**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and Physician interviews, the facility failed to ensure an effective system was in place in order that a resident's advance directive to not be resuscitated was honored when she was discovered unconscious and without pulse or respirations. This was for 1 of 22 residents reviewed for advanced directive (Resident #80). The findings included: Resident #80 was admitted to the facility on [DATE]. Resident 80's diagnoses included diabetes mellitus, congestive heart failure, stroke, end-stage renal disease (ESRD), tube feeding status, and dementia. Review of Resident 80's quarterly Minimum Data Set assessment, dated [DATE], revealed the resident was severely cognitively impaired. Review of physician orders, dated [DATE], revealed Resident #80 had an order for DNR (Do Not Resuscitate). Review of Resident 80's plan of care, dated [DATE], revealed the resident had an Advance Directive of Do Not Resuscitate Order. Honor Residents Advance Choices. Record review of the nurses' notes, dated [DATE] at 3:28 AM, indicated that at 12:25 AM, Nurse #1 assessed Resident #80 as less responsive than usual, with her blood sugar significantly above normal level (484 milligrams in deciliter, mg/dL, when normal blood sugar level is 100 mg/dL or below). Nurse #1 reported it to the Physician Assistant on call and received an order to send the resident to the hospital. Nurse #1 called Emergency Medical Service (EMS), checked the transfer binder, and could not find the DNR paper. Upon returning to the Resident 80's room, the resident was non-responsive and not breathing. Nurse #1 initiated the Code Blue (emergency code for cardiac or respiratory arrest), Nurse #2 confirmed no DNR paper, and together with Nurse #1 began CPR (cardiopulmonary resuscitation). After a few chest compressions, the EMS arrived and took over the situation. The EMS team pronounced Resident 80's death at 1:50 AM. Record review of the EMS report, dated [DATE], indicated that at 12:52 AM, EMS was dispatched for hospital transfer. The EMS team arrived at 1:01 AM, and the staff reported they just witnessed the cardiac arrest of Resident #80 with absent respirations and pulse, and initiated CPR due to no Advanced Directive in place. The EMS team determined the initial asystole rhythm, and continued the CPR, including chest compressions, non-mechanical ventilation, and medications. For thirty minutes, CPR had no effect; the resident remained asystole, and the resuscitation was terminated at 1:50 AM. On [DATE] at 3:30 PM, during the phone interview, Nurse #1 indicated that on [DATE], during 7 PM-7 AM shift, she was assigned to Resident #80. At the beginning of her shift, the resident had normal vital signs and rested in bed with her eyes closed. At 12:15 AM, Nurse #1 went to check the resident's blood sugar and found the resident less responsive, with blood sugar 484 mg/dL. She reported the situation to the Physician Assistant on call and received an order for hospital evaluation. Nurse #1 called EMS and prepared the resident's documents for hospital transport. There was no DNR paper in the transport binder. She returned to the resident's room and found Resident #80 unresponsive with no breathing or pulse. Nurse #1 initiated the Code Blue. Nurse #2 confirmed no DNR paper, and both nurses began CPR. When chest compressions started, the EMS team arrived and took over the situation. The resident passed with unsuccessful CPR. On [DATE] at 9:40 AM, during the phone interview, Nurse #2 (agency nurse) indicated that after midnight on [DATE], Nurse #1 stated she could not find the DNR paper in the transfer binder for Resident 80's hospital transfer. Nurse #2 double-checked the binder and did not find DNR paper. Nurse #1 found Resident #80 with no pulse, not breathing, and initiated the Code Blue. In response to Code Blue, Nurse #2 entered Resident 80's room, confirmed to Nurse #1 that there was no DNR paper, started chest compressions, and Nurse #1 provided bag valve ventilation when the EMS team arrived and took over the situation. In approximately thirty minutes, the EMS team pronounced resident's death. After the incident, the facility provided mandatory education for all licensed employees, including agency staff. In the case of emergency, the nurses were educated to check electronic medical records for [NAME] Directive/Code status verification. On [DATE] at 9:50 AM, during an interview, the Interim Director of Nursing indicated that at the nurses' station, there was a transport binder for all the residents with the current code status. At the same time, the Advanced Directive information was located in every resident's electronic record. The original DNR paper documents from the transport binder must be sent to the hospital with the resident. Upon the resident's return to the facility, the nurses should check for the DNR paper, and if it is missing, reach out to the provider to make a new code status order. On [DATE] at 12:05 PM, during the phone interview, Resident 80's Emergency Contact #1 indicated that she was aware of Resident 80's DNR status and thought it was not necessary to resuscitate the resident. On [DATE] at 1:40 PM, during an interview, the Regional [NAME] President of Operations indicated that the code status should be checked when a resident is found without pulse or breathing. Nurse # 1 could not find the DNR order and started the resuscitation. The Regional [NAME] President of Operations expected the electronic medical records to reflect the transport binder code status. On [DATE] at 2:30 PM, during an interview, the Medical Director indicated that Resident #80 was admitted to the facility with DNR order. On [DATE], when Resident #80 was found unresponsive with no pulse or breathing, Nurse #1 could not find the DNR order and, per the facility's protocol, initiated the Code Blue. The Medical Director mentioned that every time the resident returned from an outside appointment, the staff had to ensure the DNR order was in place. If it was missing, the nurse should contact the physician to order a new code status. The Medical Director expected the staff to verify the residents' code status before resuscitation. The facility implemented the following Corrective Action Plan with a completion date of [DATE]. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] at approximately 12:25 am Nurse #1 was in Resident #1 room to obtain blood glucose reading, blood glucose noted to be 484. Nurse #1 gave 5 units insulin per order and notified the on-call provider who gave order to send Resident #1 to the emergency room for evaluation related to elevated blood sugar and reports from Nurse #1 that Resident #1 was not responding per baseline. Nurse #1 activated 911 and returned to Resident #1 room to prepare for transfer to emergency department. Upon return Nurse #1 noted that Resident #1 was non-responsive without respirations. Nurse # 1, called Code Blue, checked the Electronic Medical Record (EMR) which noted Resident #1 to be a Do Not Resuscitate (DNR). Nurse #1 checked the transport binder along with Nurse #2 for Golden Rod and there was not one present. At that time Nurse #1 and Nurse #2 initiated Cardio Pulmonary Resuscitation (CPR). Upon arrival of Emergency Medical Services (EMS) they took over CPR efforts until 1:50 am at which time EMS called time of death. Family and Center Provider was notified. Nurse #1 obtained order to release body to funeral home of choice. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE] Interim Director of Nursing/Designee began Center audit of all residents' code status provider orders in electronic medical record versus Golden Rod/MOST forms and care plan. Any discrepancies identified were reviewed with resident and resident representative for clarification. Audit completed on [DATE]. On [DATE] Interim Director of Nursing/Designee began Center audit with all residents/ resident's representative to confirm that their current providers orders in the electronic medical record remained their desired wishes. Discussion of code status review was documented in the electronic medical record. Audit completed on [DATE]. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Interim Director of Nursing/Designee began education with all licensed nursing staff on provider orders for Advance Directives , validating code status per the provider order in the electronic medical record, location of the transport binder that contains Golden Rods/MOST Forms (Medical Order Scope of Treatment) and that CPR will be initiated unless: A valid provider order for DNR is in place or resident presents with obvious signs of irreversible death. Additionally, upon admission, re-admission, or significant change Code Status will be reviewed and discussed with resident/resident's representative and provider order obtained and placed in the EMR at which time nursing will obtain Golden Rod/Most form as applicable and place in the transport binder and update care plan for resident/resident's representative wishes. Education completed [DATE]. Any nurse not educated by [DATE] will complete education prior to next shift worked. Interim Director of Nursing/Designee will monitor schedule to ensure that no nurse works after [DATE] without receiving the education. The Licensed Nursing Home Administrator educated the Social Services Director on periodic (care connect conference, quarterly care plans, significant, and as needed) review to validate advance directives with resident/resident's representatives to ensure there is no change to their advance directive wishes. Additionally, if resident/resident's representative wishes to make changes, then Social Services will notify licensed nursing staff so that the appropriate provider order may be obtained per resident/resident's representative wishes, care plan updated and golden rod form completed, if applicable. Education completed on [DATE]. Newly hired RN/LPN will be educated on advance directives procedure during orientation by the Staff Development Coordinator/Designee. The SDC was notified of this responsibility on [DATE] by the Licensed Nursing Home Administrator. Newly hired Social Services Employees will be educated on advance directives procedures during orientation by the Licensed Nursing Home Administrator. The Licensed Nursing Home Administrator was notified of this responsibility on [DATE] by the [NAME] President of Operations. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing /designee will review during daily clinical morning meeting (Monday - Friday) new admission orders and order listing report for provider order for advance directives to ensure accuracy of provider order and that there is supporting documentation of discussion with resident/resident's representative wishes in the EMR. Additionally, the Director of Nursing/Designee will validate at the nurse's station that there is a Golden Rod/Most form complete and in the transport binder as applicable. Audit will be completed x 12 weeks. The decision was made to begin monitoring on [DATE] when the Performance Improvement Plan was reviewed by the Interdisciplinary Team. Beginning on [DATE], data obtained during the audit process will be analyzed for patterns and trends and reported to The Quality Assessment and Assurance (QA & A/QAPI) Committee by the Director of Nursing monthly x 3 or until substantial compliance is obtained. At that time, the QA & A/QAPI committee will evaluate the effectiveness of the interventions to determine if continued auditing is necessary to maintain compliance. Date of Compliance: [DATE] The Corrective Action plan was validated onsite on [DATE] when staff interviews revealed they had recently received education on Advanced Directive/Code Status verification. In-service reports and sign-in sheets were used to verify this information. The Audit tools for the Advanced Directive in electronic medical records and transport binders were completed by the Interim Director of Nursing and Unit Managers and reviewed by the Interdisciplinary Team according to the monitoring plan. No concerns were identified. Multiple staff interviews revealed they could verbalize education training provided in reference to the Advance Directive and Code status verification process. The facility's completion date of [DATE] for the Corrective Action plan was validated on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) Level II status for 1 of 3 residents (Resident #4) reviewed who were determined to have a PASRR Level II status. The findings included: Resident #4 was admitted to the facility on [DATE] with a cumulative diagnosis which included anxiety disorder, bipolar disorder, and residual schizophrenia. Residual schizophrenia is a phase where the acute psychotic symptoms of schizophrenia (such as hallucinations and delusions) have subsided, while some persistent symptoms remain. The resident's electronic medical record (EMR) included a PASRR Level II Determination Notification letter dated 4/14/23. This letter noted Resident #4 had a PASRR number ending with the letter B, which was indicative of a PASRR Level II determination with no expiration date. The results of the evaluation, including the determination of a PASRR Level II status, were used for formulating a determination of need, an appropriate care setting, and a set of recommendations for services to help develop an individual's plan of care. The resident's care plan included the following area of focus: Resident #4 has PASRR Level II with intellectual disability / mental condition and has been diagnosed with paranoid schizophrenia / schizoaffective disorder, bipolar depression, and anxiety (Initiated 3/17/23; Revised 4/10/24). Resident #4's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE]. The Identification Information section of this MDS assessment did not report Resident #4 had a PASRR Level II determination. An interview was conducted on 3/6/25 at 1:57 PM with the facility's Interim MDS Coordinator related to Resident #4's annual assessment dated [DATE]. Upon review of Resident #4's 2/4/25 MDS, the MDS Coordinator confirmed her assessment inaccurately indicated this resident had a PASRR Level I status when it should have noted she had a PASRR Level II status due to serious mental illness. An interview was conducted on 3/6/25 at 4:23 PM with the facility's Administrator. During the interview, the concern identified during the review of Resident #4's annual MDS assessment was discussed. Upon inquiry, the Administrator reported she would expect the residents' PASRR Level to be coded accurately on the MDS assessments.

Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours per day, 7 days per week for 1 of of 32 days reviewed for staffing (03/03/25). The findings included: Review of the facility's daily staffing sheet indicated there was no RN coverage for eight consecutive hours on 03/03/25. An interview was conducted on 03/06/25 at 3:45 PM with the facility scheduler and she indicated she was unable to assign an RN for 8 hours on 03/03/25 due to the RN being off. She indicated usually she would be able to get RN coverage from the agency, however, she was unable to do so on 03/03/25. The scheduler indicated she thought it was ok for the Minimum Data Set (MDS) Nurse who was an RN to count as coverage. The scheduler verified she was aware there was supposed to be RN coverage for 8 consecutive hours daily. On 03/06/25 at 4:06 PM an interview was conducted with the Administrator, and she indicated due to the survey activities the scheduler most likely was not able to get RN cover. The Administrator stated, We had the MDS Coordinator, Nurse Consultant and the Interim Director of Nursing (DON) here and she probably thought that was ok. The Administrator also stated, Our interim DON was in all the rooms providing care to residents, I thought we could use leadership as coverage.

Based on observations and staff interviews, manufacturer's literature review, the facility failed to date opened multi-dose vials of insulin medication in 2 of 5 medication administration carts (Long and Short halls), failed to discard expired insulin pens in 1 of 5 medication administration carts (Short hall) and discard loose pills in the medication cart drawers for 3 of 5 medication administration carts (Rehabilitation, Long and Short halls). Findings Included: a. On 3/3/25 at 10:00 AM, an observation of the medication administration cart of Rehabilitation Hall with Nurse #6 revealed in the second drawer of the medication cart, which contained over-the-counter medications, there were noted three white loose pills and two yellow round-shaped loose pills and one blue oval shape loose pill. On 3/3/25 at 10:05 AM, during an interview, Nurse #6 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #6 did not clean the medication cart before her shift. b. On 3/3/25 at 10:20 AM, an observation of the medication administration cart of the Long Hall with Nurse #3 revealed one opened and undated multi-dose vial of Lispro insulin. Review of the manufacturer's literature indicated to discard Lispro multi-dose vial 28 days after opening. In the second drawer of the medication cart containing over-the-counter medications, two dark red loose pills and two white round shaped loose pills were noted. On 3/3/25 at 10:25 AM, during an interview, Nurse #3 indicated that the nurses, who worked on the medication carts, were responsible for discarding opened and undated multi-dose vials. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medication vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. Nurse #3 stated she had not administered expired medication this shift. The nurse continued that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #3 did not clean the medication cart before her shift. c. On 3/3/25 at 10:45 AM, an observation of the medication administration cart of the Short Hall with Nurse #5 revealed one opened and undated Novolog Flex Pen (insulin), two opened and undated Glargine pens (insulin), three opened and undated Lantus pens (insulin), one opened Novolin pen (insulin), marked as expired on 1/25/25, and one opened Novolog Flex Pen (insulin), marked as expired on 1/30/25. A review of the manufacturer's literature indicated to discard Novolog, Glargine, and Lantus multi-dose insulin pens 28 days after opening. In the second drawer of the medication cart containing over-the-counter medications, two yellow round shape loose pills and two white round shape loose pills were noted. On 3/3/25 at 10:55 AM, during an interview, Nurse #5 indicated that the nurses, who worked on the medication carts, were responsible for discarding opened and undated or expired multi-dose vials. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medication vials. Nurse #5 stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse stated she had not administered expired medication this shift. The nurse continued that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #5 did not clean the cart before her shift. On 3/4/25 at 11:00 AM, during an interview, the Director of Nursing indicated that the nurses were responsible for checking for loose pills, the date of opening, and the expiration date of the medication at the beginning of the shift. On 3/4/25 at 11:10 AM, during an interview, the Administrator expected no loose pills or expired medications to be left in the medication carts.

Based on observations and staff interviews, the facility failed to: 1) Maintain the chemical sanitizing solution of the dish machine at the correct concentration according to the manufacturer's recommendations; 2) Change gloves/wash hands between handling soiled and clean dishes to prevent cross-contamination of the clean dishes and failed to allow all clean dishware to air dry; 3) Dispose of expired food items and seal, label, and/or date opened food items observed in food storage areas; 4) Cover facial hair for 4 of 4 Dietary staff observed with facial hair and working in food preparation (Cook #1, [NAME] #2, Dietary Aide #1 and Dietary Aide #2); and 5) Keep the kitchen food service equipment and vents clean within the Dietary Department. These practices had the potential to affect food served and distributed to 74 of 79 residents who received an oral diet. The findings included: 1. Accompanied by the Dietetic Technician (DTR), an observation was initiated within the Dietary Department on 3/5/25 at 1:37 PM to observe the dishwashing process using the facility's dish machine. At that time, the DTR reported the dishwasher was a low temperature dishwasher. The required temperatures for this machine were 120-125 degrees Fahrenheit (o F) for both the wash and rinse cycles with a chlorine solution used for sanitizing the dishes. When asked, the DTR reported the recommended level for the chlorine concentration was 50-100 parts per million (ppm). Upon request, the DTR tested the concentration of the dish machine's sanitizing solution by using chlorine test strips. The vial containing the test strips indicated the strips detected the concentration of chlorine by undergoing a color change. The DTR tested the sanitizing solution of the machine four times using four test strips. None of the test strips changed color (indicative of low or no levels of chlorine in the solution). Since she could not determine whether there was an acceptable concentration of chlorine in the sanitizing solution, the DTR told the Dietary Aides who were currently using the dishwasher to hold off on washing dishes until the sanitizing solution could be fixed. She stated she would need to ask the Maintenance Director to come and fix the dishwasher so that the correct concentration of chlorine would be dispensed to sanitize the dishes. The DTR reported she had checked the dish machine's sanitizing solution with a test strip at breakfast time on the previous day (3/4/25) and the chlorine in the sanitizing solution was at the correct concentration when she conducted that test. Upon request and accompanied by the DTR, another observation was conducted on 3/5/25 at 2:23 PM as the concentration of chlorine in the rinse cycle of the dish machine was again tested. This test confirmed the chlorine concentration was within the recommended range of 50-100 ppm. The DTR reported the facility's Maintenance Director had fixed the dish machine, so the chlorine solution was appropriately dispensed during the rinse cycle. A follow-up interview was conducted with the DTR on 3/5/25 at 2:55 PM. At that time, the DTR also reported a service technician came out that afternoon (3/5/25) to check the dish machine. The DTR stated the technician fixed the intake tube that went into the sanitizer container to ensure the problem with the sanitizing solution for the dish machine would no longer be a problem. No additional concerns were identified at that time. 2-a. Accompanied by the Dietetic Technician (DTR), an observation and interview was conducted on 3/5/25 at 1:15 PM of the facility's dish washing process using the facility's low temperature dish machine. Dietary Aide (DA) #1 was observed to be the sole staff member working at the dishwasher. While wearing a pair of disposable gloves, DA #1 was observed as he loaded dirty insulated domes (covers for the plate bases) and plate bases onto dish racks located on the left side of the dish machine (the dirty side). He then slid the dish rack containing the dirty service ware into the dish machine and activated the machine. The DA did not change gloves or perform hand hygiene. When the dish machine was finished with the wash and rinse cycles, DA #1 moved to the right side of the dish machine (the clean side). While there, he unloaded and stacked the clean domes and plate bases from the dish rack and loaded them onto a clean drying rack. He then returned to the dirty side of the dish machine to begin the process over again. Upon observing this practice, DA #1 was requested to stop. When asked if he should be moving from the dirty side of the dishwasher to the clean side without his washing hands and changing his gloves, he didn't respond. The DTR then instructed DA #1 to wash his hands if he was going to move from the dirty to the clean side of the dish machine. She told him that alternatively, he should enlist the help of a second Dietary Aide to assist him so that one Dietary Aide could work on the dirty side while a second DA worked on the clean side of the dish machine. At that time, the dishwashing process was suspended. 2-b. An observation of the facility's lunch tray line meal service was conducted on 3/4/25 at 12:14 PM. As the tray line began, the divided plates were observed to be placed in a vertical position on a rack behind the steam table. Upon review, the divided plates were noted to have water pooled in the corners of the divided sections. This was brought to the attention of the Dietetic Technician (DTR). An inspection of 24 divided plates revealed 3 of the plates were dirty, 16 of the divided plates were visibly wet where water dripped off the plates when they were tipped over, and only 5 of the divided plates were both clean and dry. The DTR instructed Dietary Aide (DA) #1 to run the divided plates back through the dish machine. He proceeded to do so. On 3/4/25 at 12:25 PM, DA #1 was observed as he pulled a rack of clean divided plates out of the dish machine and used a paper towel to wipe them dry. When the DTR was asked what she thought of that practice, she intervened and stopped DA #1 from wiping the divided plates. Instead, she instructed the DA to position the divided plates on the clean drying rack, so they were slightly tipped downward, allowing the water to drain as the plates air dried. 