any pneumonia vaccination at the facility or outside the facility. 2. Review of Resident #94's CCD showed the following: -admission date 3/23/2021; -The resident had a responsible party to help with decision making; -Diagnoses included chronic respiratory failure; -The resident was greater than [AGE] years of age. Review of the resident's quarterly MDS, dated [DATE] showed the resident's pneumococcal vaccine was up to date. Review of the resident's vaccine history showed the following; -Resident previously had the PPSV23 on 10/18/2020; - No documentation the PCV15 was offered, administered or refused; - No documentation the PCV20 was offered, administered or refused; -The resident was not up to date per CDC recommendations. During an interview on 5/14/24 at 9:50 A.M., resident's responsible party/sister said the resident has never been offered the PCV20 vaccine and he/she would like for him to have the vaccine. 3. Review of Resident #403's face sheet showed the following: -He/She admitted to the facility on [DATE]; -He/She was less than [AGE] years of age; -He/She had a diagnoses of diabetes and stroke; -He/She was his/her own person. Review of the resident's EHR immunization record showed the resident received PPSV23 outside the facility on 2/23/21. Review of the resident's vaccine consent form, dated 4/25/24, showed the following: -I would like to receive the pneumonia vaccine (Prevnar 20 or Pneumovax 23) based on CDC criteria: left blank; -I do not wish to receive the pneumonia vaccine: left blank; -Signed by the resident. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Pneumococcal vaccine not offered. Review of the resident's medical record showed no documentation facility staff offered or administered the PCV15 or PCV20 vaccine or that the resident refused the vaccines. During an interview on 5/14/24 at 12:55 P.M., the Director of Nursing (DON), said the following: -Medical Records was responsible for ensuring and checking that any new admissions and annual renewals are up to date for vaccines, filling out the consent form with the resident, and then passes the form on to the charge nurse to input the order; -She would expect the resident toreceivee the vaccine if they consented toreceivingg it; -She would expect resident vaccinations to be up to date according to the CDC guidelines. During an interview on 5/22/24 at 1:10 P.M., the Administrator said the following: -She would expect staff to offer pneumonia vaccine to all eligible residents according to CDC guidelines unless contraindicated; -She would expect staff to administer the pneumonia vaccine if a consent is signed requesting that vaccine.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in accordance with professional standards for food service safety. Staff failed to label, date, and seal opened food items. Staff failed to store food items per manufacturer's label instructions, store food items off the floor, and store food items in an area separate from resident medications and related items. Staff failed to discard food items that were expired or showed visible signs of deterioration. Staff failed to properly clean ice machines, properly store ice scoops, and ensure an air gap was present at each ice machine drain. Staff failed to ensure food and beverage containers and utensils were in good condition and were handled, dried and stored in a sanitary manner. Staff failed to ensure food service equipment and surfaces were appropriately cleaned and trash cans remained covered when not in use. Staff failed to practice proper hygienic practices when preparing and serving food to residents, including employing proper hair restraint usage, hand hygiene techniques, consumption and storage of personal food and drink items in food preparation areas, thermometer probe cleaning, and handling of ready-to-eat food items. Staff failed to monitor the dishwashing machine for appropriate parameters to ensure dishes were properly cleaned and sanitized. The facility census was 149. 1. Review of the undated facility policy, Labeling/Dating Foods (Date Marking), showed the following: -All foods stored will be properly labeled according to the following guidelines; -Date marking for dry storage foods items: -Once a case is opened, the individual food items from the case are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the first in - first out method of rotation; -Expiration dates on commercially prepared, dry storage food items will be followed; -Date marking for refrigerated storage food items; -Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in - first out method of rotation; -Once opened, all ready to eat, potentially hazardous food will be re-dated with the opened date; -Date marking for freezer storage items; -Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in - first out method of rotation; -Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date; -Prepared food or opened food items should be discarded when the food item is older than the expiration date. Review of the undated facility policy, Safe Food Handling Guidelines for Resident Representative and/or Family Members and Guests, showed the following: -Resident family members, resident representatives and guests are always welcome to bring food into the facility for their loved one(s). When doing so, the following guidance should apply to ensure food safety strategies are adhered to; -If some or all of any perishable food is not eaten immediately, please inform staff so they can properly label, date and store the food for your loved one until they are ready to eat it; -Please do not encourage residents to store food in their rooms. Please inform the staff and we will be happy to label, date, and store the food for your loved one until they are ready to eat it. Observation on 5/7/24 at 1:52 P.M., in the 100 servery, showed the following: -A bag of cereal located in the bottom cabinet under a preparation counter was loosely sealed with plastic wrap and several pieces of cereal were on the bottom surface of the cabinet; -Two metal pans of food, with plastic wrap covering them, sat by each other and were undated. The left pan contained a yellow-colored food substance and was not marked to identify the contents. The right pan contained orange fruit and was labeled with a marker 'Mech.' Observation on 5/7/24 at 2:58 P.M., in the kitchen walk-in freezer, showed a box of frozen dinner rolls and a box of frozen breadsticks did not have the inner plastic sealed, were open to air, and the box flaps of each box were loosely folded over. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said she expected food items to be sealed, labeled, and dated. 2. Observation on 5/7/24 at 1:52 P.M., in the 100 servery refrigerator, showed an opened 46-ounce bottle of nectar thick orange juice with a date of 2/19 written on the label. The label read 'discard if not used within 10 days of opening.' Observation on 5/7/24 at 3:13 P.M., of the kitchen's dry food storage room, showed an open, unrefrigerated 11-pound container of vanilla icing with an open date of 4/24. The label read 'Once icing container has been opened, the icing can be stored covered at room temperature for one week. After this time period, store covered in the cooler.' Observation on 5/7/24 at 3:35 P.M., of the shelf under the kitchen steam table, showed the following: -An opened bottle of lemon juice; the label read 'Refrigerate after opening; -An opened bottle of soy sauce; the label read 'Refrigerate after opening for quality'. Observation on 5/8/24 at 10:39 A.M., of the shelf above the wooden counter in the kitchen outside the dishwashing room, showed an opened bottle of lemon juice. The label read 'Refrigerate after opening'. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said she expected food items to be stored per manufacturer's label instructions. 3. Observation on 5/7/24 at 2:43 P.M., in the 500 division medication room, showed a box containing oatmeal pies and one box of nutritional shakes sat on the floor near the refrigerator. During an interview on 5/7/24 at 2:45 P.M., Licensed Practical Nurse (LPN) N said the oatmeal pies belonged to a resident. Observation on 5/9/24 at 8:13 A.M., in the kitchen walk-in freezer, showed a 20-pound unopened box of frozen vegetables sat directly on the floor and was not elevated on a shelf or other means off the floor. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said she expected food to be stored off of the floor. 4. Observation on 5/7/24 at 2:43 P.M., in the 500 division medication room, showed several undated and unlabeled (with the owner's name/initials) opened bottles of beverages in the refrigerator that sat next to containers that held residents' refrigerated medications. A sign on the refrigerator door indicated that no food was to be stored in the refrigerator. During an interview on 5/7/24 at 2:45 P.M., LPN N said the beverages in the refrigerator belonged to a resident. During an interview on 5/9/24 at 1:38 P.M., the director of nursing said resident food items stored in medication rooms should be stored and labeled appropriately, and not stored in a refrigerator where medication and related items are stored. 5. Observation on 5/7/24 2:23 P.M., in the 600 division living room cabinets, showed an unopened 10-ounce bottle of orange juice had a manufacturer's expiration date of 1/18/24. Observation on 5/7/24 at 1:52 P.M., in the 100 division servery refrigerator, showed a 4-ounce carton of vanilla nutritional shake with a manufacturer's use by date of 10/21/23. Observation on 5/7/24 at 2:58 P.M., in the kitchen walk-in freezer, showed two clear bags of frozen mixed vegetables had an excess accumulation of frost visible through the bags and on the food contents. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said food items that are expired or showed signs of deterioration should be discarded. 6. Review of the undated facility policy, Ice Handling and Cleaning, showed the following: -Ice will be stored and served to residents in a sanitary manner; -Ice will be handled, transported, and stored in such a manner as to be protected against contamination; -Approved containers and utensils will be provided for storing and serving ice in a sanitary manner; -Ice scoops will be kept clean and will be stored and handled in a sanitary, protected manner so that the handle does not make contact with the ice. Scoops will be cleaned/sanitized daily; -Ice machine will be wiped down daily with sanitizer; -Ice machine will be emptied quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral buildup in the ice discharge area and floor of the machine; -Ice storage bins shall be drained through an air gap. Observation on 5/7/24 at 1:52 P.M., in the 100 servery, showed the ice machine drain was connected to a 1-inch clear reinforced flexible hose that was connected directly to the nearby sink drain with a gray pipe connector and pipe clamps and contained no air gap. Observation on 5/7/24 at 12:40 P.M., in the 300 servery, showed the ice machine drain was connected to a 1-inch dark gray colored flexible hose that was inserted approximately 1 inch below the flood rim level of the floor drain located in front of the machine. There was no air gap present at the ice machine drain. Observation on 5/7/24 at 12:54 P.M., in the 700 servery, showed the interior portion of the ice machine had dried white drips with black specks with a moderate accumulation of encrusted white debris on the interior portion of the door. Observation on 5/7/24., in the 500/600 division, showed the following: -At 2:37 P.M., CNA M entered the servery and carried a cup with a straw and lid; -He/She did not wash his/her hands, opened the ice machine and used a clear disposable cup to scoop ice from the machine into his/her cup; -He/She left the disposable cup in the ice machine, closed the door, and left the servery. Observation on 5/8/24 at 8:26 A.M., of the service hall ice machine located near the kitchen, showed the following: -Various bits of trash, including cup lids and straws, and a white dried accumulation of debris covered the surface of the floor under the machine; -The interior portion contained various bits of brown wet and dried debris and visible staining above the finished ice reservoir; -The exterior was stained in several areas with dried white drips that ran down the surface of the machine; -Two 1-inch drain pipes were located at a floor drain in front of the machine; -One drain pipe extended several inches below the flood rim level of the drain and contained no air gap; -The second drain pipe, located near a discarded drinking straw, was just above the flood rim level of the drain and contained a limited air gap. During an interview on 5/8/24 at 3:14 P.M., the director of environmental services said he expected the ice machine drains to contain an appropriate air gap. He was unaware of the ice machine drains found during the survey that did not contain air gaps or adequate air gaps. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said the following: -She expected ice machines to be clean and for dietary staff to wipe the inside and outside of the ice machines one to three times per week; -The ice machine service company sanitized the machine during their routine visits; -The ice machines should have an appropriate air gap at the drain and this was the responsibility of maintenance staff; -Staff should have clean hands, use a handled ice scoop when obtaining ice from ice machines, and store the scoop sanitarily. 7. Review of the undated facility policy, Dining Servers: Guidelines for Safe Handling of Tableware, showed the following: -All staff assigned to assisting in the dining room will wash their hands before passing foods/fluids to residents; -Glasses and cups are handled as to avoid bare hand contact with the rim; -Plates are handled by the rim with no bare hand contact with the food contact area; -If anyone assisting in the dining room contaminates their hands, they will re-wash their hands before resuming passing foods/fluids to residents; -If any risk of touching the food contact or mouth contact area of a utensil exists, a washed and gloved hand will be used to handle the tableware. Observation on 5/7/24 at 1:52 P.M., in the 100 servery refrigerator, showed a one-third full clear plastic beverage pitcher that contained a brown-colored liquid. The pitcher was visibly scratched, stained, and worn across the entire plastic surface and was cloudy and no longer clear. Observation on 5/7/24 at 2:25 P.M., in the 500/600 servery cabinets, showed two blue scoops stored inside a clear container of thickener powder. Observation on 5/7/24 at 3:30 P.M., on the shelf below the steam table in the kitchen, showed a clear scoop stored inside a container of brown sugar. Observation on 5/7/24 at 3:07 P.M., in the kitchen clean dish and utensil storage area, showed moist light orange drips on the clean scoops and rubber scrapers. Various large mixing bowls and fluted clear dishes were not inverted. Observation on 5/9/24 at 8:31 A.M., in the kitchen clean dish storage area, showed a rolling blue cart of clean plates was not covered and the plates were not inverted. Another cart of plates sat near the wooden counter and the plastic cover that was over the plates was torn with moist splatters of brown debris by the top section of plates. Observation on 5/8/24 at 11:25 A.M., in the kitchen, showed Dietary Aide J and [NAME] A used paper napkins and cloth towels to dry silverware that was obtained from a dishwashing tray of wet silverware. Observation on 5/8/24 at 10:49 A.M., in the kitchen food preparation area, showed Dietary Aide H used his/her gloved hands to touch the inside eating surface of bowls as he/she scooped pudding into the bowls for the lunch meal service. Observation on 5/8/24 at 12:44 P.M., in the 500/600 servery, showed the following: -CNA P used his/her gloved hands to fill beverage pitchers at the sink; -He/She turned off the faucet handles, put the lids on the pitchers, and carried the pitchers by supporting and touching his/her gloved hands on the pouring spout of the pitchers; -He/She filled drinking glasses on a cart from the pitchers and used his/her gloved hands to touch and pick up the glasses by the inside drinking surface rim of the glasses to arrange the glasses on the cart. During an interview on 5/9/24 at 12:37 P.M., Dietary Aide I said staff should handle dishware, silverware, and beverage ware by the non-eating and drinking surfaces of those items. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said the following: -Foodware,beverageware, and utensils should be cleaned and sanitized properly. These items should be in good condition and stored clean, dry, and in a protected manner such as covered or inverted; -She expected scoops not to be stored within food items or in bulk bins; -Staff should handle foodware and beverageware items by non-food and beverage contact surfaces. 8. Review of the undated facility policy, Cleaning Rotation, showed the following: -Equipment and utensils will be cleaned according to the following guidelines or manufacturer's instructions; -Items cleaned after each use: can opener; -Items cleaned daily: stove top, grill, toaster, microwave oven, steam table, exterior of large appliances; -Items cleaned weekly: ovens; -Items cleaned monthly: ice machines, walls. Observation on 5/7/24 at 1:14 P.M., of the counter-mounted water dispenser and ice storage unit in the main dining room, showed the following: -Both portions of the unit were marked with tags that read 'Out of Service;' -Below the cabinet where the unit was located, an unlocked door opened to the lower cabinet area where dried brown and black splatters and wipe marks were visible across the surface of the cabinet's interior bottom and side portions; -The cabinet's bottom interior portion was cracked and warped in several areas across the white surface and did not provide a smooth and easily cleanable/wipeable surface. Observation on 5/7/24 at 1:52 P.M., in the 100 servery, showed the following: -The floor was very sticky and dried shoe prints were visible across the surface of the floor; -Bits of brown food debris were on the floor and various dried brown splatters were visible on the walls near the two doors of the servery; -Various bits of food debris, Styrofoam cups and lids were on the floor behind the refrigerator; -Brown sticky drips were across the front exterior surface of the refrigerator and ice machine; -Bits of food debris were underneath the microwave; -Food crumbs and a heavy accumulation of brown and black debris buildup were on the toaster; -Dried smears and drips of debris were across the metal surface of the cereal dispensing unit; -Red moist debris and an excess accumulation of ice were in the freezer compartment. Observation on 5/7/24 at 2:07 P.M., of the counter-mounted water dispenser and ice storage unit in the 200 division dining room, showed a pink plastic tub with a moderate accumulation of moist brown and tan chunks of debris was located below the counter under the unit's drain. Dried brown splatters were on the interior surface of the drain and interior cabinet area. Observation on 5/7/24 at 2:25 P.M., in the 500/600 servery, showed the following: -A moderate accumulation of dust and buildup was on a box fan that faced the steam tables and sat on a folding wooden tray stand with fabric straps that was covered in dried brown and white debris across the surfaces of the wood and fabric straps; -The steam table and clear shield had various dried smears and drips across their surface and the shield was visibly cloudy and greasy; -The shelf below the steam table was splattered with dried brown debris and had bits of food debris and trash on the metal surface. The metal surface was missing paint in an approximate 2-foot by 3-foot area; -The metal trash can lid edges was smeared with dried food debris. Observation on 5/8/24 at 1:21 P.M., in the 500/600 servery, showed a box fan with a moderate accumulation of dust and buildup sat running on a folding wooden tray stand (visibly soiled with dried brown and white debris). The fan blew directly toward the steam table of uncovered food items as staff served residents' food during the lunch meal service. Observation on 5/7/24 at 3:10 P.M., in the kitchen walk-in cooler, showed a metal conduit, that ran the length of the cooler ceiling, had black and white crusty debris accumulated across its surface. Observation on 5/7/24 at 3:35 P.M., in the kitchen, showed the following: -A moderate accumulation of yellow grease was on the range hood suppression nozzles located above the flat griddle; -A moderate accumulation of light brown residue was on one of four light covers above the flat griddle. One of four bulbs was not working on the left side of the range hood; -The floor in front of the deep fryers and tilt skillet was very slippery and there was a black buildup of residue on the nearby floor under the steam table, ovens, fryers, and tilt skillet. Bits of food and trash debris were on the floor under these units; -A thick accumulation of brown greasy debris was on the sides of the deep fryers; -The oven handles were greasy to the touch and an excessive amount of grease accumulation from the deep fryer grease collection channel was on the top right portion of the oven door; -An excessive accumulation of thick, black encrusted debris coated the interior surfaces of the top and bottom convection oven compartments. Observation on 5/8/24 at 10:49 A.M., in the kitchen, showed a can opener sat on the top shelf above the clean dish storage area. The blade of the can opener was heavily soiled with a brown moist substance that resembled chocolate pudding. Observation on 5/9/24 at 8:31 A.M., in the kitchen, showed the can opener at the end of the food preparation counter contained a small hair and dark black moist debris on the blade's surface. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said the following: -She expected surfaces and equipment to be clean; -She had worked at the facility for approximately eight weeks; -She would like all equipment to be cleaned in the kitchen a least daily and for deep cleaning to occur one to two times per month; -In the serveries, dietary staff were to clean the steam tables, toasters, refrigerators, microwaves, etc. 9. Observations on 5/7/24 at 11:22 A.M. and at 12:01 P.M., in the kitchen, showed a trash can (located between the convection oven and steamer) contained discarded plastic and food waste items. The trash can was approximately 90% full, sat uncovered, and no staff were actively using the trash can. Observation on 5/7/24 at 12:47 P.M., in the 300 servery, showed a trash can approximately 50% full of trash was uncovered. Staff were not actively using the trash can and no staff were in the servery or nearby area. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said she expected trash cans to be covered when not in use. There was no lid for the trash can located in the kitchen between the convection oven and steamer. 10. Review of the undated facility policy, Hair Restraints, showed the following: -Hair restraints shall be worn by all dining services staff when in food production, dishwashing areas, or when serving food from the steam table; -Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Review of the undated facility policy, Proper Hand Washing Procedure and Proper Use of Gloves, showed the following: -All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines; -All employees will wash hands upon entering the kitchen from any other location, after all breaks, and between all tasks; -Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident; -Gloves are to be used whenever direct food contact is required with the following exception: bare hand contact is allowed with foods that are not in a ready to eat form that will be cooked or baked; -Hands are washed before donning gloves and after removing gloves; -Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; or if the gloves become contaminated by the touching the face, hair, uniform, or other non-food contact surfaces, such as door handles and equipment; -Staff should be reminded that gloves become contaminated just as hands do, and should be changed often. When in doubt, remove gloves and wash hands again; -When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always, wash, glove, remove, rewash, and re-glove. Review of the facility's undated policy, Monitoring Food Temperatures for Meal Service, showed the following: -Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures; -Proper procedures are followed to ensure food temperatures are accurately and safely obtained according to safe food handling practices: -Thermometers are washed, rinsed, sanitized before and after each meal use. An alcohol swab may be used to sanitize between uses while taking temperatures during the same meal or if contamination of the thermometer occurs. Observation on 5/7/24 at 12:14 P.M., in the kitchen, showed Dietary Aide E was in the food serving area for the lunch meal service. Dietary Aide E did not wash his/her hands, and put on gloves. He/She cut up a resident's sandwich by touching his/her gloved hands on the bread of the sandwich. Observation on 5/8/24 at 8:38 A.M., in the 700 servery, showed Dietary Aide I used his/her bare hands to grab pieces of toast from the toaster and place them on the steam table in a pan for serving to residents at the breakfast meal service. Observation on 5/8/24 from 9:01 A.M. to 9:13 A.M., in the 500/600 servery, showed the following: -Dietary Aide G used his/her gloved hands to serve food from the steam table onto residents' plates; -He/She adjusted his/her glasses multiple times, touched the eating surfaces of plates as he/she grabbed the plates, served food items by grabbing handles of serving utensils, grabbed pieces of toast with his/her gloved hands to place on residents' plates, and grabbed the handle of a cart and moved it around in the servery; -He/She did not wash his/her hands in between tasks or after touching contaminated items. Observation on 5/8/24 at 10:26 A.M., in the kitchen, showed Dietary Aide J used his/her bare hands to adjust his/her hair restraint and touched his/her face area. He/She touched pans of food for the lunch meal service and placed them on pans of ice by handling them with his/her bare hands. He/She did not wash his/her hands after touching his/her face or adjusting his/her hair restraint. Observation on 5/8/24 at 10:58 A.M., in the kitchen, showed a daycare staff walked into the kitchen past the food preparation area where Dietary Aide H scooped pudding into bowls for the lunch meal service. The daycare staff walked into the dry storage room (located in the kitchen and beyond the food preparation area) and obtained plates from a box and did not wear a hair restraint. During an interview on 5/8/24 at 10:58 A.M., the daycare staff said he/she knew he/she was supposed to wear a hair restraint in the kitchen but needed plates to serve lunch in the daycare portion of the facility. Observation on 5/8/24 at 12:36 P.M., in the 500/600 servery, showed the following: -The dietitian washed her hands at the sink, put a glove on her left hand, opened and obtained an alcohol pad from the cabinet, donned a glove on her right hand, and obtained a pen to record temperatures of food items in the log book; -She took temperatures of food items, located on the steam table, with a prob-style thermometer and used the alcohol pad to wipe the thermometer probe in between food items; -The alcohol pad became increasingly soiled with food after she wiped the probe; -She did not obtain a new alcohol pad and continued to take temperatures of food items, wiping the probe after insertion into each food item. Observation on 5/8/24 at 12:12 P.M., in the 500/600 servery, showed Dietary Aide G dropped a packet of wrapped disposable silverware onto the floor. He/She picked up the silverware with his/her gloved hands, did not remove his/her gloves or wash his/her hands, and grabbed clean plates from a nearby cabinet and took the plates to the adjacent dining room for the lunch meal service. Observation on 5/8/24 at 12:30 P.M., in the 500/600 servery, showed Dietary Aide G washed his/her hands at the sink and turned off the faucet handle with his/her clean hands, dried his/her hands with a paper towel, and went to the steam table to arrange food items for serving at the lunch meal service. Observation on 5/8/24 at 1:02 P.M., in the 500/600 servery, showed the dietitian plated residents' food for the lunch meal service. She used the same tongs to serve fresh vegetables (onion slices, tomatoes, lettuce leaves for sandwiches) as she did for serving hot items (chicken tenders and French fries), going back and forth serving items onto plates from the two containers of food as items were needed on those plates. During an interview on 5/9/24 at 12:37 P.M., Dietary Aide I said the following: -Staff should wear a hairnet when serving food items in the serveries; -Staff should wash their hands after changing gloves, after touching unclean surfaces, prior to touching food items and clean dishes, and when entering a servery; -Staff should not touch ready-to-eat food items with their bare hands or with soiled gloves. -The 700 division servery had two sinks. He/She considered the smaller sink to be the handwashing sink and the larger sink to be used for food and beverage preparation; -The smaller sink did not have soap or paper towels so staff tended to wash their hands at the larger sink used for food and beverage preparation. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said the following: -Food items should be stored, prepared, and served under safe and sanitary conditions; -Staff should not touch ready-to-eat food items with their bare hands or while wearing unclean gloves; -Staff should serve ready-to-eat food items with tongs and should have separate tongs for each item on the steam table; -Staff should not use the same tongs to serve items such as lettuce and tomatoes and then use the same tongs to serve French fries and chicken tenders; -Staff should wear a hair restraint when preparing and serving food items; -Staff should wash their hands after performing dirty tasks, such as picking up dropped items from the floor, when entering the kitchen or a servery, prior to conducting clean tasks, and when changing gloves. Changing one's gloves did not substitute the need for hand washing. 11. Observation on 5/7/24 at 12:24 P.M., in the kitchen, showed the following: -Dietary Aide E was in the food serving area during the lunch meal service; -He/She held a pickle spear in his/her hand and took a bite of the pickle. Observation on 5/8/24 at 10:33 A.M., in the kitchen, showed various staff beverages such as bottles of tea and soda and a Styrofoam cup with a lid and straw sat on the shelf above the food preparation area. Dietary Aide H prepared pureed food items for the lunch meal service at the food preparation area. During an interview on 5/8/24 at 4:11 P.M., the dietary manager said staff should not eat or drink in food preparation or serving areas. Staff should store and consume their personal food and drink items in the dietary manager's office or in the staff breakroom. 12. Review of the undated facility policy, Dishwashing: Machine, showed the following: -All dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized in either a high-temperature dishwashing machine that uses hot water, or a chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution; -Check the dials to ensure the wash and rinse cycles are achieving proper temperature per manufacturer guidelines. Observation on 5/7/24 at 3:23 P.M., of the kitchen (loaner) dishwashing machine, showed the following: -The label on the front of the dishwashing machine read: -Wash temperature - minimum 120 degrees F, recommended 140 degrees F; -Rinse temperature - minimum 120 degrees F, recommended 140 degrees F; -Required - 50 parts per million (PPM) available chlorine. Review on 5/8/24 at 10:45 A.M., of the Low Temperature Sanitizing Dish Machine log sheet, located on a clipboard above the dishwashing machine, showed the following: -A PPM of 200 was recorded for the A.M. and P.M. columns for 5/1/24 through 5/6/24; -No data was recorded for 5/7/24 and 5/8/24; -No acceptable chemical parameter ranges were indicated on the form; -No temperature parameters were indicated or temperature levels were recorded on the form. Observation on 5/8/24 at 11:03 A.M., of the chemical test strip bottles provided by the dietary manager, showed chlorine test strips bottle, a color scale was indicated on the label from light purple (10 PPM) to a dark purple (200 PPM). During interviews on 5/7/24 at 11:43 A.M. and 5/9/24 at 2:36 P.M., the dietary manager said the following: -The facility's old dishwashing machine had been having issues off and on for the past few months; -Repairs were made to the machine but a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently follow their policy to complete skin assessments to identify areas of concern to ensure timely implementation of interventions and treatment for one sampled resident, (Resident #2) of six sampled residents. The facility census was 167. Review of the facility policy for Pressure Ulcer Care and Documentation dated 7/21 showed: -Purpose: To prevent pressure injuries and/or prevent deterioration of existing pressure injuries: -Causes in part: impaired circulation, wrinkles,lumps in bedding and chairs; fragile skin caused by the aging process, pressure on bony prominence for example heels; -Warning signs: observe daily for the following signs of potential pressure injury signs and report accordingly: redness or a darker, beeper bruise-like color, heat, tenderness, pain or discomfort, cracks in the skin, excessive dryness, sores, cuts or abrasion. Report any changes of condition to the charge nurse; -Prevention: frequent applications of lotion, or approved ointment to skin surfaces with special attention to pressure prone areas; -Frequent turning and/or repositioning no less than every two hours; -Use of anti-pressure devices: air mattress to bed, speciality mattress to bed, air cushion to wheelchair; -Straighten or tighten sheets and chair pads frequently; -Procedure: observe reddened or pressure injury prone areas; rub skin with lotion, or approved ointment; tighten linen (must be free from wrinkles; turn resident frequently; report any abnormalities to charge nurse; -Procedure for Stage I or greater pressure injuries: any time a Stage I or greater pressure ulcer is noticed on a resident the charge nurse must fill out a wound management assessment in the electronic medical record and report it: -The charge nurse must notify physician of pressure injury for treatment orders. The resident representative is also notified; -Weekly wound assessments for each pressure ulcer must be completed; -The charge nurse must notify physician if not improvement occurs after two weeks of treatment. Review of the facility policy for Pressure Ulcer/Pressure injury (PU/PI) prevention policy dated 1/21 showed: -Purpose: to identify and determine those residents are risk for the development of PU/PI; to maintain resident skin integrity; to provide early detection of skin breakdown; and to promote timely evaluation and interventions of changes in resident's skin; -Definitions: PU/PI: localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device: Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum- filled blister. -Risk factors that predispose the resident to the development of PU/PI are, but are not limited to: impaired/decrease mobility and decrease functional ability; impaired diffuse or localized blood flow such as atherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), peripheral vascular disease (PVD-narrowing of peripheral blood vessels (vessels situated away from the heart or the brain) or lower extremity arterial insufficiency); immobility during hospitalization or surgical procedures prior to coming to the community; prolonged immobility following medical event or fall; -Procedure: all residents will assessed for PU/PI upon admission and quarterly using the Braden scale assessment ( developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status); -Nurse aides (NA) will complete a bath sheet at the completion of each resident shower. The NA will indicate on the bath sheet if the skin is normal or abnormal. The charge nurse (CN) will assess any altered skin changes noted on the bath sheet by the NA. The nurse manager will review the bath sheets daily and follow up with CN if skin impairment is noted;In addition to looking at the resident's total Braden score to determine risk, nursing staff will evaluate what sub-category predisposes the resident for the development of a PU/PI; -CN will update care plan with interventions to prevent PU/PI at the time risk is identified; -Interventions to manage risk will be communicated to NA via Certified Nurse Aide (CNA) report sheet, electronic profile or CNA assignment sheet. 1. Review of Resident #2's face sheet showed: -Initial admission date was 9/30/23; -discharged from the facility on 10/1/23 then readmitted on [DATE]; -discharged from the facility on 11/13/23; -Diagnoses of sepsis ( a serious condition in which the body responds improperly to an infection); intestinal obstruction with ostomy, weakness, diabetes with chronic diabetic kidney disease. heart failure, chronic obstructive pulmonary disease. Review of the nurses notes dated 9/30/23 showed no documentation of any skin issues. Review of the Treatment Administration Record (TAR) dated 9/30/23 showed skin intact with no issues. Review of the resident's plan for skin dated 10/1/23 showed the following: -The resident is at risk for skin breakdown related to limited mobility related to generalized weakened state; -Goal: Resident's skin will remain intact; -Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible; conduct systematic skin inspection per orders keep lean and dry, report any signs of skin breakdown (sore, tender, red, or broken areas). Review of the resident's Braden Scale (a tool used to evaluate a resident's risk for skin breakdown), completed on 10/1/24 showed a score of 14, at moderate risk for skin breakdown. Review of the resident's TAR dated 10/1/23 through 10/09/24 showed: -No skin assessment documented for 10/1/23; -Hospital marked on 10/2/23; -No documentation from 10/3/23 10/8/23; -Resident readmitted to the facility on [DATE] with no documentation staff completed a skin assessment at the time of the resident's readmission. Review of the resident's admission Minimum Data Set, (MD'S) a federally mandated assessment instrument completed by facility staff, dated 10/18/23 showed: -Usually able to make self understood and sometimes understands others; -Alert and oriented and able to make decisions; -Dependent upon staff for mobility and repositioning; -At risk for the development of PU/PI, no PU/PI. Review of the resident's TAR dated 10/09/23 through 10/31/24 showed the following: -No documentation of a skin assessment completed 10/9/23 through 10/15/23; -On 10/16/23 and 10/23/23, skin intact marked yes with no abnormal skin noted; -Order for skin prep wipes to left inner heel ordered on 10/27/23; -On 10/30/23 marked not done - resident not available. Review of the resident's nurses notes dated 10/18/23 through 11/3/23 showed no documentation of any PU/PI or skin issues. There was no documentation for the order of skin prep to the left heel on 10/27/23. Review of the resident's weekly skin assessment dated [DATE] through 11/30/23 showed no skin assessment documented 11/1/23 through 11/4/23. Review of the nurses notes dated 11/04/23 at 9:59 P.M. showed: -Blister to right heel found open and skin flap loose, 4.5 cm x 4.5 cm cleansed with normal saline, applied triple antibiotic ointment (TAO) and covered with ABD (wound dressing) and gauze. Review of the resident's TAR for the weekly skin assessment dated [DATE] showed open blister to left heel. Review of the nurses notes dated 11/8/23 through 11/13/23 showed no documentation of the resident's skin for either the right or left heel. During an interview on 3/22/24 at 4:00 P.M. the resident's Family Member A said the following: -Resident #2 had been complaining about his/her right heel hurting for several weeks before the facility began treating it; -The resident had been receiving a treatment to the left heel and ankle area due to an injury that occurred during a transfer, there was no open area on the left heel; -When the resident came back from the hospital on [DATE], he/she had a large fluid filled blister on the inner aspect of the right heel; -He/She told the staff about it, but no one was doing any treatments to the heel; -The blister opened up on 10/26/23 and he/she and the resident had asked for a treatment to be done, but no one did anything until 11/4/23; -The open area was about the size of a nickel and was deep; -The resident went home and recieved services from a wound clinic. During an interview on 3/22/24 at 3:46 P.M. the Assistant Director of Nursing/Wound Nurse said the following: -Nurses will conduct the skin assessments and if a new area is noted will initiate a treatment; -They will put the concern on the 24 hour report for her to follow up on; -She does not remember Resident #2 having a blister to the right heel; -The resident was receiving skin prep to both heels for prevention; -There was no wound documentation for this resident. During an interview on 3/14/24 at 3:00 P.M. the Director of Nursing said the following: -She would expect the nursing staff to do a complete and thorough skin assessment when scheduled; -She would expect the nursing staff to assess the skin on the scheduled days per protocol and for staff to assess the skin; -Nurses should document a thorough description of any wound or PU that is found in the nurses notes and should put interventions in place to aid in the healing or the prevention of any PU or wounds. During an interview on 3/25/24 at 1:05 P.M. Physician A said: -He would expect the facility to inspect the residents skin thoroughly upon admission, with their showers and at least weekly; -He would expect the facility to notice any problems with the heels before the area was open. MO232779