3. An initial tour of the facility's Dietary Department was conducted on 3/3/25 at 10:00 AM. An observation of the contents of the walk-in freezer revealed the following concerns were identified: --One cardboard box containing an unsealed plastic liner with approximately 40 frozen waffles was open to air as it was stored in the freezer. Neither the box nor the plastic liner was dated as to when it had been opened. --One stack of lunch meat was observed to have been opened and wrapped in cellophane. The stack consisted of approximately 10 slices of meat. The cellophane-wrapped meat was not labeled or dated. Joined by Dietary Manager #1 on 3/3/25 at 10:06 AM, the initial tour of the Dietary Department continued. An observation of the contents of the facility's walk-in cooler revealed the following concerns were identified: --A clear plastic bag containing approximately 3 pounds (#) of chicken salad was opened and not sealed (open to air). The bag was dated 2/24/25. --Seven (7) and ½ quart cartons of half and half cream with a use by date of 3/2/25 were stored on a shelf, along with other dairy products. --A one-gallon container of honey mustard dressing (with approximately 1/3 remaining in the container) was not dated as to when it was opened or when it expired. An interview was conducted with Dietary Manager #1 during the tour of the walk-in cooler conducted on 3/3/25 at 10:06 AM. At that time, the Manager reported all food items identified in the walk-in freezer and walk-in cooler needed to be covered, labeled, and dated. She stated both the undated food items and expired foods needed to be discarded. Dietary Manager #1 was observed as she removed and discarded the undated and expired foods. 4. Accompanied by the Dietetic Technician (DTR) and joined by the Regional [NAME] President of Operations, a follow-up observation was conducted on 3/4/25 at 11:20 AM of the Dietary Department to observe the completion of meal preparation for the noon meal and tray line meal service. Upon entering the department, [NAME] #1, [NAME] #2, Dietary Aide #1 and Dietary Aide #2 were observed to be involved in food preparation activities. Each of these Dietary staff members were wearing hairnets or hair coverings. However, each of these four Dietary staff members had facial hair (at least ½ inch long) but were not wearing a beard cover. After watching the meal preparation activities for approximately 5 minutes, the four staff members with facial hair were observed as they each donned a beard cover. 5. Accompanied by Dietary Manager #1, observations of the kitchen equipment were made during the initial tour of the Dietary Department conducted on 3/3/25 at 10:27 AM as follows: --The hood located above the range top, oven, and convention oven had brown/black build up on its outside surface. --The outside surfaces of the oven and gas stove top had a brown/black grease buildup. --The lowerator (an appliance that stores and heats plates) had food debris on its top, sides, and on the platform where the clean plates were stored. --The sneeze guard on the steam table had multiple dried splashes and droplets of food and fluids on it. --The ice machine was empty with multiple black particles observed on the bottom and sides of the storage bin. --Three (3) vents on the side wall of the kitchen appeared to have a black substance built up on the frame and louvers of the vents. An interview was conducted with Dietary Manager #1 during the initial tour of the Dietary Department conducted on 3/3/25 at 10:27 AM (with the focus on the cleanliness of the kitchen equipment). At that time, the Dietary Manager stated the brown/black build up observed on the outside surfaces of the hood, oven, and gas stove top appeared to be grease. The Dietary Manager was shown the lowerator, steam table sneeze guard, and inside of the ice machine. She reported each needed to be cleaned. Dietary Manager #1 reported she was not sure whether the ice machine was in working order but noted it would need to be cleaned before it was put into service. When Dietary staff members were asked if the ice machine was working, the staff reported they were not sure. Upon inquiry, Dietary Manager #1 reported the Maintenance Department was responsible for cleaning the vents. An interview was conducted with the Dietetic Technician (DTR) on 3/6/25 at 2:06 PM. During this interview, the concerns identified within the Dietary Department were discussed. The DTR reported that although she had not been at the facility during the initial tour on 3/3/25, she saw pictures of the equipment that required cleaning. She reported that a crew came in the evening of 3/3/25 to concentrate on cleaning in the Dietary Department. She stated that most (if not all) of the Dietary Department staff were relatively new and required ongoing education on the topics of appropriate dish washing practices, sanitation, cleaning duties, labeling/dating of opened food items, and the use of beard covers for Dietary staff with facial hair. An interview was conducted on 3/6/25 at 2:35 PM with the Maintenance Assistant. During the interview, the Assistant reported there is a Maintenance book at each of the two nursing stations where work orders were kept. If staff preferred, they could call the Maintenance Department to put in a verbal request for work to be done (and write it in the Maintenance book afterwards). An interview was conducted on 3/6/25 at 3:10 PM with the facility's Maintenance Director. The Maintenance Director stated he started working at the facility about two weeks ago. During the interview, the following issues were discussed: --When asked about the ice machine, the Director reported he fixed the ice maker on Monday morning (3/3/25) after it was identified as not working. He stated that upon inspection, the water to the ice maker had been turned off and just needed to be turned back on. --With regards to the dish machine not dispensing the chlorine solution to sanitize the dishes, the Maintenance Director reported the tubing which went from the container of chlorine solution to the machine needed to be primed. On 3/5/25, he educated the Dietary staff on how to prime the tubing so the appropriate amount of the chlorine solution would be dispensed. --Upon inquiry, the Director confirmed the Maintenance Department was responsible for cleaning the air vents in the kitchen. He reported he just hadn't gotten to take care of that task yet, but confirmed it needed to be done. An interview was conducted with the facility's Administrator on 3/6/25 at 4:03 PM. During the interview, the Administrator was asked what her expectation would be with regards to the concerns identified in the Dietary Department. In response, the Administrator stated her expectation would be for the Dietary Department to always maintain cleanliness and sanitation in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #75 was admitted to the facility on [DATE] and had diagnoses that included chronic obstructive pulmonary disease, chronic congestive heart failure, and chronic kidney disease. A review of Resident #75's electronic medical record (EMR) and an order dated [DATE] revealed Resident's #75's code status was do not resuscitate (DNR). A review of Resident # 75's care plan last revised [DATE] revealed the Resident had an advance directive in place for full code. The goal was the advance directive would be honored by staff. The interventions included advance directive acknowledgement signed on admission on consent to treat, advance directive in medical record, CPR (cardiopulmonary resuscitation) will be provided in the event of cardiac arrest and ensure provider's order is in place. On [DATE] at 11:57 am an interview with Nurse #6 was conducted. She indicated she checked the EMR for resident's code status when a resident's health declined. Nurse #6 opened Resident # 75's EMR and the information indicated Resident was a DNR. She then checked Resident #75's care plan and it indicated Resident had an advance directive in place for full code. Nurse #6 then checked Resident #75's physician orders and read an order dated [DATE] for DNR and checked the code status book located at the Nurses station and it had a DNR form with an effective date of [DATE] for Resident # 75. An interview was conducted on [DATE] at 12:15 pm with Unit Manager #2 and she indicated all the interdisciplinary team had portions of the care plan they were responsible to update on the care plan, and she was not sure why Resident 75's care plan was not updated. She stated, maybe he went to the hospital, but I will update it now. The MDS Nurse was unavailable for interview. During an interview on [DATE] at 4:32 pm, the Administrator stated all residents should have a code status order and they should be care planned based on their code status. She indicated the code status, and the care plan should match, and the Unit Managers should ensure that the care plan reflected the correct and current code status of the resident. Based on records review, and staff interviews, the facility failed to obtain and verify Advance Directives (code status) in the residents' records (Resident #191) and failed to clarify code status in the residents' record (Resident # 75) for 2 of 2 residents reviewed for Advance Directives. Findings included: 1. Review of Resident #191's hospital Discharge summary dated [DATE] revealed the resident was coded as Full Code. Resident #191 was admitted to the facility on [DATE]. Resident's admission Minimum Data Set (MDS) dated [DATE] was in progress. At the time of review on [DATE], there was no active order for code status in Resident #191's medical record {electronic health record (EHR)}. The facility did not use any hard copy chart. During an interview on [DATE] 9:28 AM, Nurse #1 stated she would look in the EHR for a resident's code status. The code status was usually displayed next to the resident's picture or would be in the physician's orders. Nurse #1 reviewed Resident #191's electronic medical record and stated the resident did not have a code status. Nurse #1 explained if there was no code status then the hospital discharge summary would be reviewed. Nurse #1 stated the Unit Manager, was responsible to review the discharge summary and notify the physician about the discharge medications and code status. Once verbal and/or written orders were received this was entered in the resident's EHR by the Unit Manager. During an interview on [DATE] at 10:45 AM, Unit Manager #1 stated when any resident was newly admitted or readmitted , the Unit Managers would verify the code status with the admission / medical record staff. Once the code status was verified, the Unit Managers would send/ notify the physician about the resident's discharge medications and the code status for approval. The orders would be approved verbally or written. Once the orders were approved by the physician, the residents code status would be entered in the resident's EHR. Unit Manager stated the resident's code status was missed. The Unit Manager stated the code status should be entered within 24 hours after admission or readmission. During an interview on [DATE] at 1:14 PM, Nurse Practitioner #1 stated that the staff would discuss with the resident and/or resident representative about Advance Directives and code status. This information was notified to her, and the order was signed. The staff would then enter the information in the resident's record. The Director of Nursing was unavailable for interview at the time of the survey. During an interview on [DATE] at 4:32 PM, the Administrator stated the resident's code status should be entered in the resident's EHR at admission. the Administrator indicated all residents should have code status orders and they should be care planned based on their code status. The Administrator further stated the Unit Managers were responsible for verifying the code status of residents upon admission or readmit admission and entering them in their EHR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the Interview for Activity Preferences of the comprehensive Minimum Data Set (MDS) for 2 of 2 cognitively impaired residents reviewed for activities (Resident #12 and Resident #81). The findings included: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses including cognitive impairment. The admission MDS dated [DATE] noted Resident #12 had cognitive impairment and required assistance with activities. The MDS did not include the Interview for Activity Preferences. Resident #12's care plan dated 3/12/24 included an area of focus: Resident #12 has impaired cognitive function/impaired thought process related to encephalopathy. The goal included: The resident would communicate with family/caregivers regarding resident's capabilities and needs. The interventions included: the resident would engage in simple, structured activities that avoid overly demanding tasks. An interview was conducted on 4/17/24 at 4:00 PM with the Activity Director (AD). The AD stated that one-on-one in room activities were Resident# 12's preference which included story time, music, sensory stimulation of hand rubs, television programs of her choice, and family visits. The AD confirmed while completing the Preferences for Customary Routine and Activities assessment she did not conduct the Interview for Activity Preferences which would include Resident #12's specific activity interests. The AD indicated she was not formerly trained on the completion of the MDS assessment. 