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed ensure one of three residents (Resident (R)1) reviewed for activities was provided an activity calendar and invited to attend activities. Findings include: Review of a Face Sheet located in R1's electronic medical record (EMR) under the Face Sheet tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of chronic atrial fibrillation (irregular heartbeat), major depressive disorder, and anxiety. Review of R1's admission Care Plan dated 10/02/22, located in the EMR under the Care Plan tab included interventions to allow the resident to verbalize interest in activities, discuss previous activity experiences, furnish resident with current activity calendar, inform and escort to activities of interest, inform staff to make frequent visits on 1st and 2nd shifts, orient to facility and activity department, provide in room leisure interest as requested and/or needed .Resident has indicated the following leisure activities have been enjoyed in the past: Methodist faith, socializing, games, news, music, being outdoors and being with family. Review of R1's Progress Notes located in the EMR under the Progress Notes tab included a note from Social Worker (SW)1, dated 10/03/22 indicated R1 liked TV and bingo. Review of R1's Brief Interview for Mental Status (BIMS) assessment located in the EMR under the Observations tab, dated 10/03/22, revealed R1 scored 13 out of 15, which indicated the resident was cognitively intact. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/22 located in the EMR, under the MDS tab indicated in section F Interview for Activity Preferences that it was very important for her to have newspapers, books and magazines to read, listen to music, to be around animals/pets, keep up with the news, do things with groups of people, go outside to get fresh air when the weather is good, and participate in religious services. Review of R1's admission Activity Assessment dated 10/11/22, completed by the Interim Activity Director (AD), and located in the EMR under the Observation tab indicated R1's preferred activity setting was in her own room or in the day/activity room; preferred program style was large groups, independent leisure or small groups; current interests included board games/cards, current events, trips/shopping, television, exercise/sports, music, reading/writing, spiritual/religious activities, outdoor activities, socializing, and being with family. Review of the October 2022 activities calendar, provided by the facility from 10/01/22-10/21/22 indicated R1 attended a church service on 10/09/22 and no additional activities. Based on the activity calendar on 10/18/22 at 8:30 AM a Meet and Greet was scheduled, and at 2:30 PM Bingo was scheduled. On 10/19/22 at 8:30 AM a Meet and Greet was scheduled, at 10:30 AM Trivia was scheduled, and at 2:30 PM Happy Hour was scheduled. On 10/21/22 at 8:30 AM Meet and Greet was scheduled, at 10:00 AM Bible Study was scheduled, at 10:45 AM Current Events was scheduled, and at 2:30 PM Music was scheduled. During an interview on 10/19/22 at 4:45 PM with Certified Nursing Assistant (CNA)1 stated she was not sure if R1 went to any activities, CNA1 had not seen R1 attend any activities or be approached by the activities department to attend. During an interview on 10/20/22 at 1:05 PM with R1 stated she liked playing bingo and watching TV but that she didn't have a TV in her room. She revealed no one had provided an activity calendar to her, and that she had not been approached by anyone to invite her to attend activities. Additionally, the resident was unaware that the facility offered bingo or that there was a TV in the common area that she could watch. During an interview on 10/20/22 at 1:17 PM with Licensed Practical Nurse (LPN)7 revealed she had not witnessed R1 involved in any activities. During an interview on 10/20/22 at 2:49 PM with Activity Assistant (ACT)1 stated she was not very familiar with R1. ACT1 reviewed the October 2022 activity calendar and stated documentation of activities attended by each resident are kept in a binder in the activity's office. Review of R1's October 2022 activity calendar provided by the facility indicated she attended church service on 10/09/22 only. ACT1 stated that R1 was not on the list for one-to-one visits from the activity department. ACT1 stated there was not an activities policy, and typically once the Social Worker or Activity Director determined the interests of the resident, they are then provided a calendar and invited to activities. ACT1 did not know why R1 had not been invited to activities, or why she had been overlooked. During an interview on 10/21/22 at 2:05 PM with the Director of Nursing (DON) stated she had become aware that R1 had not been included in activities and the Activities Assistant approached R1 that afternoon to invite her to attend activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure behavioral health services were provided for one of one sampled Resident (R)1 reviewed for behavioral health. Findings include: Review of the facility's policy titled Behaviors Using Person-Centered Care, Accommodating, revised 02/2021 related to problem behaviors stated, behaviors- disruptive to community's routine, creates more work, upsets other residents; root cause analysis is recommended, .majority of behavior symptoms result from cognitive and functional impairments of dementia, unmet psychosocial needs, sensory deprivation, boredom, loneliness .non-pharmacological interventions . Review of the Face Sheet located in R1's electronic medical record (EMR) under the Face Sheet tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of chronic atrial fibrillation (irregular heartbeat), major depressive disorder, and anxiety. Review of R1's physician Orders dated 10/01/22 located in the EMR under the Orders tab, included celexa for major depressive disorder, quetiapine for dementia, and trazodone for difficulty sleeping. Review of R1's Brief Interview for Mental Status (BIMS) assessment located in the EMR under the Observations tab, dated 10/03/22, revealed R1 scored 13 out of 15, which indicated the resident was cognitively intact. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/22 located in the EMR, under the MDS tab was incomplete for mood/behavior. Review of R1's Medication Administration Record (MAR) located in the EMR under the Reports tab, dated October 2022, indicated staff were monitoring R1 for anti-depressant medication use, aggressive behavior, and crying. Aggressive behavior was noted on 10/11/22, 10/13/22, 10/14/22, and 10/16/22. Crying behavior was noted on 10/06/22, 10/08/22, 10/11/22-10/15/22, and 10/18/22-10/20/22. During an observation on 10/18/22 at 2:39 PM revealed R1 was sitting up in her wheelchair in her bedroom crying. At 4:23 PM R1 continued to cry out while she was lying in bed in her bedroom. Certified Nursing Assistant (CNA)1 confirmed R1 was in her room crying and stated she would notify the charge nurse. During an observation on 10/20/22 at 1:05 PM revealed R1 was in her bedroom stating, this is just a miserable place. At 6:03 PM, R1 was in her bedroom crying. During an interview on 10/18/22 at 12:46 PM with R1 she stated she couldn't sleep last night and that she was miserable at the facility. During an interview on 10/18/22 at 1:00 PM with CNA2 stated R1 cried a lot, tells her she doesn't like this place, but if she's eating or around people she is usually fine. During an interview on 10/19/22 at 4:29 PM with CNA1 confirmed that R1 cried all afternoon yesterday (10/18/22) and threw her plate during the evening meal. CNA1 could not recall if she reported behaviors to the nurse. During an interview on 10/20/22 at 2:25 PM with Registered Nurse (RN)2 stated R1 needed redirection for most tasks, had difficulty sleeping, tended to cry out when she was upset, and was very emotional at times. RN2 stated that R1 was not currently being provided services by behavioral health services at that time but should be. The facility also had a psychiatrist that oversees residents for behavioral health needs and psychiatric medication management. R1 was not currently being followed by the psychiatrist. Additionally, in order for R1 to receive a psychiatric evaluation, the charge nurse would need to notify the primary care physician and an evaluation would be conducted. During an interview on 10/21/22 at 2:05 PM with the Director of Nursing (DON) stated that staff should always report to the charge nurse when a resident was having behaviors. DON confirmed that R1 appeared depressed that morning at the nurse's station, however, was not aware of R1's behaviors of crying and calling out for help frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to ensure medication, medication carts, and treatments cart were secured when unattended. This had the potential for medications to becaome diverted or for a cogntively impaired resident to potentially take the medications. Findings include: Record review of policy titled Corum Health Services Pharmacy Policy/Procedures Storage of Drugs updated 12/21, provided by the facility, reflects in part, Compartments and areas containing drugs are locked when not in use or when left unattended. Such areas include drawers, cabinets, rooms, refrigerators, carts, and boxes. Observation on 10/18/22 at 4:30 PM of the 600-hall medication cart revealed the cart unlocked and unattended between rooms 605-607. Interview in 10/18/22 at 4:32 PM with Certified Medication Technician (CMT)1 confirmed the cart was unlocked and should not have been. CMT1 confirmed she was in a resident's room and had left the cart unlocked. She stated the facility policy was for the medication cart to be locked when stepping away from the cart. Observation on 10/20/22 at 8:38 AM of the treatment cart in the 700 nurses station area revealed that the treatment cart was unlocked and two insulin flex pens with medication in them were laying on top. The cart was easily accessible. The flex pens were insulin Aspart Flexpen and Novolin Flexpen. No staff was within sight of treatment cart. Three residents were seated in day room [ROOM NUMBER]-15 feet from and in clear view of treatment cart. Interview with Licensed Practical Nurse (LPN)5 on 10/20/22 at 8:43 AM revealed that she had left the insulin pens on top of the cart because this resident does not always eat breakfast and I was waiting to give them to her after she had something on her belly. When asked if the cart should be locked when not in sight or while using it, LPN5 stated, It should stay locked, but it doesn't always happen. LPN5 confirmed that insulins and prescription treatment supplies and medications were kept in the treatment cart. Interview on 10/21/22 at 1:57 PM with the Director of Nursing (DON) revealed that medications carts should be locked at all times, especially if unattended. When asked if medication such as insulin is allowed to be left unsecured lying on top of an unattended medication or treatment cart, she confirmed that all medication should be kept in a locked cart when unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain ceiling vents free from a buildup of dust and failed to maintain ceilings in a clean condition. The facility census was 136. 1. Observations on 10/25/22 between 11:30 A.M. and 5:00 P.M., during the life safety code tour of the facility, showed the following: -In the 100 hall soiled utility room, two 4 inch by 4 inch vents and a 6 inch by 6 inch vent were covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]B, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]B, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In the 200 hall soiled utility room, a 6 inch by 6 inch ceiling vent was covered with a thick layer of dust; -In the 200 hall housekeeping room, two 4 inch by 4 inch ceiling vents were covered in a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In the staff lounge, a 24 inch by 24 inch ceiling vent was covered with a thick layer of dust; -In the 200 hall women's spa, the exhaust vent was covered with a thick layer of dust; -In the 200 hall soiled utility room, a 12 inch by 12 inch ceiling vent was covered in a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In the 300 hall staff lounge, two 12 inch by 12 inch ceiling vents were covered with a thick layer of dust; -In the 300 hall housekeeping room, a 12 inch by 12 inch ceiling vent was covered with a thick layer of dust; -In the 300 hall soiled utility room, an 8 inch by 8 inch ceiling vent was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; Observation on 10/25/22 between 7:15 A.M. and 3:53 P.M., during the life safety code tour of the facility, showed the following: -In the 400 hall housekeeping room, two 12 inch by 12 inch ceiling vents were covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust, and a 3 foot by 3 foot area in the top of the closet was covered with a black mold-like substance; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust, and a 3 foot by 3 foot area in the top of the closet was covered with a black mold-like substance; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust, and a 3 foot by 3 foot area in the top of the closet was covered with a black mold-like substance; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust, and a 3 foot by 3 foot area in the top of the closet was covered with a black mold-like substance; -In resident room [ROOM NUMBER]B, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]B, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]B, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In the facility kitchen area, six 24 inch by 24 inch ceiling vents were covered with a thick layer of dust; -In the dietary manager's office, a 24 by 24 inch ceiling vent was covered with a thick layer of dust; -In the front office mail room, a 24 by 24 inch ceiling vent was covered with a thick layer of dust; -In the copy room, a 24 inch by 24 inch ceiling vent was covered with a thick layer of dust. During interview on 10/27/22 at 12:08 P.M., the maintenance supervisor said he was responsible for cleaning the vents. He was not aware of the ones found during the inspection, and he was not aware of the mold-like substance that was found. During interview on 10/27/22 at 12:32 P.M., the administrator said she expected the vents to be clean and for there to be no mold.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Resident Assessment Instrument (RAI) Manual, and interviews, the facility failed to timely complete and submit quarterly Minimum Data Set (MDS) assessments for six (Residents (R) R5, R10, R24, R19, R6, R7) out of 41 sample residents. This deficiency had the potential of missed opportunities for care and services due to incomplete assessments done in a timely manner. Findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated 10/01/19, indicated, . The RAI helps nursing home staff look at residents holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. Nursing homes have found that involving disciplines such as dietary, social work, physical therapy, occupational therapy, speech language pathology, pharmacy, and activities in the RAI process has fostered a more holistic approach to resident care and strengthened team communication .The Quarterly assessment is an OBRA (Omnibus Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (Assessment Reference Date) .must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. Review of R24's electronic medical record (EMR) undated Face Sheet located under the Resident tab, indicated R24 was admitted to the facility on [DATE]. Review of the recent MDS of R24 showed a quarterly was in progress on 09/10/22 and had not been submitted. The last MDS completed was on 06/10/22 on admission. 2. Review of R19's EMR undated Face Sheet located under the Resident tab, indicated R19 was admitted to the facility on [DATE]. Review of the recent MDS of R19 showed a quarterly MDS was in progress 09/14/22, however, had not been submitted. The last quarterly MDS was completed on 06/14/22. 3. Review of R7's EMR undated Face Sheet located under the Resident tab, indicated R17 was admitted to the facility on [DATE]. Review of the recent MDS for R7 showed the last MDS was completed on 06/13/22. A quarterly MDS was in process on 09/13/22, however had not been submitted. 4. Review of R5's EMR undated Face Sheet located under the Resident tab, indicated R5 was admitted to the facility on [DATE]. Review of the recent MDS for R5 showed the last quarterly MDS was completed on 06/11/22. On 09/12/22 a quarterly MDS was in process, however had not been submitted. 5. Review of R10's EMR undated Face Sheet located under the Resident tab, indicated R10 was admitted to the facility on [DATE]. Review of the recent MDS for R10 showed the last annual MDS was completed 06/12/22 then the quarterly was in process on 09/12/22, however had not been submitted. 6. Review of R6's EMR undated Face Sheet located under the Resident tab, indicated R6 was admitted to the facility 05/31/21. Review of the recent annual MDS for R6 was completed on 06/13/22, then the quarterly MDS was in process on 09/13/22, however had not been submitted Interview with MDS Coordinator (MDSC) stated I am keeping up with my skill as well as I can, but these quarterly MDSs have fallen behind. I'm behind enough that I wouldn't know if there were any late. If it says they are in process, then I'm sure they are late and have not been submitted timely. I know when things are due, I just have a hard time getting them done. Corporate has been helping some lately.

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of food borne illness to 135 residents who resided in the facility and were able to consume meals. Concerns included: ensuring expired items were disposed of timely, proper dating and labeling of all food items, and providing proper training to all staff handling food. Findings include: Review of the facility's policy titled, Food Storage (Dry/Refrigerated/Frozen), 2014 Edition, indicated All food items will be labeled. The label must include the name of the food and the date consumed or discarded .discard food that has based the expiration date .keep potentially hazardous foods out of the temperature danger zone (41 degrees Fahrenheit (F) - 135 degrees F) .Set refrigerators to the proper temperature .Keep freezer at a temperature that ensures products will remain frozen. Review of the facility's policy titled, Labeling/Dating Foods (Date Marking), 2014 Edition indicated All foods stored will be properly labeled. Review of the facility's policy titled, Monitoring Food Temperatures for Meal Service, 2014 Edition indicated Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures .The temperature for each food item will be recorded on the Food Temperature Log. Foods that required a corrective action (such as reheating); will have the new temperature recorded with a circle around it next to the original temperature .If the serving/holding temperature of a hot food item is not at 135 degrees F or higher when checked prior to meal service, the item will be reheated to at lease 165 degrees F for a minimum of 15 seconds. The item may be reheated only once and must be discarded .Any complaint regarding food temperatures by resident will be documented on the food temperature log. Review of the facility's policy titled, Use of Steam Table in Dining Area, 2014 Edition indicated If meals are to be served from the kitchen, foods will be loaded onto the steam table no more than 30 minutes prior to meal service and will be held on the steam table no more than two hours. Review of the facility's policy titled, Cleaning Rotation, 2014 Edition indicated Equipment and utensils will be cleaned according to the following guidelines .Items cleaned after each use: Small food preparation equipment (e.g. blender) .Items cleaned daily: Stove top, Grill, Steam table, Hand washing sink, Food carts, Exterior of large appliances .Items cleaned weekly: Ovens, Trash barrels .Items cleaned monthly: Refrigerators, Freezers, Ingredient bins, Ice Machines. The initial inspection of the kitchen was conducted with the Dietary Manager (DM) on 10/18/22 from 9:00 AM - 10:10 AM. The following concerns were noted: The soap machine by the handwashing sink was broken in the front where the soap was dispensed, and a thumb or finger was used to remove the soap from the machine. The trash can next to the handwashing sink was splattered in dark brown food particles. A small freezer, standing by the entrance of kitchen was observed. The freezer did not have a temperature log posted and did not have a thermometer inside. The DM stated this was an activities department freezer and kitchen staff did not monitor the temperature or the contents of the freezer. The DM stated she did not know kitchen staff were responsible for monitoring the freezer. Inside the freezer were two containers of undated lime sherbet. The bottom shelf of the freezer was covered with crumbs and a plastic bag with unidentified items. A small refrigerator, standing next to the activities department freezer, was observed. The DM stated the refrigerator was used to store drinks for the main dining room (MDR) and employee food. There were three containers of yogurt with expiration dates of 08/21/22, 09/02/22 and 09/20/22, two containers of Sugar Free Jell-O, both expired on 09/03/22. A review of the paper temperature log posted on the front of the refrigerator revealed on 10/01/02, 10/02/22, 10/08/22, 10/09/22, 10/14/22, and 10/16/22 temperatures had not been obtained. A shelf, below the food preparation area, next to the steam table revealed containers of cereal with dates of 07/27/22, 07/25/22, and 09/20/22. The DM stated the cereal should be kept for seven days and began removing containers from the shelf and threw all of the cereal away. Cook3 was observed without a hair covering and stated he never wore a hair covering for the top of his head, he just covered his braids. The DM agreed hair in its entirety, for all staff, should be covered while working in the kitchen. The walk-in refrigerator was observed and a paper temperature log, posted outside of the walk-in refrigerator, was reviewed. The log revealed morning refrigerator temperatures were not recorded on 10/08/22, 10/09/22, 10/14/22, and 10/16/22. The log revealed evening refrigerator temperatures were not recorded on 10/02/22 - 10/04/22, 10/06/22 - 10/11/22, 10/13/22 and 10/14/22. Upon entering the walk-in refrigerator, expired items were observed and included: containers of yogurt with expirations dates of 07/18/22, 08/09/22, 08/21/22, 09/02/22, 09/13/22 and 09/30/22. There was also 32-ounce bottle of chopped garlic in oil that expired on 03/12/22. The dry storage area was observed and revealed: Thickener in a four-gallon container was undated, not labeled and the lid was not secured. The DM stated it should be kept for 30 days and removed the container and stated she would dispose of the thickener. There were potato chips, granola, and almonds that were open and undated; two powdered sugar bags undated; sugar in a four-gallon container undated and not labeled; and flour tortillas had a manufacture expired date of 09/24/22 and had been labeled by staff as opened on 10/05/22. There were two rolling bins on the floor observed, one containing flour and one with oatmeal, both were undated and had a visible brown substance on the top and sides. The DM stated she had not had a chance to review food storage, labeling and dating with staff. The Ninja blender base was observed to have a thick maroon substance inside. The DM stated the blender base should be cleaned after each use. During a second inspection on 10/20/22 between 8:35 AM - 10:15 AM, in the main kitchen and in the Unit 100, 300, 500/600 and 200 kitchens, with the DM and the Registered Dietician (RD), the following concerns were noted: The soap machine by the handwashing sink remained broken in the front where the soap was dispensed, and a thumb or finger was used to remove the soap from the machine. The RD stated they would put in a work order to replace the soap machine. The small refrigerator, standing next to the activities department freezer, revealed a container of yogurt with an expiration date of 09/30/22. The walk-in freezer revealed loose ice cream bars and small cups of orange sherbet on the shelves with no dates. A cloth shopping bag was observed sitting on the floor and contained nine frozen pizzas, unboxed, and wrapped in plastic, a box of chocolates and a box of caramel candy. The RD agreed items were disorganized and all food that was out of the package should be dated and labeled. She removed the shopping bag and stated she was not aware why these items were in the walk-in freezer. The grill, stove, fryer, and tilt skillet revealed a thick brown substance on all sides and on the front. The floor underneath was observed and had a black thick substance. The RD stated they did not have a deep cleaning schedule but needed one. She said everything that touches food should be cleaned daily. The dry storage area was observed and a rolling bin, which contained flour, remained undated. The DM stated it had been filled with new flour but had not been dated. The Ninja blender base was observed a second time and the thick maroon substance remained inside. The RD stated the blender base should be cleaned after each use. A tour of the Unit 500/600 kitchen revealed undated and unlabeled opened lemonade drink mix, bagged cereal, and potato chips. Cereal was observed in a plastic container with two dated labels of 04/17/22 and 09/21/22. A tour of the Unit 200 kitchen revealed a plastic container of cereal with two dates, 09/04/22 and 10/18/22. A tour of the Unit 300 kitchen revealed in the overhead cabinets were three bags of dry cereal, with no labels or dates. During observations and interviews in the Unit 100 Kitchen, on 10/21/22 between 7:45 AM - 8:37 AM, Dietary Assistant (DA)8 stated he had dropped off the Unit 100 food at approximately 7:00 AM. He stated he had taken the temperatures when he delivered the food and placed it on the steam table. At 8:06 AM, 66 minutes after food initially arrived on the steam table. During an interview with the DM on 10/21/22 at 9:14 AM, she stated all food was prepared in the main kitchen and then transported to each Unit kitchen. She stated food should be taken to the Unit kitchens no more than 15 minutes before serving time. She said her expectation was that all food temperatures should be obtained and recorded on the temperature log at each unit. She stated temperatures should be taken by dietary staff. She said once service begins, dietary staff are expected to stay in the kitchen to help CNAs with passing plates, passing drinks, and removing plates from the dining room. She stated staff would not typically take any more food temperatures but agreed, temperatures should be taken right before service begins if there had been a delay. She said she was not aware that food was left on the steam table for a prolonged amount of time. She stated an hour was too long for the food to be sitting on the steam table. She stated that proper temperatures of food should be posted in the kitchen, and currently were not. During an interview with the RD on 10/21/22 at 9:39 AM, she said the expectation was that the food temperatures should be taken after cooking and prior to going out to the Unit kitchen, because there was a delay between cooking and transporting to the unit kitchen. She said the main kitchen should not be transporting food to the unit kitchens no more than 15 minutes before meal service. She said if it takes longer than 15 minutes after food arrives then the temperatures of the food need to be taken again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to turn and reposition two additional residents (Residents #2 and #601), who were at risk for developing pressure ulcers. The total facility census was 183 with a certified census of 128. 1. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -A pressure ulcer is an inflammation, sore, or lesion that develops over areas where the skin and tissue underneath are injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation/blood flow and oxygen supply usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; pressure is the main cause; -Residents prone to forming pressure ulcers include elderly residents due to sluggish circulation, poor hydration, poor nutrition, and lack of exercise/mobility; paralyzed, thin, malnourished, obese, and incontinent residents; and residents with chronic diseases; -Prevention of pressure ulcers includes: change the resident's position at least every 2 hours or more frequently if indicated in the care plan, encourage residents in a geri chair or wheelchair to raise themselves every 10-15 minutes, use anti-pressure devices, promote good circulation by giving passive and active ROM exercises, promote good skin condition, and prevent friction on the resident's skin; -Turning should be scheduled for residents who are helpless; -A pressure ulcer can be as stressful to the human body as major surgery; it is worth every effort to prevent one; for every minute it takes to cause a pressure ulcer, it takes weeks to heal. 2. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009, showed the following: -Ongoing assessment of the skin is necessary to detect early signs of pressure damage; -Repositioning should be considered in all at-risk individuals, repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; -In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to; -When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high, therefore, without pressure relief, a pressure ulcer will occur very quickly. 3. Review of Resident 2's October 2019 physician order sheet (POS) showed the following: -Transfer status: two staff; -Toilet before and after meals, upon rising and before bed and as needed. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/01/19, showed the following: -Required extensive physical assistance from two staff for bed mobility, transfers, toileting and personal hygiene; -Frequently incontinent of urine; -Occasionally incontinent of bowel; -At risk for pressure ulcers. Review of the resident's care plan, dated 10/02/19, showed the following: -At risk for developing alterations in skin integrity/pressure injuries related to Braden score of 12; -Encourage repositioning. Observation on 10/09/19 at 5:38 A.M. showed the resident sat in his/her wheelchair at the nurses station. The resident's head was down and his/her eyes were closed. During interview on 10/09/19 at 5:47 A.M., Certified Nurse Assistant (CNA) E said he/she got the resident up at 5:00 A.M. Observation of the resident on 10/09/19 showed the following: -At 7:02 A.M., the resident sat in his/her wheelchair by the nurses station; staff spoke to the resident as they walked by; -At 7:40 A.M., the resident sat at the nurses station with his/her head down and eyes closed; staff awakened the resident and propelled the resident in his/her wheelchair to the dining room; -At 8:00 A.M., the resident sat in his/her wheelchair in the dining room and ate his/her morning meal; -At 8:34 A.M., staff propelled the resident in his/her wheelchair to the day area where the resident sat, looking at the television; -Staff did not reposition the resident in his/her chair during this time. Further observation of the resident on 10/09/19 showed the following: -At 9:40 A.M., the resident remained in his/her wheelchair in the day area where the resident sat, looking at the television; -At 10:00 A.M., staff propelled the resident in his/her wheelchair from the television area to an activity area, where the resident sat and watched the activity in his/her wheelchair; staff did not reposition the resident in his/her chair at this time; -At 10:50 A.M., staff propelled the resident from the activity to the area of the nursing station; staff did not reposition the resident in his/her chair at this time; -At 11:25 A.M., staff propelled the resident in his/her wheelchair from the nurses station to the dining room; staff did not reposition the resident in his/her chair at this time. Review of therapy notes provided by the facility dated 10/09/19 showed the resident participated in physical therapy from 11:35 A.M. to 12:05 P.M. During interview on 10/09/19 at 11:30 A.M., CNA I said the following: -He/She worked day shift and came in around 6:30 A.M.; -Staff should turn and reposition residents every two hours to help prevent skin breakdown; -The resident was up when he/she came on duty; -He/She had not had a chance to provide any assistance to the resident since coming on duty; -The resident required assistance of two staff for transfers and toileting and he/she had not had a chance to get with another CNA to get assistance in laying the resident down, toileting or repositioning him/her; -The resident was incontinent of bowel and bladder; -The resident had been busy with breakfast and activities and he/she had been busy with other resident care; -He/She hoped to be able to lay the resident down after lunch. Observation of the resident on 10/09/19 showed the following: -At 1:25 P.M., CNA I propelled the resident in his/her wheelchair from the dining room to his/her room; -CNA I and CNA J transferred the resident to his/her bed; -CNA J removed the resident's urine saturated incontinence brief; -The resident had reddened areas across his/her buttocks and bony prominences, approximately the size of an orange on each buttock. (The resident remained in his/her wheelchair from approximately 5:00 A.M. to 11:30 A.M., approximately six hours and 25 minutes, without staff repositioning, toileting or checking the resident for incontinence.) 4. Review of Resident #601's care plan, dated 9/30/19, showed the following: -Resident currently with an alteration in skin/pressure injury: small, red open area noted to coccyx; -Encourage frequent repositioning in bed and wheelchair. Review of the resident's admission MDS, dated [DATE], showed the following: -Required extensive physical assistance from two staff for bed mobility, transfers and toileting; -Required extensive physical assistance from one staff for personal hygiene; -Always continent of urine; -Frequently incontinent of bowel; -At risk for pressure ulcers; -Diagnoses included hip fracture and dementia. Review of the resident's October 2019 POS showed staff was to keep the resident in the common area as much as possible to monitor; resident is a high fall risk. Observations on 10/09/19 showed the following: -At 5:39 A.M. to 6:00 A.M., the resident sat in the area by the nurses station; -At 6:00 A.M., the resident began to self-propel back towards his/her room. CNA G brought the resident from down the hallway back to nurses station where the resident sat in his/her wheelchair with his/her head down until 7:30 A.M. During interview on 10/9/19 at 6:05 A.M., CNA G said he/she got the resident up around 4:30 A.M. or 5:00 A.M. Further observation of the resident on 10/09/19 showed the following: -At 7:30 A.M., staff propelled the resident in his/her wheelchair from the nurses station to the dining room where the resident waited for breakfast; staff did not reposition the resident at this time; -At 8:02 A.M., staff assisted the resident with his/her morning meal; -The resident remained in the dining room between 8:02 A.M. and 9:05 A.M.; -At 9:05 A.M., staff propelled the resident in his/her wheelchair to the nurses station day area where the resident sat, leaning to the right, with his/her head down; staff did not reposition the resident in his/her chair during this time; -The resident remained in the day area between 9:05 A.M. and 10:00 A.M.; -At 10:00 A.M., the resident's family member propelled the resident in his/her wheelchair down the hallway and back to the nurses station. The family member asked staff if there was a place they could go to visit. Staff directed them to the private dining room to visit. Staff did not reposition the resident in his/her chair during this time. Observation of the resident on 10/09/19 at 11:05 A.M. showed the following: -The resident's family member propelled the resident in his/her wheelchair from the private dining room down the hallway to CNA F and told CNA F the resident needed changed; -CNA F and Occupational Therapy Staff H assisted the resident on the toilet in the resident's bathroom; -As the resident stood up with the assistance of a stand-up lift device, the outside of the resident's pants was visibly wet and soiled. The resident had a urine odor. The pad in the resident's chair had a visible stained wet ring approximately the size of a dinner plate; -CNA F pulled down the resident's pants and removed the resident's urine saturated incontinence brief; -The resident had reddened areas across his/her buttocks and bony prominences, approximately the size of a fist on each buttock; -The resident's buttocks appeared macerated (prolonged exposure to moisture); (The resident remained in his/her wheelchair for approximately four and a half hours, without staff repositioning, toileting or checking the resident for incontinence.) During interview on 10/10/19 at 12:05 P.M., CNA F said the following: -He/She was responsible for the resident's care that day; -He/She came on duty at 6:30 A.M. that morning; -The resident was already up when he/she came on duty; -He/She had not provided any care to the resident since coming on duty; -The resident had behaviors and always had to be monitored, so frequently was left sitting at the nursing station; -The behaviors included falls and the resident self-transferring when he/she should not, so they did not leave the resident unattended in his/her room if he/she was awake; -Residents were to be toileted and repositioned every two hours or more frequently if needed. During interview on 10/10/19 at 2:35 P.M., the Director of Nursing said the following: -She expected staff to follow physician orders and care plan instructions to provide resident directed care; -She expected staff to reposition and toilet residents or provide incontinence care every two hours or more frequently if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medication regimen for one resident (Resident #53), in a review of 25 sampled residents, and for one additional resident (Resident #10), were free of unnecessary medications when their medical record lacked evidence the facility had a system to monitor the residents to ensure gradual dose reductions (GDR) were made in an effort to reduce or discontinue the medications. The facility also failed to ensure physicians orders for as needed (PRN) psychotropic medications were limited to 14 days as required except when an attending physician believed it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the as needed order. The total facility census was 183 with a certified census of 128. 1. Review of the facility policy, dated September 2013, titled Accommodating Behaviors Using Person-Centered Care, showed the following: -Gradual Dose Requirements: First year after being admitted on /or started on an psychopharmacologic agent, attempt reduction in two separate quarters at least one month in between. Annually thereafter, unless clinically contraindicated; -GDR may be considered clinically contraindicated if: Physician has documented clinical rationale for why any attempted dose reduction would be likely to impair resident function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder OR the resident's target symptoms returned/worsened after most recent dose tapering attempt AND the physician has documented the clinical rationale for why any additional attempted reduction would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; -PRN (As Needed) Usage of ANY Psychopharmacological Agent (including antidepressants) -Charting requirements: Any and all behavioral interventions that have been tried prior to use of the PRN agent must be documented on the PRN anti-psychotic, anti-anxiety, and hypnotic check list. This checklist can be used for medical record documentation purposes in the nursing notes. 2. Review of Resident #10's progress notes, dated 3/27/19 at 3:26 P.M., showed the following: -The Anti-Psychotic Medication Review (AMR) committee met and recommended continuation of the resident's current Risperdal (anti-psychotic medication) order due to failed GDR the previous year; -The committee would address the pharmacist consultant to reduce the resident's Zoloft (a medication used to treat anxiety and depression); -The resident was also on Xanax (a sedative used to treat anxiety and panic disorder) each evening due to anxiousness. Record review of the resident's care plan, dated 7/3/19 showed the resident was at risk for adverse consequences related to receiving antipsychotic medications (Risperdal, Xanax, and Zoloft). Record review of the resident's pharmacy review sheet, dated 8/15/19, showed the following: -Regarding CMS-F329: ANXIOLYTICS (a medication that inhibits anxiety)- GRADUAL DOSE REDUCTION (GDR); -The resident has received Xanax 0.25 milligrams (mg) every evening since at least February, 2017. Charting indicates that anxiety/behaviors have not been present for at least several months. Resident is due for an anxiolytic drug evaluation per CMS guidelines pertaining to use in elderly. A dose reduction must be attempted yearly unless a clinical contraindication is documented; -Please evaluate therapy and select an option below: - [ ] Decrease dose to alprazolam (Xanax) 0.125 mg every evening; - [ ] The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; - [ ] An attempted GDR is likely to result in impairment of function or increased distressed behavior; -Facility response: Anti-psychotic Medication Review (AMR) committee meeting today, recommend GDR on alprazolam. Review of the resident's medical record showed no evidence the resident's physician responded to the GDR request for Xanax, dated 8/15/19. Review showed no evidence the resident's physician provided a clinical rationale as to why a GDR of the Xanax should not be attempted. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/29/19, showed the following: -No documentation of behavioral symptoms; -Diagnoses included dementia, anxiety and depression; -The resident received anti-psychotic medication seven of the last seven days; -The resident received anti-anxiety medication six of the last seven days; -The resident received anti-depressant medication seven of the last seven days; -The resident's anti-psychotic medications were reviewed on a routine basis; -A GDR had been attempted; the last attempt was 3/28/19; -A GDR had not been documented by a physician as clinically contraindicated. Record review of the resident's October 2019 physician's orders (POS) showed the following: -Diagnoses included anxiety, major depressive disorder and delusional disorder; -Risperdal 0.25 mg every day (start date 4/7/18); -Xanax 0.25 mg every evening (start date of 2/1/17); -Zoloft 150 mg every day (start date of 2/1/17). Record review of the resident's pharmacy review sheet, dated 10/02/19, showed the following: -Regarding CMS-F329: ANTIDEPRESSANT GRADUAL DOSE REDUCTION ATTEMPT; -Resident has received Zoloft 150 mg daily since 2/2017 and is due for an evaluation of therapy; -All agents falling within the psychoactive category (without regard to indication) fall under gradual dose reduction guidelines. This includes agents within the antidepressant category; -Please address the appropriate response below: - [ ] Decrease dose to: Zoloft 100 mg daily; - [ ] An attempted GDR is likely to result in impairment of function or increased distressed behavior; - [ ] The resident's target symptoms returned or worsened after previous attempts at gradual dose reduction. Review of the resident's medical record showed the following: -No evidence the resident's physician responded to the GDR request for Zoloft, dated 10/2/19; -No evidence the resident's physician provided a clinical rationale as to why a GDR of the Zoloft should not be attempted. -No evidence a GDR of the resident's Risperdal (ordered 4/7/18) was attempted since ordered in 2018, and no clinical rationale provided by the resident's physician for not conducting a GDR. 3. Record review of Resident #53's quarterly MDS, dated [DATE], showed the following: -No documentation of behavioral symptoms; -Diagnoses included anxiety and depression; -No documentation the resident received anti-anxiety medication in the last seven days. Review of the resident's October 2019 POS showed the following: -Diagnoses included anxiety disorder and major depressive disorder; -Xanax 0.25 mg PRN prior to magnetic resonance imaging (MRI; procedure to form pictures of the anatomy and physiological processes of the body), start date of 7/31/19. Review of the resident's progress notes, dated 10/2/19 at 5:47 P.M., showed the AMR committee met and recommended continuing PRN alprazolam (Xanax) to be administered prior to outpatient physician appointments and testing, noting the resident had an upcoming oncology appointment on 10/17/19. Review of the resident's medical file showed no documentation the resident's physician believed it was appropriate the PRN order be extended beyond 14 days, or that the physician had documented a rationale in the resident's medical record and indicated the duration for the as needed order. 4. During interview on 10/10/19 at 9:10 A.M., the director of nursing said the following: -The AMR committee consisted of the social worker, activity staff, nurses, nurse aides and pharmacist. They met quarterly to discuss and complete a medication and reduction review; -The facility would like to see a 24 hour response to GDR requests, or nurses were to follow up with the physician after 24 hours; -Attempts were made to get a GDR from Resident #10's physician, but he refused to complete one because he had not prescribed the medication and wanted the resident's psychiatrist to address the GDR; -Resident #10 refused to see a psychiatrist, so a GDR had not been completed on any of the resident's medications; -She knew Resident #53's Xanax was an open ended PRN order, but the committee felt like the resident needed it prior to procedures, so a specific duration or rationale had not been requested from the physician.

Based on observation, interview, and record review, the facility failed to maintain and implement a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease). The total facility census was 183 with a certified census of 128. 1. Record review of the facility policy and plan, Water Management Program, showed the following: -The program was developed to identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in the facility water systems; -The program was a multi-step process that required continuous review and actions to be taken during regularly scheduled intervals to prevent Legionella and other bacteria from developing in the water delivery system; -Specific control measure locations were identified in the program and required an action, documentation of the action, and results; -The facility was to make sure the program was running as designed, was effective and that they documented and communicated all the activities; -The facility was to review the elements of the program at least once per year; -The policy and plan contained Maintenance K's name and a date of 3/21/18, acknowledging he/she knew what the policy/plan required. 2. Review of the Centers for Medicare and Medicaid Services (CMS), Survey and Certification memo, revised 7/6/18, showed the following: -CMS expects certified healthcare facilities to have water management policy and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems; -Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system; -Develops and implements a water management program that considers The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control (CDC) toolkit; -Specify testing protocols and acceptable ranges for control measures. 3. During an interview on 10/10/19 at 1:37 P.M., Maintenance Staff K said the following: -The facility was just getting started and had not yet fully implemented the Legionella program; -The facility was to have an upcoming meeting with the program management team (who supplied the plan and policy) where he and the facility would be getting guidance, instructions and tools on how to implement the program. During an interview on 10/10/19 at 12:06 P.M., the administrator said the following: -Maintenance staff was responsible for the handling of the Legionella Program; -The facility had an upcoming meeting with the program management team where the facility was to receive further instruction on implementing the program; -She was not sure what parts, if any, the maintenance staff had implemented.