2. Resident #81 was admitted on [DATE] with diagnoses including cognitive impairment. The admission MDS dated [DATE] noted Resident #81 had cognitive impairment and required assistance with activities. The MDS did not include the Interview for Activity Preferences. An admission activity assessment dated [DATE], revealed no information was included about Resident 81's preferences or interests in activities. A focus area on the care plan dated 12/29/23 revealed Resident #81 enjoyed participating in favorite activities and spending time outdoors. There was no further information provided on the care plan regarding Resident# 81's activity interests. An interview was conducted on 4/17/24 at 4:00 PM with the Activity Director (AD). The AD confirmed while completing the Preferences for Customary Routine and Activities assessment she did not conduct the Interview for Activity Preferences which would include Resident #81's specific activity interests. The AD indicated she was not formerly trained on the completion of the MDS assessment. An interview was conducted on 4/17/24 at 4:30 PM with the Administrator and the Regional Director of Operations. Both stated the activity section on the MDS for both Resident #12 and Resident #81 were incomplete, and they were unable to provide any further information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record reviews, the facility failed to provide an on-going activity program that met the individual interests and needs for 2 of 2 cognitively impaired residents reviewed for activities (Resident #12 and Resident #81). The findings included: The activity calendar was posted and offered the following scheduled activities: 4/15/24 at 10:00 AM morning stretch, 10:15 AM current events, 10:30 AM creative corner, 2:00 PM, movies and popcorn, 4:00 music and sensory. 4/16/24 at 10:00 AM news and views, 10:15 AM puzzles and coloring, 10:30 AM music and manicures, 2:00 PM arts and crafts, 2:45 PM bingo with friends and 4:00 PM music and reminiscing. 4/17/24 10:00 AM coffee and chat, 10:30 AM arts and crafts, 11:00 AM music and sensory, 2:00 PM, Bible study, 3:15 PM Bible study social and 4:00 PM create club. 1. Resident #12 was admitted to the facility on [DATE], with a diagnosis of encephalopathy. Resident #12 was coded on the admission Minimum Data Set (MDS) assessment dated [DATE] as having moderate cognitive impairment and she needed assistance with activities of daily living and assistance to attend activities. The MDS also did not code any of Resident #12's activity interests. The resident was coded for total assistance with transfers and locomotion. A focus area of the care plan dated 3/12/24 revealed Resident #12 had impaired cognitive function/impaired thought process. The goal included the resident would communicate with family/caregivers regarding resident's capabilities and needs. The intervention included the resident would engage in simple, structured activities that avoid overly demanding tasks. Record review revealed there were no activity notes available after the 3/12/24 assessment for Resident #12. There were no preferences listed. There were no documented notes or activity participation records for Resident #12. A continuous observation of Resident #12 was conducted on 4/16/24 from 10:00 AM to 11:30 AM. Resident #12 was in her room sitting in her wheelchair with no television on or any other form of social stimulation. The scheduled activities were held in the activity room during the time of the observation were news and views at 10:00 AM, 10:15 AM puzzles and coloring, and 10:30 AM music and manicures. An observation was conducted on 4/16/24 at 2:16 PM. Resident #12 was observed in bed with television on low volume and the remote control was across the room on the counter. There were no other stimulatory items in the room or within reach of the resident. An interview was conducted with Nurse Aide # 8 on 4/16/24 at 2: 16 PM, who stated she had not seen Resident #12 involved in group activities or provided with One-to-One (1:1) activities by the activity staff. Nurse Aide #8 further stated the aides try to assist with getting residents to activities, but if they were providing care to other residents, they were unable take residents to activities. An interview was conducted on 4/17/24 at 10:57 AM with Resident #12 during which she stated she enjoyed religious services, sports, gospel music and food events. Resident #12 further stated she had limited physical mobility and was unable to go to activities herself. Resident #12 reported she was not provided with in-room activities or offered to attend group activities. A continuous observation was conducted 4/17/24 from 3:15 PM to 3: 30 PM of Resident #12 seated in her room. The observation revealed she was not provided with any form of activity or stimulation while in her room. The television and the radio were off. The scheduled activity during the time of the observation was Bible study social at 3:15 PM. An interview was conducted on 4/17/24 at 4:00 PM with the Activity Director who stated that one to one (1:1) in room activities were Resident# 12's preference which included story time, music, sensory stimulation of hand rubs, television of her choice and family visits. The Activity Director confirmed the Minimum Data Set (MDS) assessment, or activity assessment completed on 3/12/24 did not include Resident #12's specific activity interest. The Activity Director further stated documentation of the resident's response would be in the activities note. The Activity Director could not confirm Resident #12 received any 1:1 activity or been offered any group activities of preferences based on the activities that were being provided. The Activity Director further stated she did not have a specific 1:1 schedule that was consistent with residents who needed 1:1 activity or that assistance was provided for residents to participate in small group activities. An interview was conducted on 4/17/24 at 9:15 AM with the Administrator who stated the expectation was for the activities team to develop a program, to include residents in small group activities and develop a system to ensure residents received 1:1 activity. The activities staff would document participation and refusal of activities in notes. An interview was conducted on 4/17/24 at 4:30 PM with the Regional Director of Operations and the Administrator. Both stated they were unable to provide documentation of the resident activity assessment for Resident #12, that included preference list or any actual participation records for group activity or 1:1 record of the resident's involvement. 2. Resident #81 was admitted to the facility on [DATE]. The diagnoses included both hemiparesis, hemiplegia, and cerebral infarction. Resident #81 was coded on the admission MDS assessment dated [DATE] as having severely impaired cognition and he needed assistance with activities. The MDS coded Resident #81 needed assistance with ADLs and assistance to recreational activity. The MDS also did not code any of Resident #81's activity interests. The resident was coded for total assistance with transfers and locomotion. A focus area on the care plan dated 12/29/23 revealed Resident #81 enjoys participating in favorite activities spending time outdoors. There was no further information provided on the care plan regarding Resident# 81's activity interests. Record review revealed there were no activity notes available after 3/21/24. Observation was conducted on 4/15/24 at 10:30 AM of Resident #81 who sat in his wheelchair in the doorway of his room and there was no social stimulation. The Activity Director was in a group activity (creative corner) with 6 other residents in the activity room. The resident indicated he wanted to go the activity but did not know what activity was happening. Observation and interview were conducted on 4/15/24 at 2:00 PM with Resident #81 who sat in his wheelchair in the doorway of his room without staff interaction or any other sensory stimulation. The activity being offered was a movie and popcorn. Resident #81 asked staff what's going on. Staff briefly spoke with the resident and walked away. Resident #81 stated he had limited physical mobility and was unable to go to activities himself. Resident #81 reported he was not provided with in-room activities, offered to go to activities. There was no other stimulation in the room. An interview on 4/17/24 at 2:45 PM, of Resident #81 revealed he was in bed with the ability to communicate his social interest. Resident#81 stated he enjoyed cooking, electronics, sports movies, cards and wanted to go to activities. Resident #81 further stated no one asked him to go to anything, so he did not know what was offered. An interview was conducted on 4/17/24 at 10:16 AM, with the Activity Director who stated she did not have any documentation of the actual group or one to one activity that the resident participated in or a complete activity assessment of the resident's activity preference. The Activity Director stated she did not have time to do a lot of the one-to-one activities because she was the only person who provided the activities for the entire building. Staff had not consistently brought residents to activities, therefore she had to go around the facility to get those who wanted to go and escort them to the activity. An interview was conducted on 4/17/24 at 4:30 PM with the Regional Director of Operations and the Administrator. Both stated they were unable to provide documentation of the resident activity assessment for Resident #81, that included preference list or any actual participation records for group activity or 1:1 record of the resident's involvement. An interview was conducted on 4/17/24 at 9:15 AM with the Administrator who stated the expectation was for the activities team to develop a program, to include residents in small group activities and develop a system to ensure residents received 1:1 activity. The activities staff would document participation and refusal of activities in notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview the facility failed to secure medications stored in the room/bathroom for 1 of 1 resident (Resident #62) reviewed for medication storage. The findings included: Resident #62 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, hypertension, chronic pain, and spinal stenosis. Review of Resident #62's physician orders sheet dated April 2024 revealed an order dated 04/11/24 for Nystatin External Powder (Topical)) Apply to skin folds topically two times a day for yeast. On 04/17/24 at 9:53 am an observation of activities of daily living (ADL) care was conducted. After ADL care was provided by NA #3, the NA applied Nystatin powder (used to treat fungal infections of the skin) under Resident # 62's bilateral breast, under abdomen (panniculus), inner thigh creases and between legs. During an interview with NA#3 on 04/17/24 at 10:01am it was indicated she had applied the Nystatin powder to the same areas on Resident #62 after ADL care last week. On 04/17/24 at 12:17 pm an observation was conducted in Resident #62 room with Unit Manager #2. Two bottles of Nystatin powder were observed in Resident #62's bathroom, one bottle on her bedside table and 2 bottles in Resident's drawer. During an interview with the Administrator on 04/18/24 at 4:38 pm she indicated it was her expectation medications would not be at beside without physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview and record reviews, the facility failed to provide foot care and arrange podiatry services for 2 of 2 dependent residents reviewed for foot care. Resident #4 was discovered to have a buildup of skin between her toes and had curled toenails which extended 1.5 inches beyond the base of the nail. Resident #81 was discovered to have thick layers of skin between the toes, thick, dry patches on the bottoms of his feet and long toenails beyond the base of the nail growing into the next toe. (Resident #4 and Resident #81). The findings included: 1. Resident #4 was admitted on [DATE] and readmitted [DATE]. The diagnoses included cognitive impairment, Parkinson's disease, chronic pulmonary obstructive disease, and diabetes. The significant change Minimum Data Set (MDS) dated [DATE] coded Resident #4 as having moderate cognitive impairment and he needed assistance with activities of daily living. A care plan focus area dated 2/4/24 revealed Resident #4 was at risk for impairment to skin integrity related to incontinent of bowel and bladder. The goal included risk for injury would be minimized. The interventions included Resident #4 would avoid mechanical trauma of constrictive shoes and cutting/trimming corns/callouses. Review of the podiatry schedule from January 2024 and April 2024 revealed no consultation report or notation was made in Resident #4's chart that she had been seen by the podiatrist or had been scheduled to be seen. Review of Resident #4's skin assessments done by nursing dated 3/13/2024, 3/17/24, 3/28/24 and 3/30/24. There was no information documented about the condition of Resident #4's feet. An observation was conducted on 4/15/24 at 10:15 AM with Resident #4. The resident was in her room seated in a wheelchair pulling her socks off, the big toenails and 2nd toes on both feet were discovered to have a buildup of skin between her toes and had curled toenails which extended 1.5 inches beyond the base of the nail. Resident #4's toenails on both feet were observed to have visible thick layers of what appeared to be dirt and thick layers of skin between the toes, and thick, dry patches on the bottoms of her feet. A follow-up observation in conjunction with an interview on 04/16/24 at 10:38 AM revealed Resident #4 's bilateral toenails were long and sharp on the big and second toes. Resident #4 reported her feet were hurting due to the long toenails and has reported the need to see the podiatrist several times to the aides and nursing , but no-one responded. The resident stated her feet had been in this condition since admission. Resident #4 stated staff were not washing her feet regularly. An observation was conducted of Resident #4 on 4/17/24 at 9:47 AM, in conjunction with an interview with the Director of Nursing from another facility (the current Director was out due to illness) revealed the condition of Resident #4's feet. The Director of Nursing confirmed Resident #4's feet needed to be cleaned and the toenails needed to be cut/trimmed. The Director of Nursing further stated it was the responsibility of the nurse aides to report to nursing when the toenails needed to be cut for all residents, especially diabetic residents. She explained nursing staff were responsible for doing a full head to toe assessment and document on the weekly skin assessment for any changes of the resident's body including the condition of the toenails. An interview was conducted on 4/17/24 at 9:54 AM, Nurse #7 stated the nursing staff were responsible for doing a head-to-toe assessment of the resident and document any change of condition including the condition of the resident's feet. She was unaware of the condition of Resident #4's feet or the need to see a podiatrist. The last skin assessment was on 3/30/24 done by Nurse #7. An interview was conducted on 4/17/24 at 10:15 AM with the Social Work Director who stated the podiatrist visited the facility every three months and any diabetic resident would be added to the schedule when nursing reported a resident needed podiatry services. The Social Work Director confirmed Resident #4 had not been on the podiatry list for the April visit on 4/11/24. She was unaware the resident needed to be seen by the podiatrist. She further stated nursing was responsible for letting the social work department know when podiatry services were needed. An interview was conducted on 4/17/24 on 10:30 AM with the Administrator who stated Nurse Aides and nursing were responsible for ensuring residents skin/toenails were being checked and cleaned during personal care and Nurse Aides should report to nursing any resident that needed podiatry services. He explained Nurse Aides could cut resident toenails that were not diabetic and should be cleaned. Nurse Aides should clean and check between toes to ensure the area was thoroughly clean. The Administrator added residents' feet should be checked on all residents when skin assessments were being completed and the condition of the resident's feet/toenails should be reflected on the assessment. The Administrator stated nursing should be notifying the social workers to let them know when a resident needed to be seen by an outside service. In addition, the Administrator added nursing should be cutting residents' toenails in between appointments until the resident could be scheduled. An interview was conducted on 4/18/24 at 11:20 AM, Nurse #8 stated she did the weekly skin checks but did not document the condition of the resident's feet or toenails. She explained that unless there was an impairment documented, the form does not advance to document any other condition. The nurse stated if a skin impairment was checked then the full body diagram would come up and nursing would then document what they observed. Nurse #8 confirmed a complete assessment of head-to-toe findings would include the condition of a resident's feet and/or need for podiatry services. 2. Resident #81 was admitted to the facility on [DATE]. The diagnoses included cognitive impairment, diabetes, hemiparesis, hemiplegia, and cerebral infarction. Resident #81 was coded on the admission Minimum Data Set (MDS) dated [DATE] as having severe cognitive impairment and he needed assistance with activities of daily living. A focus area on the care plan dated 3/29/23 [NAME] is at risk for impairment to skin integrity related to decreased mobility. The goal included the resident's risk for injury would be minimized. The interventions included avoid scratching and keep hands and body parts from excessive moisture; encourage good nutrition and hydration to promote healthier skin; and identify potential causative factors and eliminate/resolve where possible. Review of the podiatry schedule from January 2024 and April 2024 revealed no consultation report or notation was made in Resident #81's chart that he had been seen by the podiatrist or had been scheduled to be seen. Review of 81's head-to-toe skin assessments done by nursing dated 3/4/2024, 3/11/2024, 3/12/2024, 3/18/2024, 3/25/2024, 4/1/2024, 4/6/2024 and 4/8/2024 revealed no documentation of the condition of Resident #81's toenails from either foot, or other concerns regarding the resident's feet. An observation was conducted on 4/17/24 at 2:45 PM of Resident #81. The resident was lying in bed with their feet exposed from under the covers a strong foul odor was detected near his feet as he moved them around in the bed. Resident #81's toenails on both feet were observed to have visible thick layers of what appeared to be dirt and thick layers of skin between the toes, thick, calcified, dry patches on the bottoms of his feet. The toenails were several inches beyond the base of the nail growing into the next toe. An observation was conducted 4/17/24 03:28 PM with the Unit Manager #2 of Resident #81's feet. Unit Manager #2 confirmed the condition of the resident's feet had visible thick layers of what appeared to be dirt and thick layers of skin between the toes, and thick, calcified, dry patches on the bottoms of his feet. The toenails were dirty, and a strong foul odor was detected near his feet as he moved them around in the bed. An interview with Resident #81 was conducted during the observation with Unit Manager #2. Resident #81 stated that he needed his feet checked and cleaned. During an interview on 4/17/24 at 3:28 PM Unit Manager #2 stated the nurse aides were expected to provide foot care during baths/showers, report any change of condition of the resident's feet, and notify the nurse if the resident's toenails needed to be cut/trimmed. She further stated the charge nurse would do a weekly full body assessment on the residents and document any changes, including the condition of the resident's feet, so appropriate referrals could be made. She explained the charge nurse would then provide the social workers with the names of the residents who would need to be seen for podiatry. She indicated the nurses would also document in the physician/nurse practitioner notebook to inform them of the change in the resident foot condition as they would for other concerns. Unit Manager #2 stated she had also done skin checks on Resident #81 but did not document the condition of the resident's feet. The current skin check form only asked 2 questions. She explained, if there was not an impairment with the skin, the form did not allow for other documentation. During an interview on 4/17/24 at 4:25 PM the Social Worker stated based on her podiatry schedule and list of residents seen in January 2024 and April 2024, Resident #81 was not seen by podiatry. The Social Worker further stated she had not received notification from nursing that Resident #81 needed to be scheduled. An interview was conducted on 4/17/24 at 4:45 PM, in conjunction with a record review with the Regional Clinical Nurse the current head-to-toe skin assessment form was reviewed. She confirmed the 2 questions on the form did not include the condition of the resident's feet. She stated unless the nurse checked an impairment was observed there was no way of nursing documenting foot care or other concerns. The Regional Clinical Nurse further stated if a skin impairment was checked then the full body diagram would come up and nursing would then document what they observed. She indicated it would be expected that nursing checks the condition of resident feet for further evaluation and treatment and do a referral for podiatry care.