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #28 and #68), in a review of 25 sampled residents, and four additional residents (Residents #32, #115, #602 and #603) were treated with dignity and respect. The total facility census was 183 with a certified census of 128. 1. Review of the facility's undated policy, Resident Rights, showed the following: -Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based; -You will have the right to expect that we will treat you as an individual and assist you in getting the most out of the programs and services we offer. 2. During a group interview on 10/8/19 at 3:32 P.M., residents said the following: -Resident #115 said his/her table mate had to go to the bathroom and staff told this resident to go in his/her pants; -Resident #32 said he/she had an accident (soiled himself/herself) waiting to go to the bathroom. He/She apologized to the staff for doing this but he/she shouldn't have had to apologize. It made him/her feel bad; -Resident #68 said staff had told him/her to go to the bathroom in his/her pants. Staff don't care about our dignity. 3. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 7/21/19, showed the following: -Moderate cognitive impairment; -Required extensive assistance from one staff for transfers and toileting; -Required limited assistance from one staff for personal hygiene; -Used a wheelchair for mobility; -Always incontinent of bladder and bowel; -Diagnoses included dementia and cerebrovascular accident (an interruption of blood flow to the brain). Review of the resident's Physician Order Sheet (POS), dated October 2019, showed the resident was incontinent. Review of the resident's care plan, last revised 10/2/19, showed the following: -The resident required assistance with activities of daily living (ADLs) and used a wheelchair; -Transfer with assist of one staff; -Functional/urge incontinence; -Required assistance with toileting; -Respond in timely manner. During interview on 10/9/19 at 11:00 A.M., the resident said he/she was not having a good day. He/She said he/she was in the hallway this morning when he/she needed to go to the bathroom. He/She asked four different staff for help and they all said they could not help. He/She said he/she waited two hours to go to the bathroom and had not made it in time and had a bowel movement in his/her pants. He/She said it was very humiliating to him/her. During interview on 10/10/19 at 2:36 P.M., the director of nursing (DON) said she would not expect residents to wait for two hours for staff to toilet them. Even if staff were busy, he/she would expect them to stop to toilet residents. This would be considered a dignity issue. If a resident had soiled themselves and felt humiliated, it would be a dignity issue. 4. Record review of Resident #603's care plan, dated 11/23/18 showed the following: -Resident may eat a regular diet; -Staff to encourage meals. The resident may need feeding assistance/cueing with start of meals then will finish feeding self. Review of the resident's October 2019 POS showed the following: -Diagnoses included dementia, anxiety and gastro-esophageal reflux disease (stomach disorder); -Regular diet; -Consider resident preferences; -May need assistance with cutting food and eating. Observation on 10/07/19 at 1:05 P.M. showed the following: -The resident sat at the dining room table in his/her wheelchair; -Certified Nurse Assistant (CNA) X stood at the resident's right side; -CNA X put meat on a spoon and then put it up to the resident's lips. The resident opened his/her mouth and took a bite. CNA X did not speak with the resident as he/she assisted the resident to eat; -CNA X left the resident's side and assisted another resident away from the dining room table; -CNA X returned to the resident, put slaw on a spoon and held it at the resident's lips while the resident chewed; -After giving the resident the bite of slaw, CNA X left the resident's side, went to the kitchen and got another resident a cup of hot chocolate; -CNA X casually spoke and laughed with nearby staff in the dining room about unrelated resident cares; -CNA X stood the entire time he/she assisted the resident to eat. During an interview on 10/7/19 at 1:23 P.M., CNA X said the following: -The resident could not feed himself/herself; -He/She was trying to multi-task with resident cares in-between giving the resident bites of food to eat; -He/She did not have time to sit down by the resident while feeding, there was too much to do; -He/She preferred to stand, making it easier to multi-task. During interview on 10/10/19 at 2:35 P.M., the DON said it was better for staff to sit while assisting residents with feeding rather than to stand. 5. Review of Resident #602's care plan, dated 10/09/19, showed the resident required a urinary catheter related to urinary retention. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/10/19, showed the following: -Diagnoses included obstructive uropathy (a condition where urine cannot drain through the urinary tract and backs up into the kidney); -The resident had a urinary catheter. Observation on 10/07/19 at 12:57 P.M. showed the following: -The resident sat in his/her wheelchair in the dining room; -The resident's urinary catheter bag, which contained approximately 200 cubic centimeters (cc) of urine was visible under his/her wheelchair. -The resident's urinary catheter bag was not covered to conceal the urine within the catheter bag. Observation on 10/08/19 at 10:25 A.M. showed the following: -The resident self-propelled in his/her wheelchair in the hallway toward the therapy room; -The resident's urinary catheter bag was visible under his/her wheelchair and held approximately 250 cc of urine; -The resident's urinary catheter bag was not covered. Observation on 10/08/19 at 2:20 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The door to the resident's room was open; -The resident's urinary catheter bag was visible under his/her wheelchair and held approximately 300 cc of urine; -The resident's urinary catheter bag was not covered. Observation on 10/09/19 at 6:36 A.M. showed the following: -The resident rested in his/her bed; -The resident's urinary catheter bag was visible and hung from the metal frame on the right side of his/her bed; -The urinary catheter bag held approximately 175 cc of urine; -The urinary catheter bag was not covered. During interview on 10/10/19 at 2:35 P.M., the DON said she expected urinary catheter bags to be kept in dignity bags or covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant to them for five residents (Residents #44, #51, #62, #424, and #426), in a review of 25 sampled residents, and for three additional residents (Residents #2, #58, and #601), when the facility failed to honor residents' preferences for time to awaken. The total facility census was 183 with a certified census of 128. 1. Review of the facility Resident [NAME] of Rights provided in the admission Agreement showed the following: -You are entitled to take part in planning your care and in being informed of all aspects of you care; -You may refuse any treatment you do not want. 2. Review of the facility policy, dated June 2002, titled Staff Assignments, showed the following: -The facility was to provide person-centered/directed care; -Find out resident's preferences and routines; -Record and discuss treatment and care preferences; -The care staff assignments are done according to the individual resident's preferences, needs and goals. These are communicated through the care plan process that begins upon admission and is updated quarterly or with change in condition. 3. Review of Resident #424's October 2019 Physician Order Sheets (POS) showed a preferred waking time between 7:00 A.M. and 8:00 A.M. Review of the resident's care plan, dated 10/02/19, showed the following: -Preferred waking time was between 7:00 A.M. and 8:00 A.M.; -Staff will attempt to assist the resident out of bed for breakfast within preferred time frame; -Staff may offer gentle wake-up during preferred time. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/10/19, showed the following: -Mild cognitive impairment; -Independent with decisions; was consistent and reasonable; -Required extensive physical assistance of one staff for bed mobility, transfers, dressing and toileting. Observation of the resident on 10/09/19 showed the following: -At 6:17 A.M., the resident lay quietly in bed with his/her eyes closed. Certified Nurse Aide (CNA) E and CNA G entered the resident's room. CNA E told the resident, It's time to get up, and CNA G shut the resident's room door; -At 6:28 A.M., the resident sat in his/her wheelchair at his/her bedside with his/her eyes closed. During interview on 10/09/19 at 6:30 A.M., the resident said the following: -He/She was only up because he/she does everything staff tell him/her to do. Staff said it was time to get up, so he/she did; -He/She normally doesn't get up that early. During interview on 10/09/19 at 6:40 A.M., CNA E said the following: -There are certain residents staff get up to make sure they are ready for breakfast; -The resident usually puts his/her light on to go to the bathroom about that time, so he/she got him/her ready for the day and did not ask the resident if he/she wanted to get up or even if he/she had to go to the bathroom. 4. Review of Resident #601's October 2019 POS showed a preferred waking time between 6:00 A.M. and 7:00 A.M. Review of the resident's care plan, dated 9/22/19, did not address the resident's preferred wake up time. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required extensive physical assistance from two staff for bed mobility, transfers and toileting; -Required extensive physical assistance from one staff for dressing. Observations on 10/09/19 at 5:39 A.M., 5:45 A.M., 5:50 A.M. and 6:00 A.M. showed the following: -The resident sat in his/her wheelchair in the area by nurses station; -The resident began to propel himself/herself towards his/her room; -The resident said, I want to go back to bed. I did not want to be up this early; -CNA G brought the resident from down the hallway back to the nurses station; -The resident asked CNA E where his/her bed was, saying he/she just wanted to go to bed; -The resident told CNA E if he/she would put him/her back to bed, he/she would make everyone a coffee cake in the morning. During interview on 10/9/19 at 6:05 A.M., CNA G said the following: -He/She had not been told to get any certain resident up for the day; -He/She liked to get those residents up he/she could to help out day shift staff; -He/She usually started getting residents up around 4:30 A.M. or 5:00 A.M. depending on what hall he/she worked; -He/She got the residents up who needed assistance or were more dependent; -Resident #601 was a fall risk and would try to get out of bed if he/she was left in bed when awake. CNA G got the resident up early, because he/she would be busy getting other residents up and he/she did not want to risk the resident falling and getting hurt. 5. Review of Resident #426's care plan, dated 9/27/19, showed the resident likes to sleep in. Review of the resident's October 2019 POS showed the resident likes to sleep in. Review of the resident's admission MDS, dated [DATE], showed the following: -Mild cognitive impairment; -Required extensive physical assistance from two staff for bed mobility, transfers and toileting; -Required extensive physical assistance from one staff for dressing. Observation on 10/09/19 at 6:06 A.M. showed the resident sat in his/her wheelchair in his/her room. His/Her head was down and his/her eyes were closed. During interview on 10/09/19 at 6:15 A.M., the resident said the following: -He/She was sleepy; -He/She didn't know why he/she was up; -He/She did not ask to get up. During interview on 10/9/19 at 6:45 A.M., CNA E said the following: -He/She assisted residents up on various halls that morning. When making rounds, he/she thought he/she would be helpful and get the resident up for day shift; -He/She did not know the resident's preferred wake up time, but he/she knew the resident liked breakfast, and breakfast would be served around 7:30 A.M. or 8:00 A.M.; -He/She assisted the resident in getting up for the day around 5:30 A.M. 6. Review of Resident #2's October 2019 POS showed the resident's preferred waking time was 7:00 A.M. Review of the resident's care plan, dated 9/27/19, showed the following: -Preferred waking time was 7:00 A.M.; -Staff will attempt to assist the resident out of bed for breakfast within the preferred time frame; -Staff may offer gentle wake-up during the preferred time. Review of the resident's MDS, dated [DATE], showed the following: -Mild cognitive impairment; -Required extensive physical assistance from two staff for bed mobility, transfers and toileting; -Required extensive physical assistance from one staff for dressing. Observation of the resident on 10/09/19 at 5:38 A.M. showed the resident sat in his/her wheelchair at the nurses station. The resident's head was down and his/her eyes were closed. During interview on 10/09/19 at 5:40 A.M., the resident said the following: -He/She wished he/she was still in bed; -Staff did not ask him/her if he/she wanted to get up, they just got him/her up. During interview on 10/09/19 at 5:47 A.M., CNA E said the following: -He/She got the resident up at 5:00 A.M.; -He/She knew the resident had Parkinson's disease (movement disorder), and shakes a lot in bed; -He/She figured he/she wanted to get out of bed because he/she shakes less in his/her wheelchair; -He/She did not ask the resident if he/she wanted up for the day. 7. Review of Resident #44's care plan, dated 2/12/18 and last reviewed on 8/12/19, showed the following: -The resident's preferred waking time is 6:00 A.M.; -Staff may offer gentle wake-up during preferred time; -Respond to call light requesting to get up in a timely manner. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from two staff for bed mobility; -Required total assistance from two staff for transfers and toileting; -Required extensive assistance from one staff for dressing and hygiene; -Diagnosis included dementia and hemiplegia. Review of the resident's October 2019 POS showed the resident's preferred waking time was between 6:00 A.M. and 7:00 A.M. Observation on 10/9/19 at 5:32 A.M., showed the following: -The resident lay in bed; -CNA W entered the resident's room, turned on the light, and asked the resident if he/she was ready to get up; -The resident replied, no; -CNA W pulled back the resident's blanket and proceeded to provide perineal care, dressed the resident, then covered the resident with his/her blankets, turned on the television, and left the room. During interview on 10/9/19 at 05:57 A.M., CNA W said the following: -He/She has a routine in the morning; -He/She has a few residents he/she gets ready in the morning to help out the day shift staff. 8. Review of Resident #62's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Totally dependent on staff for transfers. Review of the resident's care plan, reviewed 10/10/19, showed the following: -Preferred waking time was between 6:00 A.M. and 7:00 A.M. -Staff to respond to call light requesting to get up in a timely manner; -Staff may offer gentle wake-up during preferred time. Observation of the resident on 10/9/19 showed the following: -At 5:45 A.M., CNA R finished dressing the resident in a sweat shirt, slacks, socks, and shoes and placed a mechanical lift vest beneath the resident. CNA R covered the resident with a sheet and blanket, placed a neck pillow behind the resident's neck, and left the room; -At 6:40 A.M., the resident remained in the same position in bed. The resident's eyes were closed. The mechanical lift sling was under the resident who was fully dressed in bed and wearing shoes. During interview on 10/9/19 at 5:50 A.M., CNA R said there were at least ten to 11 residents who transferred with the mechanical lift and they were short of staff all the time. He/She had two other residents already dressed but they remained in bed since they required assistance from two staff with the mechanical lift for transfers. He/She dressed these residents to wait for day shift to help him/her get them up. The day shift aides got upset if the residents weren't dressed for them to get up. He/She left Resident #62 dressed in bed lying on the mechanical lift sling. During interview on 10/9/19 at 6:36 A.M., Licensed Practical Nurse (LPN) S, night charge nurse, said there was no list for staff to get up certain residents. Staff get residents ready and leave them in bed if they require two staff assistance to transfer on the day shift with two aides. 9. Review of Resident #58's annual MDS, dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for bed mobility and dressing; -Required extensive assistance from two staff for transfers. Review of the resident's care plan, last revised 9/19/19 showed the following: -Preferred waking time was 6:00 A.M. to 7:00 A.M.; -Required extensive assist of all aspects of care; -Two person assist with bed mobility; -Transfer per two staff assist and mechanical lift. Review of the resident's POS, dated October 2019, showed the following: -Diagnoses included dementia and right sided hemiplegia (paralysis on one side of the body); -Preferred waking time is 6:00 A.M. Observation of the resident on 10/9/19 showed the following: -At 6:00 A.M., the resident lay in the bed fully clothed and wearing shoes; -CNA DD and CNA FF entered the room, placed the mechanical lift sling under the resident and transferred him/her to the wheelchair. 10. Review of Resident #51's care plan, dated 5/3/19, showed the following: -Preferred waking time was 7:00 A.M. to 8:00 A.M.; -Mechanical lift with two staff assist; -Adapt environment to maximize resident's safety and independence. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Totally dependent on two staff for transfers. Review of the resident's POS, dated October 2019, showed the following: -Diagnoses included muscle weakness, difficulty walking and unsteadiness on feet; -Preferred waking time was 8:00 A.M. Observation of the resident on 10/9/19 showed the following: -At 5:20 A.M., the resident lay dressed in the bed with his/her eyes closed; -At 6:45 P.M., CNA DD and CNA FF entered the room, placed a mechanical lift sling under the resident and transferred him/her to the broda chair. During interview on 10/9/19 at 7:00 A.M., CNA DD said the following: -Staff began waking residents and providing cares around 5:00 A.M. Night shift staff predressed four residents, including Residents #51 and #58, who required a mechanical lift to transfer. Staff pre-dressed the residents so they would be ready to transfer with the lift when a second staff was available; -Residents may lay dressed in bed for 45 minutes to an hour depending on when help arrived to assist. During interview on 10/09/19 at 7:45 A.M., CNA B said the following: -Night shift staff usually got residents up and dressed for day shift; -Those residents that were not up and ready for the day were at least dressed and ready to be gotten up to make day shift's morning routine go easier; -Dependent residents were the ones that generally were awakened and predressed; independent residents were allowed to sleep until they wanted. 11. During interview on 10/10/19 at 2:45 P.M., the Director of Nurses said if it was not too early in the morning, the night staff would dress the residents who needed assistance of two staff for transfers. When the day shift came on, they would assist the night staff with the two person transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure facility staff provided five of 25 sampled residents (Resident #28, #44, #16, #426, and #51) and one additional resident (Resident #601), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The total facility census was 183 with a certified census of 128. 1. Review of the facility's policy, Perineal Care, dated 01/2017, showed the following: -Purpose: to establish a routine for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection and prevent odors; -All residents will receive perineal care, as needed, in the morning before breakfast, every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent; -FEMALE: Make a mitten with the washcloth, wet and apply soap or peri-wash. Wash perineal area thoroughly. Separate the labia and wash the entire surface from pubis to around vagina; -MALE: Pull skin away from head of penis and wash around head of penis. Wash all surfaces of the scrotum. **If resident is not circumcised, retract skin from head of penis and wash around head of penis. Pull skin back over head of penis after cleansing. Wash all surfaces of scrotum; -Wash front peri-area with soap and water or use peri-wash. Wash inner thighs and all exposed areas with soap and water or peri-wash; -Rinse washcloth in basin if using soap or grab warm washcloth from plastic bag; -Rinse all cleansed areas if using soap and water, and dry thoroughly; -Turn resident on side away from you; -Lather washcloth and wash rectal area and buttocks if using soap and water, otherwise use peri-wash; -Rinse all cleansed areas where soap and water was used, and dry thoroughly. Review of the facility policy, Shaving, dated June 2002, showed the following: -Purpose: to remove excessive hair from the face, to improve cleanliness and to improve resident morale and appearance; -Female residents with excessive facial hair should be shaved as needed; -Facility policy did not direct staff when to shave a resident. Review of the facility policy, Nail Care, undated, showed the following: -Purpose: to provide cleanliness, to prevent spread of infection, for comfort and to prevent skin problems; -Fingernails of a diabetic residents are to be cut by the nurse; -Toe nails of diabetic residents are to be cut by the podiatrist or licensed nurse; -Facility policy did not direct staff when to provide nail care. 2. Review of Resident #426's face sheet showed the resident's diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement) cognitive communication deficit, and muscle weakness (generalized). Review of the resident's care plan, dated 9/27/19, showed the following: -The resident had a deficit in activities of daily living (ADL) functioning; -Encourage ADL participation to maximize independence. Provide set-up/cueing/assistance as needed. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/05/19, showed the following: -Required supervision, oversight, encouragement and cueing of staff or personal hygiene; set up help only; -Diagnosis included stroke. Observation on 10/08/19 at 2:49 P.M. showed the following: -The resident rested in bed in his/her room; -The resident had unshaven facial hair resembling stubble. Observation on 10/09/19 at 6:06 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident had unshaven facial hair resembling stubble. Observation on 10/09/19 at 2:15 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident had unshaven facial hair resembling stubble. During interview on 10/08/19 at 2:53 P.M., the resident said the following: -He/She needed help shaving his/her facial hair and staff never assisted him/her; -Staff never brings him/her supplies to shave or offers to help him/her shave; -He/She likes to be clean shaven; -He/She has told staff he/she used to shave daily. During an interview on 10/09/19 at 2:15 P.M., the resident's spouse said the following: -The resident needed help shaving his/her facial hair and staff never assisted him/her; -He/She sometimes asked for supplies to shave and assisted the resident because staff never seemed to have time to do it; -The resident liked to be clean shaven. During interview on 10/09/19 at 7:30 A.M., Certified Nurse Assistant (CNA) B said the following: -Staff were to shave residents daily or to their request and liking, but usually on shower days; -The resident's spouse had asked him/her for shaving supplies before to shave the resident. 3. Review of Resident #601's care plan, dated 9/22/19 and revised 10/5/19, showed the following: -The resident was incontinent of bowel and bladder related to dementia. The resident will be dry/free of odors and attain highest level of continence; -If the resident is incontinent, provide peri-care as soon as possible after incontinent episode per facility policy being sure to cleanse well and cleanse from front to back; -Provide assistance with activities of daily living as indicated (requires extensive assistance). Review of the resident's admission MDS, dated [DATE], showed the following: -Required extensive physical assistance from one staff for personal hygiene; -Required extensive physical assistance from two staff for toilet use; -Always continent of urine; -Frequently incontinent of bowel. -Diagnoses did not include diabetes. Record review of the resident's final urinalysis culture and sensitivity report, dated as final 10/05/19, showed the following: -Greater than 100,000 colony-forming units (CFU) per milliliter (ml) of proteus (gram negative bacteria that is widely distributed in human feces) and 10,000 CFU/ml of Escherichia coli (bacteria that normally lives in ones intestines) and mixed skin flora (bacteria from the skin associated with urinary tract infections); -Suggested medications to treat urinary tract infection included Bactrim DS. Review of the resident's October 2019 POS showed an order for Bactrim DS (antibiotic) 800-160 milligrams twice daily times 10 days, start date of 10/05/19. Observation on 10/07/19 at 1:16 P.M. showed the following: -The resident sat in his/her wheelchair in the dining room. The resident ate his/her lunch meat sandwich with his/her hands; -The resident's finger nails were long and had brown debris under them. Observation on 10/08/19 at 1:14 P.M. showed the following: -Staff assisted the resident in his/her wheelchair down the hallway; -The resident's finger nails were long and had brown debris under them. Observation on 10/09/19 at 5:39 A.M. showed the following: -The resident sat in the area by the nurses station; -The resident's finger nails were long and had brown debris under them. Observation on 10/09/19 at 11:05 A.M. showed the following: -CNA F and Occupational Therapy Staff H assisted the resident on the toilet in the resident's bathroom; -Staff removed the resident's urine saturated incontinence brief; -CNA F cleansed the resident's buttocks with washcloths; -CNA F and Occupational Therapy Staff H applied a clean incontinence brief on the resident; -Neither CNA F and Occupational Therapy Staff H cleansed the resident's front peri-area. During interview on 10/09/19 at 11:06 A.M., CNA F said the following: -He/She had not provided front peri-care for the resident because he/she was positioned to the back of the resident; -He/She did not feel it was Occupational Therapy Staff H's responsibility to provide front peri-care and did not think it would be appropriate to ask because the resident and the staff member were of the opposite sex; -He/She was going to treat the resident to a whirlpool bath later where he/she would get the resident cleaned up well. Observation on 10/09/19 at 2:00 P.M. showed the following: -The resident sat in the area by the nurses station; -The resident's finger nails were long and had brown debris under them. 4. Review of Resident #28's quarterly MDS, dated [DATE], showed the following: -Mild cognitive impairment; -Required limited assistance from one staff for personal hygiene; -Diagnoses included dementia and cerebral vascular accident (CVA; an interruption of blood flow to the brain). Review of the resident's care plan, last revised 10/2/19, showed the following: -Required assist to maintain grooming/personal hygiene with shaving; -Resident will be well groomed; -Provide assistance for facial hair. Check the need for hair removal on shower days and remove as needed. Observation on 10/7/19 at 12:48 P.M. showed the resident sat in his/her wheelchair with white facial hair noted on bilateral corners of his/her mouth and upper lip. Observation on 10/8/19 at 2:33 P.M. showed the resident lay in his/her bed. The resident's facial hair observed on 10/7/19 remained on the resident's face. During interview on 10/9/19 at 7:26 A.M. CNA DD said staff usually shave residents in the afternoons, but staff should offer touch up shaving for residents as needed. 5. Review of Resident #16's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for personal hygiene. Review of the resident's care plan, last revised 10/10/19, showed the following: -Limited mobility/functional status; -Resident will safely maintain personal hygiene; -Provide set up, oversight, encouragement, cueing, physical assistance, full staff performance assistance for ADLs. Observations on 10/8/19 showed the following: -At 8:13 A.M., the resident sat in his/her wheelchair by the nurse's desk. The resident's teeth were caked with debris and had a build-up of a white/yellowish substance on them and along his/her gum line; -At 2:00 P.M., staff pushed the resident to his/her room after lunch and exited the room. Staff did not offer oral care. The resident's teeth continued to be covered with food debris and a build-up of a white substance on his/her teeth and gum line. Observation on 10/9/19 at 5:45 A.M. showed the following: -The resident lay in his/her bed; -CNA DD and CNA FF entered the room, dressed the resident, transferred him/her to the wheelchair and performed morning cares; -Staff did not offer to set up oral care or provide oral care for the resident. The resident's teeth remained with debris and a pasty film build up. During interview on 10/9/19 at 7:26 A.M. CNA DD said staff should offer oral care with morning cares. 6. Review of Resident #51's care plan, dated 5/3/19, showed the following: -Limited mobility/functional status, required ADL assistance; -Provide set up, oversight, encouragement, cueing, physical assistance, full staff performance assistance for ADLs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Required extensive assistance from two staff for personal hygiene. Observation on 10/8/19 at 2:00 P.M. showed the following: -At 1:36 P.M., the resident sat in his/her broda chair (specialized wheelchair) in the dining room. The resident's lips had dried food on them and the resident's teeth were caked with white/yellowish debris; -At 2:00 P.M., staff pushed the resident to his/her room. Staff did not offer oral care for the resident prior to leaving the room. Observation on 10/9/19 at 6:45 P.M., showed CNA DD and CNA FF transferred the resident into his/her chair and pushed him/her to the dining room. The resident's teeth had yellowish/white debris on and in between them. Staff did not offer oral care for the resident. During interview on 10/10/19 at 7:55 A.M., CNA DD said he/she did not perform oral care for residents before getting them out of bed. 7. Review of Resident #44's care plan, dated 2/12/18 and last reviewed on 8/12/19, showed the following: -The resident is incontinent of bowel and bladder; -Provide incontinence care after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Totally dependent on two staff for toileting; -Required extensive assistance from one staff for personal hygiene; -Always incontinent bowel and bladder; -Diagnoses included dementia and hemiplegia (paralyzed on one side of the body). Observation on 10/9/19 at 05:32 A.M., showed the following: -The resident lay on his/her back in bed; -CNA W uncovered the resident; -The resident told staff he/she had voided; -CNA V cleaned the resident's right groin area, folded the cloth, wiped the resident's left groin, then using the same cloth surface, wiped back up the left groin area; -CNA V picked up a new cloth and wiped down the left groin then up in an upward motion cleansing the top of the front genitalia; -CNA V did not cleanse the resident's genitalia. During interview on 10/9/19 at 12:06 P.M., CNA V said staff should cleanse the groin areas, front genitalia, buttocks and rectal areas when providing care. 8. During an interview on 10/10/19 at 2:35 P.M., the director of nursing said the following: -She expected staff to shave residents on their shower day, when they requested it or at the resident's preference or liking; -CNAs were responsible for removing facial hair. Staff should offer to shave men and women anytime unwanted facial hair was observed; -Staff was to complete nail care during skin assessments, on showers days and as needed; -Nurse aides were allowed to complete nail care on all residents other than diabetic residents; -When providing incontinence care, staff should cleanse any area that had been in contact with urine or feces. Staff should use soap and water or peri-wash for cleansing. Staff should fold the washcloth or disposable wipe after each swipe; -She expected staff to offer oral care or perform oral care in the morning, after meals and at bedtime; -She did not feel oral care was completed appropriate if residents were observed with debris and pasty like substance on their teeth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ appropriate methods for repositioning for three additional residents (Residents #2, #600 and #601), when staff lifted and repositioned the residents under their arms and by the waist of the resident's pants. The facility also failed to ensure staff consistently implemented interventions identified to prevent falls for three residents (Residents #93, #77 and #426), in a review of 25 sampled residents. The total facility census was 183 with a certified census of 128. 1. Review of the Nurse Assistant in Long-Term Care Facility Student Reference, 2001 revision, Lesson Plan 3, Unit VII, titled Transferring Residents, showed: -The gait belt is a special belt that is placed around the resident's waist and provides the nurse assistant. with a handle to hold onto for those who require assistance during transfers, ambulation, or repositioning in the chair; -The purposes of using a gait belt is to ensure optimum safety and comfort for the resident and to minimize the risk of injury to the resident and/or nurse assistant; -The nurse assistant should not transfer or ambulate residents by grasping their upper arms or under their arms. Such a transfer could result in skin tears, damage to nerves and arteries, and possible dislocation of the shoulder. The gait belt increases the comfort and safety of the resident during the transfer procedure and prevents injury to the resident that could be caused by pulling on his/he arms, shoulders, or wrist; -Gait belts are required for all residents when performing transfers, ambulation, or repositioning in a chair; -For the resident who slides forward in the chair: Apply gait belt. Use two people. They should stand on opposite sides of the resident. Each grasps the belt in back and places one hand under the thigh in front. On the count of three, lift, and move the resident back in the chair. 2. Review of a facility policy, dated January 2017, titled Positioning Residents, did not address how staff was to re-position residents in wheelchairs. 3. Review of the facility policy, dated 7/1/15, titled Gait Belt use, showed gait belts should be used with all residents that require physical lifting assistance. 4. Review of Resident #2's care plan, dated 9/27/19, showed the resident had a deficit in mobility and activities of daily living. Review of the resident's October 2019 physician orders sheets (POS) showed the resident's diagnoses included muscle weakness, stroke and mobility abnormality. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/01/19, showed the resident required extensive assist from two staff for transfers. Observation on 10/07/19 at 1:22 P.M. showed the following: -The resident sat in his/her wheelchair in the 700 hall dining room. Staff assisted the resident to eat his/her lunch; -Certified Nurse Assistant (CNA) BB asked Registered Nurse (RN) A for assistance in repositioning the resident in his/her wheelchair; -Standing on the resident's right side, CNA BB positioned his/her right arm under the resident's right arm while placing his/her left hand around the back side of the resident's waistband of his/her shorts; -Standing on the resident's left side, RN A positioned his/her left arm under the resident's left arm while placing his/her right hand around the back side of the resident's waistband of his/her shorts; -Neither CNA BB and RN A applied a gait belt around the resident to assist in repositioning the resident in the wheelchair; -Together, CNA BB and RN A, lifted the resident up by lifting under the resident's arms and pulling him/her up by the waistband of his/her shorts. During interview on 10/07/19 at 1:30 P.M., CNA BB said the following: -He/She had a gait belt available and on his/her person. He/She just forgot to use it; -Pulling on the resident's arms and shorts probably was uncomfortable for the resident. 5. Review of Resident #600's care plan, dated 4/30/19, showed the resident had mobility/functional deficit and required assistance with activities of daily living. Review of the resident's October 2019 POS showed his/her diagnoses included muscle weakness. Observation on 10/07/19 at 12:12 P.M. showed the following: -The resident sat in his/her wheelchair in the 300/400 hall dining room, awaiting lunch service; -The resident asked staff to assist him/her up in his/her wheelchair, stating he/she was slipping downward; -Standing on the resident's right side, CNA X positioned his/her right arm under the resident's right arm while placing his/her left hand around the back side of the resident's waistband of his/her pants; -Standing on the resident's left side, CNA CC positioned his/her left arm under the resident's left arm while placing his/her right hand around the back side of the resident's waistband of his/her pants; -Together, CNA X and CNA CC, lifted the resident up by lifting under the resident's arms and pulling him/her up by the waistband of his/her pants; -Neither CNA X and CNA CC placed a gait belt around the resident to assist in the repositioning. During interview on 10/07/19 at 12:30 P.M., CNA X said the following: -He/She would have normally used a gait belt to reposition the resident, but he/she did not have it with him/her and he/she just wanted to get the resident scooted up in his/her chair; -Resident #600 was light weight and he/she did not think this pulled too much on the resident's arms. 6. Review of Resident #601's care plan, dated 9/22/19, showed the resident required two staff to assist with transfers. Review of the resident's admission MDS, dated [DATE], showed the following: -Required extensive physical assistance from two staff for transfers; -Balance was not stable; only able to stabilize with staff assistance; -Lower extremity impairment on one side; -Diagnoses included arthritis, hip fracture and dementia. Observation on 10/09/19 at 11:05 A.M. showed the following: -CNA F assisted the resident into the bathroom in his/her wheelchair and positioned the resident next to the grab bar; -CNA F placed a gait belt around the resident and positioned the resident's hands on the grab bar and instructed the resident to stand; -While the resident attempted to stand, CNA F stood by the resident's right side and placed his/her right hand around the gait belt to the resident's back and his/her left hand on the back waistband of the resident's pants, attempting to assist the resident in a standing position; -CNA F placed his/her right hand on the gait belt near the resident's left hip while his/her left hand remained on the back waistband of the resident's pants, further trying to assist the resident to a standing position; -When CNA F was not able to get the resident to a standing position, CNA F lowered the resident back down into his/her wheelchair by holding onto the back of the resident's pants with his/her left hand. During interview on 10/10/19 at 12:05 P.M., CNA F said the following: -He/She knew he/she should use the gait belt when assisting residents; -Resident #601 was just not cooperating with standing, and he/she felt he/she had to get hold of the resident to try and get him/her to stand up, giving him/her that umph to stand, so he/she grabbed onto the resident's pants to try and help him/her stand; -He/She had always been able to assist the resident to stand alone; the resident must be requiring more help now. 7. Review of Resident #93's care plan, dated 1/4/19, showed no documentation staff was to utilize fall mats for the resident. Review of the resident's fall assessment, dated 2/27/19, showed the resident was at high risk for falling. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included dementia, stroke, and hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body); -Required extensive physical assistance from one staff for transfers; -Required limited physical assistance from one staff for bed mobility; -Used a wheelchair for mobility; -Not steady, only able to stabilize with staff assistance; -Had falls since admission. Review of the resident's October 2019 Physician Order Sheet (POS) showed fall mat next to bed at all times when in bed (original order dated 3/30/19). Observation on 10/7/19 at 3:00 P.M. showed the following: -The resident was resting in bed with his/her eyes closed; -There was no fall mat next to the resident's bed. Observation on 10/8/19 at 1:30 P.M. showed the following: -The resident was resting in bed with his/her eyes closed; -There was no fall mat next to the resident's bed. Observation on 10/9/19 at 6:44 A.M. showed the following: -The resident was resting in bed with his/her eyes closed; -There was no fall mat next to the resident's bed. During interview on 10/9/19 at 7:00 A.M. and 7:10 A.M., CNA B said the following: -The resident was to have a fall mat placed on the floor at his/her bedside, while he/she was in bed because the resident was at risk for falls; -He/She had just come on duty and did not realize the resident's fall mat was not placed at the resident's side of the bed; -He/She had found the fall mat shoved under the resident's bed along the wall; he/she did not know why night shift had not placed the fall mat correctly when the resident went to bed. 8. Review of Resident #426's face sheet showed the resident's diagnoses included history of falling, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), cognitive communication deficit, and generalized muscle weakness. Review of a post fall assessment, dated 9/30/19 at 9:00 P.M., showed the resident was attempting to answer his/her phone and slid off the bed and was found sitting on the floor. Review of the resident's care plan, dated 9/29/19 and revised 10/04/19, showed the following: -The resident was at risk for falls; -Keep frequently used items within reach. Review of the resident's admission MDS, dated [DATE], showed the following: -Required extensive physical assistance from two staff for bed mobility and transfers; -Not steady, only able to stabilize with staff assistance; -Used walker and wheelchair for mobility; -Diagnoses included stroke. Observation on 10/08/19 at 2:49 P.M. showed the following: -The resident rested in bed; -The resident's bedside table, with his/her phone and water cup, were across the room and not within the resident's reach. Observation on 10/09/19 at 6:06 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room, his/her back to his/her bed, where the call light hung from the headboard of the bed; -The resident's bedside table, with his/her phone and drinks, were across the room and not within reach for the resident. During an interview on 10/09/19 at 2:15 P.M., the resident's spouse said the following: -He/She liked to call the resident when he/she was not able to come to the facility or in the evenings before he/she went to bed; -The resident had a fall one evening when he/she had tried to call the resident. The resident had tried to get up out of his/her bed to reach his/her phone because it was not close by; -He/She was hesitant to call, in case the phone was not close by, but he/she always did, because if he/she didn't, he/she knew the resident would be upset; -He/She had called the facility a few times to make sure the resident's phone was close by before he/she called; -He/She frequently came to visit and found the resident's bedside table nowhere near the resident where he/she had access to his/her phone and liquids. 