Based on record reviews and staff interviews, the facility failed to complete a performance review every 12 months to provide in-service education based on the outcome of the performance reviews for 3 of 5 nursing assistants (NAs) reviewed (NA # 1, #2, and #3). The findings included: 1a. Review of NA #1's employee file revealed a date of hire of 2/3/2016. The employee file for NA #1 did not include annual performance review documents based on the date of hire including February 2023 and February 2024. b. Review of NA #2's employee file revealed a date of hire of 12/23/2021. The employee file for NA #2 did not include annual performance review documents based on the date of hire including December 2022 and December 2023. c. Review of NA #3's employee file revealed a date of hire of 5/1/2014. The employee file for NA #3 did not include annual performance review documents based on the date of hire including for May 2022 and May 2023. During an interview on 4/18/24 at 3:30 PM, the Staff Development Coordinator (SDC) stated she was hired 2 months ago by the facility and was in-training for the past month. She indicated she was currently doing new employee orientation in-services and competencies. She stated she had not been in the role of SDC for very long and she had not started to review employee training files or started training nursing staff to have started completing annual performance evaluation or review. During an interview on 4/18/24 at 4:25 PM, the Administrator stated Nurse Aides' skills assessment /competencies should be completed at hire and annually. The facility should also have a performance review completed annually to address the needs of staff. The Administrator stated at this time the facility was unable to provide documentation to indicate Nurse Aides' annual performance reviews were completed. The Administrator indicated the skill competencies evaluation and annual performance review should be completed and signed by Staff Development Coordinator (SDC) or her designee. The Administrator stated the facility had some turnover in the SDC position, resulting in not knowing if they were completed as no documentation was available. During an interview on 4/18/24 at 4:30 PM, the Regional Clinical Director stated she expected staff competencies and performance review of NA's to be completed annually. She indicated there had been some changes in SDC staffing and currently only new hire competency skills assessments were available. She explained there was an online education program which consisted of learning modules allowing the NAs to receive their 12 hours yearly education. The NA's education was not based on their annual performance review. She indicated the annual skill assessment and performance review documentations were not available at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, and physician interview the facility failed to 1) assure treatments were provided to a resident's pressure sore and 2) place the resident on a special mattress per the physician's recommendations. This was for one (Resident # 7) of three sampled residents reviewed for pressure sore care. The findings included: 1a. Resident # 7 was admitted on [DATE] and readmitted on [DATE] after a hospitalization. Resident # 7's diagnoses in part included chronic osteomyelitis, chronic wounds, neuromuscular dysfunction with functional paraplegia, and vascular dementia. Resident # 7's significant change Minimum Data Set assessment, dated 2/12/23, coded Resident # 7 as cognitively intact. He was also assessed to need total assistance with his bed mobility and bathing needs. He was further assessed to have two Stage IV pressure sores, which had been present upon admission. Resident # 7's care plan, updated on 2/24/23, included the information that Resident # 7 had been admitted with Stage IV pressure sores to his left hip and his sacrum. This had originally been added to his care plan on 11/17/22 and remained part of his current care plan. The care plan also noted Resident # 7 was noncompliant with turning and repositioning. Care plan interventions included directions to provide treatments as ordered. Orders for the left hip included the following. From 3/16/23 to 4/3/23 the left hip pressure sore was to be cleansed with saline or wound cleanser; patted dry; skin prep applied to the peri wound; the wound bed was to be lightly packed with Mesalt; and a foam dressing applied. From 4/4/21 to 4/21/23 the orders remained the same, with the addition of also adding collagen powder to the wound bed with the Mesalt. Orders for the sacrum included the following. From 3/16/23 to 4/21/23 the sacrum pressure sore was to be cleansed with normal saline or wound cleanser; skin prep applied to the peri wound; the wound was to be allowed to dry; collagen with silver was then to be applied to the wound bed followed by silver alginate; and the wound was then to be covered with a dry dressing. Review of the facility record revealed Resident # 7 was again hospitalized from [DATE] to 4/28/23 for reasons not related to his pressure sore. Upon hospital discharge on [DATE], notations in the hospital discharge summary noted Resident # 7 continued to have chronic pressure sore wounds to his sacrum and left hip which required care. According to facility records, Resident # 7 was readmitted to the facility on [DATE]. There were no orders for the care of his pressure sores from 4/28/23 until 5/1/23. On 5/1/23 the following orders were obtained. The left hip was to be cleansed with normal saline or wound cleanser; 0.5% Dakins moistened guaze was to be applied to the wound bed; and the wound was to be covered with a dry foam dressing. The sacrum was to be cleansed with normal saline or wound cleanser, and patted dry. Then wound collagen with silver was to be applied to the wound bed followed by a dry foam dressing. Resident # 7's treatment administration records (TARs) for April and May, 2023 were reviewed. The left hip and sacrum dressing changes were scheduled on the TARs to be completed by the day shift nurse. There was documentation Resident #7 received treatment for his sacral and hip pressure sore one day in April. This was on 4/11/23 when Nurse # 1 signed she performed the dressing change. There were no documented dressing changes for May 2023. On 5/4/23 at 10:06 AM Resident # 7 was interviewed and reported the following. He had been having trouble getting his pressure sore dressings changed. He had missed multiple days. It was most problematic on the weekends. On 5/4/23 at 4:45 PM the Administrator was interviewed, and it was brought to her attention that Resident # 7's digital TARs were mostly blank for April and May 2023. The Administrator stated she would look into it and see if the staff were using alternate documentation to the digital TAR. On 5/5/23 at 10:32 AM the Administrator and the Director of Nursing (DON) were interviewed and reported the following. Nurse # 2 worked as the wound nurse Monday through Friday. They had spoken to Nurse # 2 (Wound Nurse) the previous evening of 5/4/23, and she had indicated she had done the dressing changes when she worked but not documented them. After they talked to her on 5/4/23, Nurse # 2 had gone back on the TAR and filled in all the blanks for April and May, 2023 on the days she had worked. She had also been working on the day when Resident # 7 was readmitted to the facility on [DATE], and it had been her responsibility to obtain and initiate orders for his pressure sores on that date. She had not obtained the orders until 5/1/23, and Nurse # 2 had not had any reason for the delay in obtaining orders when they talked to her on 5/4/23. An attempt to interview Nurse # 2 (the facility's wound nurse) was made on 5/5/23 at 1:20 PM and she could not be reached for interview. On 5/5/23 at 11:15 AM the DON provided a list of Nurses who had been responsible for the dressing changes for the April and May, 2023 weekends. Nurse # 1 was responsible for the ordered dressing changes on 4/1/23; 4/2/23; 4/15/23; 4/16/23. Nurse # 3 was responsible for 4/8/23 and 4/9/23. Nurse # 1 was interviewed on 5/5/23 at 10:10 AM and again on 5/5/23 at 12:00 PM. Nurse # 1 stated she had also been the nurse who cared for Resident # 7 on the weekend of 4/29/23 and 4/30/23. Nurse # 1 reported the following about the April weekends she worked. She had not done Resident # 7's dressing changes. The dressing changes prior to Resident # 7's discharge on [DATE] had been assigned to day shift, and she had not had the time to do them. She stayed over after her shift ended as long as possible so she could complete tasks, but due to personal responsibilities had to leave before doing the dressing changes. On the weekend of 4/29/23 and 4/30/23 there had been no orders for the pressure sore dressing changes, and she did not have access to the 4/28/23 hospital discharge summary to know what to do. In addition, she had time constraints. On 4/28/23 she had the additional responsibility of sending a resident out. There was no supervisor on the weekend to report she needed help and she had not called the DON to ask for help. Nurse # 3 was interviewed on 5/5/23 at 11:40 AM and reported the following. She had 30 to 33 residents for whom to care on the weekends and the dressing changes could take approximately 20 minutes. If she had not documented the dressing change, then she had not done them because of time constraints. Interview with the DON and Administrator on 5/5/23 at 12:40 PM revealed the following. The nurses had not called her on the weekends to let her know that they could not do the dressing changes for Resident # 7. If they had done so, she would have come in to help or worked to allocate staff. The facility's wound physician was interviewed on 5/5/23 at 2:00 PM and reported the following. Resident # 7's pressure sores were chronic in nature. Although it was not ideal and did not benefit the resident to have missed dressing changes, the Wound Physician did not feel as if Resident # 7 had been harmed by the missed dressing changes. He also reported that Resident # 7 was noncompliant with turning. 