9. Review of Resident #77's fall risk assessment, dated 8/15/19, showed the resident was high risk for falls. Review of the resident care plan, last revised 8/16/19, showed the following: -At risk for falls; -Will remain free from injury related to falls; -Evaluate history/cause of past falls. Incorporate findings into care needs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required extensive assistance from one staff for transfers; -Balance was not steady, only able to stabilize with human assistance; -Functional range of motion impairment on one side; -No falls in the last six months. Review of the resident's October 2019 POS, showed the following: -Diagnoses included history of falls, muscle weakness, and abnormalities of gait and mobility; -High fall risk; -Fall mattress next to bed while resident in bed (original order dated 5/10/18). Observation on 10/9/19 at 6:45 P.M. showed the resident lay in his/her bed. There was no fall mat on the floor by the resident's bed or in the resident's room. Observation on 10/10/19 at 8:30 A.M. showed there was no fall mat in the resident's room. CNA GG, who was present in the room with the resident, said the resident did not have a fall mat. 10. During an interview on 10/10/19 at 2:35 P.M., the director of nursing (DON) said the following: -She expected staff to use gait belts versus pulling on residents' pants and under their arms during repositioning; -She expected staff to follow physician orders and care plans to provide resident directed care; -He/She expected a fall mat to be used for a resident if ordered on the POS and the resident was at risk for falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain urinary drainage bags (bag attached to a catheter to collect urine) below the level of the bladder and failed to keep catheter tubing and urinary drainage bags off of the floor or other surfaces for three sampled resident (Residents #51, #62, and #83), and for one additional resident (Resident #602). The total facility census was 183 with a certified census of 128. 1. Review of the facility policy, Catheter Care, dated October 2008 and last revised December 2009, showed the following: -Attach catheter bag to bed frame only; -Never lift bag above bladder level (source of infection). 2. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -The bladder is considered sterile. The catheter, drainage tubing, and bag are a sterile system; -Drainage tubing/bags must not touch the floor; always hook to unmovable part of the bed frame or chair; -When transferring residents from bed to chair, always move the drainage bag over to the chair before moving the resident; -The drainage bag should always be below the level of the bladder; -If moved above, urine could flow back into the bladder. 3. Review of Resident #83's urine culture report, dated 8/7/19, showed the following: -Escherichia Coli (bacteria found in the intestines) 50,000-100,00 colony forming units (CFU)/milliliter (ml); -Proteus Mirablilis (pathogen of the urinary tract) 50,000-100,00 CFU/ml; -Enterococcus Faecalis (gram positive bacterium)10,000-50,000 CFU/ml. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/28/19, showed the following: -Totally dependent on two staff for transfers; -Urinary catheter. Review of the resident's care plan, last revised 8/29/19, showed the following: -Urinary catheter. -Resident will have catheter care managed appropriately as evidenced by: not exhibiting signs of urinary tract infection or urethral trauma; -Position bag below level of bladder. Do not allow tubing or any part of the drainage system to touch the floor. Avoid obstructions in the drainage. Review of the resident's October 2019 physician order sheets (POS) showed the resident's diagnoses included neurogenic bladder (inability to control bladder). Observation of the resident on 10/8/19 showed the following: -At 8:24 A.M., the resident sat in his/her wheelchair in the dining room. The resident's urinary drainage bag hung under the resident's chair and did not have a cover. The urinary drainage bag and the catheter tubing touched the floor; -At 9:40 A.M., the resident sat in his/her wheelchair near the nurses desk. The resident's catheter tubing rested on the floor; -At 1:33 P.M., the resident sat in his/her wheelchair in the dining room. The resident's urinary drainage bag hung under the resident's wheelchair and did not have a cover. The urinary drainage back touched the floor under the resident's wheelchair. Observation of the resident on 10/8/19 at 2:50 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room. The resident's urinary drainage bag was on the floor; -Certified Nurse Assistant (CNA) EE and CNA DD prepared to transfer the resident to the bed with the mechanical lift; -CNA DD hung the urinary drainage bag from the front arm of the lift which raised the bag above the level of the resident's bladder as staff transferred the resident to the bed. During interview on 10/10/19 at 8:02 A.M., CNA EE said a urinary drainage bag and catheter tubing should not touch the floor. 4. Record review Resident #602's October 2019 physician's orders, showed the following: -Urinary catheter inserted on 9/30/19; -Diagnoses included urinary retention. Review of the resident's care plan, dated 10/09/19, showed the following: -Resident requires a urinary catheter related to urinary retention; -Do not allow tubing or any part of the drainage system to touch the floor. Review of the resident's admission MDS, dated [DATE], showed the following: -Diagnoses included obstructive uropathy (a condition where urine cannot drain through the urinary tract and backs up into the kidney); -The resident had a urinary catheter. Observation on 10/07/19 at 12:57 P.M. showed the following: -The resident sat in his/her wheelchair in the dining room; -The resident's urinary catheter bag was visible under his/her wheelchair and was not contained within a dignity bag; -The urinary catheter bag held approximately 200 cubic centimeters (cc) of urine; -The urinary catheter bag and catheter tubing rested on the floor. Observation on 10/08/19 at 10:25 A.M. showed the following: -The resident self-propelled in his/her wheelchair in the hallway toward the therapy room; -The resident's urinary catheter bag was visible under his/her wheelchair and was not contained within a dignity bag; -The urinary catheter bag held approximately 250 cc of urine; -The urinary catheter bag and catheter tubing dragged along the floor as the resident self-propelled down the hallway. Observation on 10/08/19 at 2:20 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident's urinary catheter bag was visible under his/her wheelchair and was not contained within a dignity bag; -The urinary catheter bag held approximately 300 cc of urine; -The urinary catheter bag and catheter tubing touched the floor. Observation on 10/09/19 at 6:36 A.M. showed the following: -The resident rested in his/her bed; -The resident's urinary catheter bag, not contained within a dignity bag, hung from the metal frame on the right side of his/her bed; -The urinary catheter bag held approximately 175 cc of urine; -The urinary catheter bag and catheter tubing touched the floor. 5. Review of Resident #62's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Totally dependent on two staff for transfers; -Urinary catheter. Review of the resident's care plan, reviewed 10/10/19, showed the following: -Required a urinary catheter related to urinary retention due to neurogenic bladder; -Position bag below level of bladder; -History or urinary tract infection 8/20/19; -Two person mechanical lift transfer. Observation on 10/08/19 at 8:56 A.M. showed CNA M prepared to transfer the resident with the mechanical lift. CNA M attached the resident's urinary drainage bag up high on the side of the mechanical lift. Urine was visible in the catheter tubing. The catheter bag was higher than the resident's bladder and the catheter bag remained on the side of the lift as staff transferred the resident to the broda chair (specialized wheelchair). Observation on 10/9/19 at 1:58 P.M. showed CNA U sat in his/her broda chair. CNA U removed the resident's catheter bag with urine from beneath the geri chair, and laid the catheter bag flat on the resident's lap. CNA U transferred the resident from the broda chair to the recliner in the resident's room with the mechanical lift. The catheter bag remained in the resident's lap during the transfer. During interview on 10/10/19 at 8:15 A.M., CNA M said he/she could hold the catheter bag when they used the mechanical lift to transfer the resident, but it would be hard to do this and maneuver the lift. He/She knew not to raise the catheter bag above the level of the resident's bladder since the urine was draining through the tubing. CNA M said he/she should not place the catheter bag on the lift to transfer the resident. 6. Review of Resident #51's care plan, dated 5/3/19, showed the following: -Indwelling catheter: maintain tubing below the level of the bladder; -Full staff performance assistance for activities of daily living (ADLs); -Mechanical lift with two staff assist. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Totally dependent on two staff for transfers; -Required extensive assistance from two staff for personal hygiene; -Presence of a urinary catheter. Review of the resident's October 2019 POS showed the following: -Diagnoses included urinary retention and muscle weakness. -Urinary catheter. Observation on 10/9/19 at 6:45 P.M., showed the following: -CNA DD and CNA FF entered the resident's room and placed a mechanical lift sling under the resident as he/she lay in bed, attached the lift sling to the lift, and prepared to transfer the resident to the bed; -CNA DD hung the resident's urinary drainage bag from his/her uniform pants pocket and then hung the resident's urinary drainage bag from the lift arm (above the level of the resident's bladder) and allowed urine to flow back towards the resident's bladder; -CNA DD and CNA FF transferred the resident to the broda chair and laid the catheter bag on the foot rest of the chair. The resident placed his/her right socked foot partially on top the drainage bag; -Staff finished cares and pushed the resident to the dining room. The drainage bag remained on the foot rest of the resident's chair. During interview on 10/10/19 at 7:55 A.M., CNA DD said staff urinary drainage bags should not be on the floor and staff should never raise the bags above the level of the resident's bladder. 7. During interview on 10/10/19 at 2:35 P.M., the Director of Nurses said the following: -Urinary catheter bags and tubing should be positioned where they are kept up off of the floor; -The catheter bag should be held below the level of the bladder at all times even when transferring the resident with a mechanical lift and should be covered with a dignity bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five residents (Residents #51, #425, #426, #62, and #93), in a review of 25 sampled residents and six additional residents (Resident #2, #58, #601, #603, #800 and #801). The total facility census was 183 with a certified census of 128. 1. Review of the facility assessment, reviewed with the Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement Plan Review (QAPI) committee, dated 9/11/19, showed: -There were 132 residents who required assistance from one to two staff with dressing, and 14 residents who were totally dependent on staff; -There were 115 residents who required assistance from one to two staff with bathing, and 38 residents who were totally dependent on staff; -There were 58 residents who required assistance from one to two staff with eating, and ten residents who were totally dependent on staff; -There were 118 residents who required assistance from one to two staff with toileting, and 27 residents who were totally dependent on staff; -There were 95 residents who required assistance from one staff for transfers, 24 residents who required assistance from two staff, 11 residents who utilized a stand-up lift, and 32 residents who required a full body lift for transfers; -Daily staffing plan included four to seven professional nurses providing direct care and ten to 24 certified nurse aides; -Staffing plan was based on acuity and other factors for licensed nurses providing direct care. For day shift was six to eight nurses, evening shift was six to eight nurses, and night shift was three to four nurses; -Staffing plan based on acuity and other factors for direct care staff for day shift was 19 to 23, evening shift was 18 to 22, and night shift was ten to 13; -The care staff (floor nurses, certified nurse aides and certified medication aides) assignments are done according to the individual resident's preferences, needs and goals. 2. Review of Resident #601's care plan, dated 9/30/19, showed the following: -Resident currently with an alteration in skin/pressure injury: small, red open area noted to coccyx (tailbone); -Encourage frequent repositioning in bed and wheelchair. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 9/30/19, showed the following: -Severely impaired cognition; -Required extensive physical assistance from two staff for bed mobility, transfers and toileting; -Required extensive physical assistance from one staff for personal hygiene; -Always continent of urine; -Frequently incontinent of bowel; -At risk for pressure ulcers; -Diagnoses included hip fracture and dementia. Review of the resident's October 2019 physician order sheets (POS) showed the following: -Staff was to keep the resident in the common area as much as possible to monitor; resident is a high fall risk; -The resident's preferred waking time was between 6:00 A.M. and 7:00 A.M. Observations on 10/09/19 showed the following: -From 5:39 A.M. to 6:00 A.M., the resident sat in the area by the nurses station; -At 6:00 A.M., the resident began to self-propel back towards his/her room. The resident said, I want to go back to bed. I did not want up this early. Certified Nurse Assistant (CNA) G brought the resident from down the hallway back to nurses station. The resident asked CNA E where his/her bed was, stating he/she just wanted to go to bed. -The resident remained in his/her wheelchair at the nurses station until 7:30 A.M. During interview on 10/9/19 at 6:05 A.M., CNA G said the following: -He/She got the resident up around 4:30 A.M. or 5:00 A.M.; -He/She liked to get up those residents he/she could to help out day shift staff. There never seemed to be enough staff on any shift to get all the duties done. Further observation of the resident on 10/09/19 showed the following: -At 7:30 A.M., staff propelled the resident in his/her wheelchair from the nurses station to the dining room where the resident waited for breakfast; staff did not reposition the resident at this time; -At 8:02 A.M., staff assisted the resident with his/her morning meal; -The resident remained in the dining room between 8:02 A.M. and 9:05 A.M.; -At 9:05 A.M., staff propelled the resident in his/her wheelchair to the nurses station day area where the resident sat, leaning to the right, with his/her head down; staff did not reposition the resident in his/her chair during this time; -The resident remained in the day area between 9:05 A.M. and 10:00 A.M.; -At 10:00 A.M., the resident's family member propelled the resident in his/her wheelchair down the hallway and back to the nurses station. The family member asked staff if there was a place they could go to visit. Staff directed them to the private dining room to visit. Staff did not reposition the resident in his/her chair during this time. Observation of the resident on 10/09/19 at 11:05 A.M. showed the following: -The resident's family member propelled the resident in his/her wheelchair from the private dining room down the hallway to CNA F and told CNA F the resident needed changed; -CNA F and Occupational Therapy Staff H assisted the resident on the toilet in the resident's bathroom; -As the resident stood up with the assistance of a stand-up lift device, the outside of the resident's pants was visibly wet and soiled. The resident had a urine odor. The pad in the resident's chair had a visible stained wet ring approximately the size of a dinner plate; -CNA F pulled down the resident's pants and removed the resident's urine saturated incontinence brief; -The resident had reddened areas across his/her buttocks and bony prominences, approximately the size of a fist on each buttock; -The resident's buttocks appeared macerated (prolonged exposure to moisture); (The resident remained in his/her wheelchair from before 5:00 A.M. to 11:05 A.M., six hours and five minutes, without staff repositioning, toileting or checking the resident for incontinence.) During interview on 10/10/19 at 12:05 P.M., CNA F said the following: -He/She was responsible for the resident's care that day; -He/She came on duty at 6:30 A.M. that morning; -The resident was already up when he/she came on duty; -He/She had not provided any care to the resident since coming on duty; -Because the resident was at the desk, and he/she was up and down the halls providing cares, he/she just got busy and had not assisted the resident; he/she was just so busy and wished the licensed staff would actually help with resident cares; -Residents were to be toileted and repositioned every two hours or more frequently if needed. 3. Review of Resident #2's care plan, dated 9/27/19, showed the following: -Preferred waking time was 7:00 A.M.; -Staff will attempt to assist the resident out of bed for breakfast within preferred time frame; -Staff may offer gentle wake-up during preferred time. Review of the resident's October 2019 physician order sheet (POS) showed the following: -Required two staff to transfer; -Toilet before and after meals, upon rising and before bed and as needed; -Preferred waking time was 7:00 A.M. Review of the resident's MDS, dated [DATE], showed the following: -Mildly impaired cognition; -Required extensive physical assistance from two staff for bed mobility, transfers, toileting and personal hygiene; -Frequently incontinent of urine; -Occasionally incontinent of bowel; -At risk for pressure ulcers. Review of the resident's care plan, dated 10/02/19, showed the following: -At risk for developing alterations in skin integrity/pressure injuries; -Encourage repositioning. Observation on 10/09/19 at 5:38 A.M. showed the resident sat in his/her wheelchair at the nurses station. The resident's head was down and his/her eyes were closed. During interview on 10/09/19 at 5:40 A.M., the resident said the following: -He/She wished he/she was still in bed; -Staff did not ask him/her if he/she wanted to get up, they just got him/her up. During interview on 10/09/19 at 5:47 A.M., CNA E said he/she got the resident up at 5:00 A.M.; Observation on 10/09/19 showed the following: -At 7:02 A.M., the resident sat in his/her wheelchair by the nurses station; staff spoke to the resident as they walked by; -At 7:40 A.M., the resident sat at the nurses station with his/her head down and eyes closed; staff awakened the resident and propelled the resident in his/her wheelchair to the dining room; -At 8:00 A.M., the resident sat in his/her wheelchair in the dining room and ate his/her morning meal; -At 8:34 A.M., staff propelled the resident in his/her wheelchair to the day area where the resident sat, looking at the television; -Staff did not reposition the resident in his/her chair during this time. Further observation on 10/09/19 showed the following: -At 9:40 A.M., the resident remained in his/her wheelchair in the day area where the resident sat, looking at the television; -At 10:00 A.M., staff propelled the resident in his/her wheelchair from the television area to an activity area, where the resident sat and watched the activity in his/her wheelchair; staff did not reposition the resident in his/her chair at this time; -At 10:50 A.M., staff propelled the resident from the activity to the area of the nursing station; staff did not reposition the resident in his/her chair at this time; -At 11:25 A.M., staff propelled the resident in his/her wheelchair from the nurses station to the dining room; staff did not reposition the resident in his/her chair at this time. During interview on 10/09/19 at 11:30 A.M., CNA I said the following: -He/She worked day shift and came in around 6:30 A.M.; -The resident was up when he/she came on duty; -He/She had not had a chance to provide any assistance to the resident since coming on duty; -The resident required assistance of two staff for transfers and toileting and he/she had not had a chance to get with another CNA to get assistance in laying the resident down, toileting or repositioning him/her; -The resident was incontinent of bowel and bladder; -He/She did not feel the facility staffed to ensure there were enough staff to complete all of the responsibilities; -He/She hoped to be able to lay the resident down after lunch. Observation on 10/09/19 at 1:25 P.M., showed the following: -CNA I propelled the resident in his/her wheelchair from the dining room to his/her room; -CNA I and CNA J transferred the resident to his/her bed; -CNA J removed the resident's urine saturated incontinence brief; -The resident had reddened areas across his/her buttocks and bony prominences, approximately the size of an orange on each buttock. (The resident remained in his/her wheelchair from 5:00 A.M. to 1:25 P.M., eight hours and 25 minutes, without staff repositioning, toileting or checking the resident for incontinence.) During interview on 10/09/19 at 1:30 P.M., CNA J said the following: -He/She did not feel the facility staffed enough staff to complete all of the responsibilities he/she was expected to get done; -He/She felt like the licensed staff needed to help out more with answering lights and providing resident cares; -He/She felt like the level of care the residents needed required more staff than were scheduled. 4. Review of Resident #426's face sheet showed the resident's diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement) cognitive communication deficit, and muscle weakness (generalized). Review of the resident's care plan, dated 9/27/19, showed the following: -The resident had a deficit in activities of daily living (ADL) functioning; -Encourage ADL participation to maximize independence. Provide set-up/cueing/assistance as needed. Review of the resident's admission MDS, dated [DATE], showed the following: -Mildly impaired cognition; -Required extensive physical assistance from two staff for transfers and toilet use; -Required supervision, oversight, encouragement and cueing of staff or personal hygiene; set up help only; -Totally dependent on two staff for walking; -Was occasionally incontinent of bowel and bladder; -Diagnoses included stroke. During interview on 10/07/19 at 11:33 A.M., the resident said the following: -He/She used his/her call light to request help to the bathroom; -His/Her call light was not always answered in a timely manner and he/she had to sometimes wait 10 to 45 minutes for staff to respond; -Staff had told him/her not to get up on his/her own because he/she had a tendency of falling because he/she had a diagnoses of Parkinson's disease; -He/She had wet his/her pants when staff had not placed his/her urination device close by and staff did not respond to his/her call light when he/she tried to call for help; -He/She did not like waiting for help or wetting his/her pants. 5. Review of Resident #62's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Totally dependent on staff for transfers. Review of the resident's care plan, reviewed 10/10/19, showed the following: -Preferred waking time was between 6:00 A.M. and 7:00 A.M. -Staff to respond to call light requesting to get up in a timely manner; -Staff may offer gentle wake-up during preferred time. Observations on 10/9/19 showed the following: -At 5:45 A.M., CNA R finished dressing the resident in a sweat shirt, slacks, socks, and shoes and placed a mechanical lift sling beneath the resident. CNA R covered the resident with a sheet and blanket, placed a neck pillow behind the resident's neck, and left the room. -At 6:40 A.M., the resident was in same position in bed. The resident's eyes were closed. The mechanical lift sling was under the resident who was fully dressed in bed wearing shoes. During interview on 10/9/19 at 5:50 A.M., CNA R said there were at least ten to 11 residents who transferred with the mechanical lift and they were short of staff all the time. He/She had two other residents already dressed but they remained in bed since they required assistance from two staff with the mechanical lift for transfers. He/She dressed these residents to wait for day shift to help him/her get them up. During interview on 10/9/19 at 6:36 A.M., Licensed Practical Nurse (LPN) S, night charge nurse, said staff get residents ready and leave them in bed if they require two staff assistance to transfer on the day shift with two aides. 6. Review of Resident #58's annual MDS, dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for bed mobility and dressing; -Required extensive assistance from two staff for transfers. Review of the resident's care plan, last revised 9/19/19 showed the following: -Preferred waking time was 6:00 A.M. to 7:00 A.M.; -Required extensive assist of all aspects of care; -Two person assist with bed mobility; -Transfer per two staff assist and mechanical lift. Review of the resident's POS, dated October 2019, showed the following: -Diagnoses included dementia and right sided hemiplegia (paralysis on one side of the body); -Preferred waking time is 6:00 A.M. Observation of the resident on 10/9/19 showed the following: -At 6:00 A.M., the resident lay in the bed fully clothed and wearing shoes; -CNA DD and CNA FF entered the room, placed the mechanical lift sling under the resident and transferred him/her to the wheelchair. 7. Review of Resident #51's care plan, dated 5/3/19, showed the following: -Preferred waking time was 7:00 A.M. to 8:00 A.M.; -Mechanical lift with two staff assist; -Adapt environment to maximize resident's safety and independence. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Totally dependent on two staff for transfers. Review of the resident's POS, dated October 2019, showed the following: -Diagnoses included muscle weakness, difficulty walking and unsteadiness on feet; -Preferred waking time was 8:00 A.M. Observation of the resident on 10/9/19 showed the following: -At 5:20 A.M., the resident lay dressed in the bed with his/her eyes closed; -At 6:45 P.M., CNA DD and CNA FF entered the room, placed a mechanical lift sling under the resident and transferred him/her to the broda chair. During interview on 10/9/19 at 7:00 A.M., CNA DD said the following: -Staff began waking residents and providing cares around 5:00 A.M. Night shift staff predressed four residents, including Residents #51 and #58, who required a mechanical lift to transfer. Staff pre-dressed the residents so they would be ready to transfer with the lift when a second staff was available; -Residents may lay dressed in bed for 45 minutes to an hour depending on when help arrived to assist. 8. During interview on 10/9/19 at 6:40 A.M., CNA E said there are certain residents staff get up to make sure they are ready for breakfast. Night shift staff does this the best they can to help out day shift because there just does not seem to be enough staff to get all of the tasks completed. 9. Record review of Resident #603's care plan, dated 11/23/18 showed the following: -Resident may eat a regular diet; -Staff to encourage meals. The resident may need feeding assistance/cueing with start of meals then will finish feeding self. Review of the resident's October 2019 POS showed the following: -Diagnoses included dementia, anxiety and gastro-esophageal reflux disease (stomach disorder); -Regular diet; -Consider resident preferences; -May need assistance with cutting food and eating. Observation on 10/07/19 at 1:05 P.M. showed the following: -The resident sat at the dining room table in his/her wheelchair; -CNA X stood at the resident's right side; -CNA X put meat on a spoon and then put it up to the resident's lips. The resident opened his/her mouth and took a bite. CNA X did not speak with the resident as he/she assisted the resident to eat; -CNA X left the resident's side and assisted another resident away from the dining room table; -CNA X returned to the resident, put slaw on a spoon and held it at the resident's lips while the resident continued to chew the meat; -After giving the resident the bite of slaw, CNA X left the resident's side, went to the kitchen and got another resident a cup of hot chocolate; -The resident had swallowed the bite of slaw and waited for CNA X to return; -CNA X returned to the resident, put fruit on a spoon and then put it up to the resident's lips. The resident opened his/her mouth and took a bite; -The resident had to wait until CNA X returned to his/her side to be offered another bite; -CNA X stood the entire time he/she assisted the resident to eat. During an interview on 10/7/19 at 1:23 P.M., CNA X said the following: -The resident could not feed himself/herself; -He/She was trying to multi-task with resident cares in-between bites he/she was feeding the resident; -He/She did not have time to sit down by the resident while feeding, there was too much to do. The facility actually needed to hire more staff or the licensed staff needed to help out more. 10. Review of Resident #93's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -Required extensive physical assistance from one staff for transfers; -Did not walk; -Required extensive physical assistance from one staff for toilet use; -Was frequently incontinent of bowel and bladder. During interview on 10/07/19 at 11:53 A.M., the resident said the following: -He/She used his/her call light to request staff assistance for help with going to the bathroom; -He/She believed the facility was very short of help because call light response time was 10 minutes to two hours; -He/She wet his/her pants as a result of having to wait on staff to answer his/her call light; -He/She did not like wetting his/her pants. 11. Review of Resident #800's admission MDS, dated [DATE], showed the following: -The resident had mild cognitive impairment; -Required extensive physical assistance of two staff for transfers and toileting; -Required extensive physical assistance of one staff to walk; -Was frequently incontinent of bowel; -Was always continent of bladder. During interview on 10/07/19 at 11:16 A.M., the resident and his/her spouse said the following: -The resident used his/her call light to ask for staff assistance to go to the bathroom; -The resident had waited as long as an hour for staff to respond to his/her call light; -When the resident had to go to the bathroom, he/she had to go; -The resident sometimes took himself/herself to the bathroom and he/she was not supposed to because he/she had a broken hip. 12. Review of Resident #425's admission MDS showed the following: -The resident was admitted on [DATE]; -The resident's MDS was incomplete and did not address transfers, walking or toilet use. During interview on 10/07/19 at 11:08 A.M., the resident said the following: -Staff's response to his/her call light was slow; -He/She had waited 15 minutes to an hour for staff to respond and then not always was his/her concern addressed right then; -He/She was concerned the facility did not have enough staffing. 13. Review of Resident #801's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -Required extensive physical assistance from two staff for transfers and toileting; -Did not walk; -Was always continent of bowel; -Was occasionally incontinent of bladder. During interview on 10/07/19 at 1:35 P.M., the resident said the following: -He/She believed the facility was under staffed; -He/She used his/her call light to call for help to have his/her incontinence brief changed, be placed on the bed pan or be transferred from his/her wheelchair to bed or visa versa; -Staff responded to call lights anywhere from 15 minutes to over an hour; during meal times was the worst. 14. During interview on 10/10/19 at 9:02 A.M., CNA B said the following: -He/She did not feel the facility had enough care staff scheduled to meet the residents' needs; -He/She ran his/her tail off answering call lights and providing care all day while capable staff, licensed staff, sat at the desk and refused to answer call lights or toilet residents. 15. During interview on 10/10/19 at 2:45 P.M., the director of nursing (DON) said when charge nurses felt there was not enough staff, they were to address this issue with the DON. She had intermittently had concerns brought to his/her attention regarding staffing. She hoped the nurse aides, residents, and families would relay this information regarding staffing concerns to them. All staff are expected to answer call lights.

Based on observation, interview, and record review, the facility failed to ensure staff served residents on a pureed diet the correct portion sizes of protein, and failed to serve residents on a regular diet full serving scoops of food items according to the spreadsheet menu. The total facility census was 183 with a certified census of 128. 1. Record review of the Order Report by Category, dated 10/7/19, showed three residents had a physician's order for a pureed diet. Review of the Diet Spreadsheet, Week 5, showed staff was to serve residents on a pureed diet a #6 serving (2/3 cup) of pureed Philly sandwich with bread. Observation on 10/7/19 at 12:19 P.M. of the 200 Hall servery steam table showed a #8 scoop (1/2 cup) sat in the pan of pureed Philly sandwich with bread. Observation on 10/07/19 at 12:20 P.M. in the 200 Hall servery showed Licensed Practical Nurse (LPN) Y plated four trays for residents on pureed diets. He/She used the #8 scoop to serve the pureed Philly sandwich. He/She did not serve a full #8 scoop to the residents or use a #6 scoop as directed by the spreadsheet menu. Certified Nurse Assistant (CNA) Z delivered the prepared plates to the residents in the 200 hall dining room. Observation on 10/07/19 at 12:41 P.M. at the conclusion of the lunch meal service, showed LPN Y and CNA Z did not refer to spreadsheet during serving of the lunch meal. 2. Record review of the Order Report by Category, dated 10/7/19, showed 12 residents had a physician's order for a regular diet. Review of the Diet Spreadsheet, Week 5, showed staff was to serve residents on a regular diet a 4-ounce (#8 scoop or ½ cup) of Philly sandwich meat. Observation on 10/7/19 at 12:19 P.M. of the 200 Hall servery steam table showed a #8 scoop sat in the pan of Philly sandwich meat. Observations on 10/07/19 from 12:20 P.M. to 12:41 P.M. in the 200 Hall servery showed LPN Y plated the lunch trays for the residents in the 200 hall dining room. LPN Y served all residents on a regular diet approximately one-half of a #8 scoop of Philly sandwich meat. 3. During an interview on 10/8/19 at 4:15 P.M., the dietary manager said nursing and dietary staff were trained how to use the dietary spreadsheet menu and portion sizes during orientation. During an interview on 10/9/19 at 10:25 A.M., the facility dietician said staff should use the dietary spreadsheet menu when plating meals and appropriate full scoop sizes should be utilized.

Based on interview and record review, the facility failed to provide evening snacks for two residents (Resident #93 and #96), in a review of 25 sampled residents, and for four additional residents (Residents #23, #32, #60, and #115) who participated in a group interview. The total facility census was 183 and the certified census was 128. 1. Review of the facility policy Snack Availability from the Family Dining Services Policy and Procedure Manual, dated 2014, showed the following: -Evening snacks were offered to all residents unless contraindicated by the physician's order; -A variety of snacks were offered to residents at bedtime. The variety will include snacks for various textures and therapeutic restrictions; -The food service department will be responsible for supplying, refilling and discarding unused snacks in the designated snack area(s). 2. During a group interview on 10/08/19 at 3:32 P.M., the residents said the following: -Resident #60 said he/she was diabetic and was not offered an evening snack. He/She would like to have an evening snack; -Residents #115, #93, #96, #32, and #60 said they would have to ask for an evening snack; -Resident #23 said staff never offered him/her an evening snack and he/she would like to have one. During interview on 10/8/19 at 4:46 P.M., Nurse Aide (NA) P said staff lay every resident down before they would give a bedtime snack. He/She did not ask every resident if they would like a bedtime snack. There were only a few residents who requested the bedtime snack. During interview on 10/10/19 at 11:58 A.M., [NAME] Q said nurses had a list or they knew which residents received bedtime snacks. A list of diabetic residents was in the servery areas on each division on the wall. The nurse or CNA on the division had a basket for snacks at the desk. They were responsible to fill the basket from the main kitchen when they were getting low on snacks. During interview on 10/10/19 at 2:45 P.M., the director of nursing said the certified medication technicians were responsible for offering evening snacks to the residents. Every resident should be offered a bedtime snack between 7:00 P.M. to 9:00 P.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the walk-in freezer at 0 degrees Fahrenheit (F) or below to keep items frozen solid; failed to ensure food items were labeled, dated, covered and discarded when expired; and failed to maintain an appropriate air gap on two ice machines. The total facility census was 183 with a certified census of 128. 1. Record review of the Refrigerator/Freezer Temperature Log sheet for the walk-in freezer located in the main kitchen, dated October 2019, showed the following morning and evening freezer temperatures: -October 1: 6 degrees F and 5 degrees F; -October 2: 14 degrees F and 6 degrees F; -October 3: 17 degrees F and 8 degrees F; -October 4: blank and 4 degrees F; -October 5: blank and 3 degrees F; -October 6: blank and 1 degree F. Observation on 10/07/19 at 11:03 A.M. showed the walk-in freezer in the main facility kitchen had an exterior digital temperature display of the internal temperature that read 12 degrees F. The thermometer inside the freezer measured 10 degrees F. Food items such as ice cream cups and chicken tenders were soft to touch and were not frozen solid. Observation on 10/07/19 at 3:05 P.M. of the walk-in freezer showed an external digital temperature display of the internal temperature read 10 degrees F. The thermometer inside the freezer measured 8 degrees F. The freezer contained meat patties, chicken, fish, etc. Items within the freezer were soft to touch and were not frozen solid. Observation on 10/08/19 at 8:16 A.M. of the walk-in freezer in the main kitchen showed a sign taped over the external digital temperature display that read, Take temps from inside thermometer. The internal thermometer measured 8 degrees F. During an interview on 10/8/19 at 4:15 P.M., the dietary manager said the walk-in freezer defrosts two or three times a day. Staff opened the freezer door often in order to retrieve food preparation items during the day. Staff also opened the door frequently when the facility got a food delivery and staff needed to place items into the freezer. The defrost cycle times could be configured according to facility preference and these times may need to be changed. Perishable foods, such as meat, needed to be moved towards the back of the freezer where it stayed the coldest. Staff had been documenting the temperature by using the outside digital display and had not been writing down the actual temperature of the internal thermometer. During an interview on 10/09/19 at 9:05 A.M., the maintenance supervisor said the walk-in freezer temperature was set to 0 degrees F. He checked the freezer this morning when he got to work and adjusted the temperature setting to -10 degrees F. He thought the defrost cycle settings were behind a different panel, but he had not checked to see how often the unit was set to defrost. Staff should contact maintenance if they felt any equipment was not working properly. He would check into the issue and contact a vendor if needed. During an interview on 10/9/19 at 10:25 A.M., the facility's dietician said the freezer needed to keep food items frozen solid. 2. Observation on 10/07/19 at 10:53 A.M. and on 10/8/19 at 9:36 A.M. in the dry storage room of the main kitchen showed a 25-pound box of instant food and beverage thickener. The box flaps had been cut off and the box was completely open. A large clear plastic bag sat inside the box and was completely open and not closed or sealed. Observation on 10/07/19 at 3:12 P.M. in the Family Lounge, located next to resident room [ROOM NUMBER]B, showed a refrigerator in the room that contained the following items: -A 46-ounce carton of orange juice with a best buy date of 4/5/19; -Two 5.3-ounce container of strawberry yogurt, labeled with a resident's name and had a manufacturer's use by date of 7/21/19; -A 5.3-ounce container of strawberry yogurt, labeled with a resident's name and had a manufacturer's use by date of 7/29/19; -A 5.3-ounce container of strawberry cheesecake, labeled with a resident's name and had a manufacturer's use by date of 7/18/19; -A round black plastic container with a clear lid contained a [NAME]-tan colored food item that appeared to be soup was not labeled or dated; -A rectangular Styrofoam container with spaghetti and red sauce that had approximately six areas of fuzzy and furry white areas of mold growth. The container was not labeled or dated; -An 8-ounce cream cheese container with manufacturer's use by date of 7/4/19 was stored in a clear plastic bin inside the refrigerator and was labeled with a resident's name and room number. Observation on 10/7/19 at 3:30 P.M. in the 300/400 dining room and servery, showed the following: -A large pizza box sat on counter in the separate dining area near the shared 300/400 dining and had two pieces of pizza with meat topping inside. The pizza was cold to touch and was not refrigerated; -A plate contained a round bun with a Philly cheese steak sandwich covered in plastic and sat on top of the 300/400 servery steam table. The sandwich was not labeled, dated or refrigerated; -A complete lunch tray from lunch 10/7/19 sat on the countertop in the servery next to the coffee machine. The tray had a plate that contained a full cheese steak sandwich, cole slaw and chips. A small plastic bowl contained Jello. The plate and bowl were covered with plastic and were not labeled, dated or refrigerated. During an interview on 10/9/19 at 9:25 A.M., the dietary manager said leftovers should labeled with a resident's name and dated with the day staff placed the leftovers in the refrigerator. The item should be discarded after three days or upon the manufacturer's use by date. Food items should be covered and/or closed. The food thickener should be closed and this is a re-occurring issue with this food item. All food items or plates of food in the serveries that are extras or leftovers are to be stored in the refrigerator, should be covered, labeled and dated and should not be left sitting out on the counters. She was unaware there was a refrigerator in the 700 hall family lounge. She was not sure who was responsible for going through and maintaining that refrigerator, but it was not dietary's responsibility. During an interview on 10/9/19 at 10:25 A.M., the facility's dietician said staff should label, date and cover food items appropriately. Staff should discard food items after three days or after the manufacturer's use by date. 3. Observation on 10/7/19 at 12:15 P.M. of the 200 hall servery showed no air gap was present on the ice machine drain. The ice machine drain hose extended downward through the floor drain grate and ran approximately 3-inches into the drain below the floor. Observation on 10/7/19 at 3:30 P.M. of the 300/400 servery showed no air gap was present on the ice machine drain. The ice machine drainage hose passed through a grate in the floor and extended downward approximately 4-inches below the floor level. During an interview on 10/9/19 at 9:05 A.M., the maintenance supervisor said he was unaware the ice machines needed to have an air gap. During an interview on 10/9/19 at 9:25 A.M., the dietary manager said maintenance staff was responsible for maintaining the air gaps on the ice machines. She was aware ice machines were required to have an appropriate air gap from taking the ServeSafe course. During an interview on 10/9/19 at 10:25 A.M., the facility's dietician said she was not aware the ice machines did not have an air gap.