1b. Review of Resident # 7's Wound Physician notes revealed the following. On a note, dated 2/16/23, the Wound Physician had recommended Resident # 7 be placed on a Group-2 mattress. Wound Physician notes, dated 5/4/23, noted a Group-2 mattress was continued to be recommended and had been ordered. On 5/4/23 at 10:06 AM and 5/5/23 at 9:40 AM Resident # 7 was observed on a regular facility mattress. Interview with the Wound Physician on 5/5/23 at 2:00 PM revealed a Group 2 mattress came in varying styles and provided air flow beneath the resident. Some were overlays and some came as an entire bed system. He had been persistent in recommending the mattress and it was his understanding that the facility was trying to acquire additional Group 2 mattresses. An attempt to interview Nurse # 2 (the facility's wound nurse) was made on 5/5/23 at 1:20 PM and she could not be reached for interview. Interview with the DON on 5/5/23 at 2:45 PM revealed all the facility mattresses had some degree of pressure relief mechanism built into them, and if something further was needed, the supply clerk could order any type of specialty mattress. The facility's supply clerk was interviewed on 5/5/23 at 2:55 PM and reported the following. She had air mattresses, which the facility rented in her supply room, but she did not know Resident #7 needed one. The treatment nurse had previously asked her to purchase air mattresses rather than use the rented ones. It was her understanding that the rented air mattresses provided the same pressure relief as the ones the treatment nurse wanted purchased. She was told to order the new mattresses for all the residents who had been on rented air mattresses, and Resident #7 had not been on a rented air mattress. Therefore, she did not know he needed any type of air mattress, or she would have made sure he had one. On 5/5/23 at 9:40 AM Resident # 7's pressure sores were observed as Nurse # 1 provided care to them. The pressure sores appeared to have predominantly red, healthy tissue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to ensure a resident's urinary catheter drainage bag was secured in a manner to keep it off the floor or below the level of the bladder for 2 of 2 residents observed with indwelling urinary catheters (Resident #66 and Resident #37). Findings included: 1. Resident #66 was admitted to the facility on [DATE] with diagnoses of overactive bladder, benign prostatic hyperplasia and urinary retention. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #66 as cognitively impaired. He required one person assistance with personal hygiene and had an indwelling catheter. A review of the care plan dated 12/12/22 revealed staff were to check tubing for kinks each shift and as needed and keep drainage bag covered, position/secure tubing to prevent traumatic removal. Observation and interview was conducted on 2/06/23 at 10:23 AM, Resident #66's catheter drainage bag and the tubing was on the floor under the left side of resident's bed on a towel. The catheter could be seen from the hallway as staff passed by resident's room. The catheter drainage bag was not attached to the bed. Resident #66 stated the catheter drainage bag had been on the floor over the weekend. Resident #66 further stated staff acted like it was no big deal for it to be on the floor. It would pull sometime when he moved the covers. Staff stated they did not have the clips for the catheter drainage bag to place the bag in the right position below the bladder. An interview was conducted on 2/6/23 at 10:24 AM. Nurse Aide #1 entered the room and stated the catheter drainage bag should not be on the floor. She stated she did not know who placed the catheter in this position. An interview was conducted on 2/6/23 at 10:28 AM. Nurse #1 stated the catheter drainage bag should not have been placed on the floor. Nurse #1 stated the weekend nurses did not have access to the supply closet to get the proper clips for the catheter. An interview was conducted on 2/6/23 at 10:28 AM, Nurse #2 confirmed the catheter drainage bag was on the floor. Nurse #2 stated the weekend nurses did not have access to the supply closet to obtain needed supplies. Nurse #2 stated the concern about lack of access to the supply closet had been discussed with the Unit Manager on several occasions, however, there had been no response in allowing weekend staff access to the supply closet for items like catheters and/or urinary bag covers. An observation was conducted on 2/6/23 at 10:36 AM, Nurse Aide #2 stated she was assigned to the room. The Nurse Aide #2 emptied the catheter and placed the catheter drainage bag back on the floor with a towel under it. She stated the clip on the top of the bag was broken and she would have to speak with nursing about it. When asked how long the clip had been broken and the urinary drainage bag placed on the floor, there was no response. She stated she should not have returned the catheter to the floor after it was emptied. An observation was done on 2/6/23 at 11:00 AM. Nurse #3 observed the catheter drainage bag on the floor under the resident's bed. Nurse #3 confirmed the catheter was positioned incorrectly. The catheter bag should be below the bladder and secured to bed. Nurse #3 stated she would follow up with the Director of Nursing about nursing staff access to the supply room on the weekends. An interview was conducted on 2/7/23 at 11:15 AM. The Director of Nursing (DON) stated the catheter should be below the bladder and secured to resident bed. The tubing nor the bag should be dragging or placed on the floor. She further stated she had been made aware on 2/6/23 the supply closet was locked over the weekend and nursing could not get the needed supplies for the catheter. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses of benign prostatic hyperplasia, urinary retention, and urinary tract infection. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #37 was cognitively impaired. He required one person assistance with personal hygiene and had an indwelling catheter. The resident was coded as having a urinary tract infection in the last 30 days. A review of the care plan dated 12/12/22 revealed staff were to check tubing for kinks each shift and as needed and keep drainage bag covered, position/secure tubing to prevent traumatic removal. An observation and interview was conducted on 2/06/23 at 10:21 AM. Resident #37's catheter drainage bag tubing was observed on the floor under the bed at the foot of the bed unattached. Staff were observed walking past the resident's room, looking in room, but did not stop to pick up the catheter drainage bag from the floor. Resident #37 stated staff don't really check the catheter position unless they were going to empty it. An observation was conducted on 2/8/23 at 9:17 AM. Resident #37 was lying in bed in a supine (lying face up) position and the catheter drainage bag was positioned on the bed near the resident's left elbow. The catheter bag was not positioned below the bladder. The catheter had a back flow valve to stop the urine going back up. An observation on 2/6/23 at 11:00 AM, Nurse #3 observed the catheter drainage bag on the floor under the resident's bed. Nurse #3 confirmed the catheter was positioned incorrectly and should have been placed below the bladder. Nurse #4 stated she would follow up with Director of Nursing about nursing staff access to the supply room on the weekends. An interview was conducted on 2/7/23 at 11:15 AM, the Director of Nursing (DON) stated the catheter should be below the bladder and secured to the bedframe. The tubing nor the bag should be dragging or placed on the floor. She further stated she had been made aware on 2/6/23 the supply closet was locked over the weekend and nursing could not get the needed supplies for the catheters.

Based on staff interview and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee after the annual recertification/complaint investigation survey of 10/28/21 with a citation that was recited on the current complaint survey of 2/9/23. This was evident for one recited deficiency in the area of Food Safety Requirements (F812). The continued failure of the facility during two federal surveys of record within the last 3 years show a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F812: Based on observations, staff interviews and an interview with the service technician for the facility's dish machine, the facility failed to: 1) Maintain the chemical sanitizing solution of the dish machine at the correct concentration according to the manufacturer's recommendations during 1 of 1 observations of the dish washing process; 2) Failed to change gloves/wash hands between handling soiled and clean dishes to prevent cross-contamination of the clean dishes and failed to allow all clean dishware to air dry during 1 of 1 observations of the dish washing practices; and 3) Dispose of expired food items and seal, label, and/or date opened food items observed in food storage areas during 2 of 2 observations of the facility's food storage areas. During the recertification / complaint investigation survey of 10/28/21, the facility was cited for failing to label leftovers and discard expired food from their walk- in refrigerator and failed to maintain the walk-in freezer in a safe operating condition. The kitchen's walk-in freezer had accumulated ice on the freezer floor. The facility failed to ensure the commercial dishwasher was maintaining wash and rinse temperatures according to the manufacturer's recommendations, failed to use clean lids to cover food on the steam table, failed to ensure the glasses and cups stacked on the drying rack were clean and failed to ensure the sanitization solution strength used on the kitchen counter tops was within manufacturer's recommendation. The facility failed to keep the nourishment refrigerators clean, failed to label and discard food from 2 of 2 nourishment refrigerator/freezers and failed to maintain one of two nourishment refrigerator/ freezer (Station # 2) in safe temperature zone. The nourishment refrigerator temperature was above 40 degrees and the freezer must keep frozen foods frozen solid reviewed for food storage. An interview was conducted on 2/9/23 at 3:00 PM with the facility's Interim Administrator. During the interview, the Interim Administrator reported she was fairly new to the facility. She confirmed her responsibilities included taking the lead for the facility's QAA committee. She stated her first participation in the facility's QAA program took place in January 2023. The Administrator reported since coming to the facility, she and the QAA team have identified several concerns within the Dietary Department and the kitchen was being monitored by the new consultant Registered Dietitian (RD) as part of the QAA program. When asked, the Administrator reported the previously identified concerns in the kitchen were not the same as those identified by the current survey process. The Interim Administrator stated when concerns were identified, she requested the department complete a QAPI action plan. The QAA committee would revisit the issue, monitor the outcomes, and revise the action plan as needed.

Based on observations, staff interviews and an interview with the service technician for the facility's dish machine, the facility failed to: 1) Maintain the chemical sanitizing solution of the dish machine at the correct concentration according to the manufacturer's recommendations during 1 of 1 observations of the dish washing process; 2) Failed to change gloves/wash hands between handling soiled and clean dishes to prevent cross-contamination of the clean dishes and failed to allow all clean dishware to air dry during 1 of 1 observations of the dish washing practices; and 3) Dispose of expired food items and seal, label, and/or date opened food items observed in food storage areas during 2 of 2 observations of the facility's food storage areas. The findings included: 1. Accompanied by the facility's Dietary Manager, a continuous observation was conducted on 2/8/23 from 1:10 PM to 1:20 PM of the facility's dish washing process using a low temperature dish machine. Upon request, the Dietary Manager tested the concentration of the dish machine's sanitizing solution by using chlorine test strips. The vial containing the test strips indicated the strips detected chlorine from 0 to 200 parts per million (ppm) by undergoing a color change. The Dietary Manager tested the sanitizing solution of the machine three times using three different test strips. None of the test strips changed color (indicative of low or no levels of chlorine in the solution). He reported the test strips should have changed color to indicate the chlorine sanitizing solution was at a level of 100 ppm. Since he could not determine there was an acceptable concentration of chlorine in the sanitizing solution, the Dietary Manager told the dietary assistants using the dish machine to stop washing dishes until the sanitizing solution could be fixed. At that time, the facility's consultant Registered Dietitian (RD) and Corporate [NAME] President (VP) of Operations joined the Dietary Manager near the dish washing station. The consultant RD reported she had checked the dish machine's sanitizing solution with a test strip during the previous week. The RD stated the chlorine in the sanitizing solution was at the correct concentration when she conducted the test. On 2/8/23 at 1:32 PM, the Corporate VP of Operations reported a servicing technician for the facility's dish machine had been called and was expected to arrive shortly to correct the problem with the sanitizing solution for the dish machine. An interview was conducted on 2/8/23 at 2:45 PM with the servicing technician for the dish machine in the presence of the facility's Maintenance Director. During the interview, the technician reported the hose running from the container of chlorine sanitizing solution to the dish machine had slid out of the solution so none was going into the machine. Once that was corrected, he tested the concentration of the sanitizing solution and reported the concentration of chlorine actually tested high (about 300 ppm) so he adjusted it to the manufacturer's recommendation of 100 ppm of chlorine. When asked, the technician reported he did not notice how far out of the sanitizing solution the hose was when he first checked it. He could not provide an estimate of how long the sanitizing solution was not going into the machine. The service technician recommended chlorine test strips be used at least daily to ensure the chlorine sanitizing solution was kept at an appropriate level of 100 ppm of chlorine. When asked, the technician stated he typically came to the facility once a month to check the dish machine (and sanitizing solution) but it had been two months since he had last done so. A follow-up interview was conducted on 2/8/23 at 3:00 PM with the Dietary Manager. During the interview, the Dietary Manager reported he was certain he himself had checked the dish machine's sanitizing solution with a test strip on Monday (2/6/23) and it checked out to be okay at that time. He reiterated the chlorine sanitizing solution for the dish machine should have a concentration of 100 ppm. 2. Accompanied by the facility's Dietary Manager, a continuous observation was conducted on 2/8/23 from 1:10 PM to 1:20 PM of the facility's dish washing process using a low temperature dish machine. Dietary Assistant #1 (DA #1) was observed to be the sole staff member working at the dishwasher. While wearing a pair of gloves, DA #1 was observed as he rinsed dirty dishes with a spray of water on the left side of the dish machine, slid the dish rack containing dirty dishes into the dish machine, and activated the machine. The DA did not change gloves or perform hand hygiene. When the dish machine was finished with the wash and rinse cycles, DA #1 moved to the right side of the dish machine. While there, he unloaded and stacked the cleaned plates and bowls from the dish rack. He then returned to the dirty side of the dish machine to begin the process over again. When the Dietary Manager was asked what his thoughts were about DA #1 working on both the dirty and clean dishes without performing hand hygiene in-between, he stated that shouldn't be done. The Dietary Manager was observed as he called another DA (DA #2) over to work on the clean side of the dish machine while DA #1 worked on the dirty side. When asked, DA #1 stated he had not been told in the past that he needed to wash his hands when going between the dirty and clean sides of the dish machine. The observation of the dish machine station continued as DA #1 was assigned to work exclusively on the dirty (left) side of the dish machine while DA #2 worked on the clean side of the dish machine. On 2/8/23 at 1:15 PM, DA #2 was observed as he pulled dome lids (used to cover plates) and divided plates from the clean rack of the dish machine after having been washed. He used a white cloth to dry the remaining water off the inside and outside of each dome lid and both sides of the divided plates before stacking them on a nearby rack. An interview was conducted with the Dietary Manager on 2/8/23 at 1:15 PM. During this interview, the Dietary Manager was asked what his thoughts were regarding the practice of using a cloth to dry the dome lids and plates. The manager stated he was not sure. By this time, the facility's consultant RD had joined the Dietary Manager in the kitchen. The consultant RD was also asked what she thought about the practice of using a cloth to dry the dome lids and plates. The RD stated, They have to be air dried. 3-a. Accompanied by the facility's Dietary Manager on 2/6/23 at 10:25 AM, an initial tour of the Dietary Department was conducted beginning on 2/6/23 at 10:25 AM. The observations included the Department's dry storage area with the following concerns identified: -- 2-16 ounce containers of parmesan cheese (one full and the other partially used) were stored in the dry storage area. The label on the parmesan cheese containers read, Keep refrigerated. Upon inquiry, the Dietary Manager reported he would need to discard the parmesan cheese. --A 50-pound (#) bag of pinto beans with approximately ½ remaining was labeled with a best by date of 12/16/22. The Dietary Manager reported the beans were beyond the best by date and needed to be discarded. --An unlabeled, plastic zippered bag containing approximately 2-3 cups of an off-white, powder-appearing dry product was stored on a shelf in the dry storage area. The bag was not labeled with the product name or date the original container had been opened. Upon inquiry, the Dietary Manager reported the bag contained grits. He reported the bag containing the grits would need to be discarded. --Two partially filled plastic bags of dried pasta were observed to be sealed but not labeled or dated as to when they had been opened. --A plastic bag was observed to be stored inside the manufacturer's box labeled to contain 25 # of Instant Food Thickener. The plastic bag was left open with the thickener exposed to the air. Neither the bag nor the box were dated as to when the thickener had been opened. The Dietary Manager reported he would need to go get a container to store the thickener in an air-tight container. --A 50 # bag of parboiled rice was observed to be opened with the top of the bag loosely folded over. The rice was not in a sealed container. Accompanied by the facility's Dietary Manager, an observation was conducted 2/6/23 at 10:35 AM of the walk-in cooler. Eight (8) 8-ounce cartons of whole milk were noted to have an expiration date of 2/4/23. The Dietary Manager reported the milk was expired and needed to be discarded. 3-b. Accompanied by the Maintenance Director and joined by the Corporate VP of Operations, a follow-up observation was conducted on 2/8/23 at 12:52 PM of the Dietary Department's food storage areas. The observations included the Department's dry storage area with the following concerns identified: --A plastic bag was again observed to be stored inside the manufacturer's box labeled to contain 25 # of Instant Food Thickener. The plastic bag remained open with the thickener exposed to the air. Neither the bag nor the box were dated as to when the thickener had been opened. --One (1) opened 46 oz. bottle of thickened iced tea was observed to be stored on a shelf in the dry storage room. The manufacturer labeling on the bottle read, Refrigerate unused portion. A follow-up interview was conducted on 2/8/23 at 3:00 PM with the Dietary Manager. During the interview, the Dietary Manager reported a Dietary staff in-service was scheduled with the consultant RD to re-educate staff on the survey concerns identified in the Dietary Department.