**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. An observation was conducted on 3/29/2022 at 9:34 AM of Resident #38 lying in bed, turned to her right side, sitting with the head of the bed elevated, being fed her meal by Nursing Assistant, NA, #2. The NA was standing beside the bed while feeding assistance was provided from 9:34 AM until 9:45 AM. An interview was conducted on 3/29/2022 at 9:30 AM with NA #2 and the NA revealed that Resident #38 was the only Resident she had to provide total feeding assistance to during the breakfast meal on this day because other staff helped with the other residents. She added that she preferred to stand when she fed residents but does not always stand, it depended on how the day goes and the Resident she was working with. She stated she stood while feeding Resident #38 often. She denied being told to not stand while feeding. During the interview Nurse #3 was present and did not add any further information. An interview was conducted with Nurse #3 on 3/29/2022 at 9:46 AM upon exiting Resident #38's room. When asked what the facility policy for feeding a resident while standing was, she identified it was the facility policy to not stand while feeding a resident. She then went back into Resident #38's room and requested NA #2 to not stand while feeding the Resident. Based on 2 of 2 dining observations, record reviews, and staff interviews, the facility failed to ensure staff were seated while assisting Resident #38 during dining. Findings included: 1a. Resident #38 was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, diabetes mellitus, and protein-calorie malnutrition. The quarterly Minimum Data Set, dated [DATE] indicated Resident #38 was severely, cognitively impaired; was total dependent on staff for eating; and had a swallowing disorder of holding food in her mouth/cheeks. The care plan revealed Resident #38 received a mechanically altered and therapeutic diet and was at high risk for weight loss. Interventions included: the resident was to be fed by staff. On 3/28/22 at 1:01 p.m., Resident #38 was in bed with the head of the bed raised to approximately 85 degrees. Nursing assistant (NA#1) was standing next to the resident's bed as he fed the resident a pureed meal with regular liquids. During an interview on 3/30/22 at 10:04 a.m., nursing assistant (NA#1) acknowledged his standing while feeding Resident #38. He revealed he had been educated on the correct way to feed residents; he should have been sitting in a chair when feeding the resident. NA#1 stated he stood while feeding Resident #38 because there was no chair in the room, and he did not want to disrespect the resident by sitting in her wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #11 was admitted to the facility on [DATE]. Diagnoses included, in part, cerebral infarction and dysphagia. The medical record revealed Resident #11 was admitted to Hospice services on 1/1/22. The comprehensive MDS assessment dated [DATE] indicated the resident received Hospice services. Further review of the MDS assessment revealed a prognosis of less than six months was not checked. The Hospice agency's plan of care dated 1/1/22 was reviewed and indicated a prognosis of a life expectancy of six months or less. During an interview with MDS Nurse #1 on 3/29/22 at 11:21 AM, she explained she routinely checked Hospice care on the MDS when she completed the assessment for a resident who was admitted to Hospice services and checked yes on the assessment that the resident had a life expectancy of less than six months. MDS Nurse #1 verified she completed the MDS assessment dated [DATE] and stated the prognosis of less than six months should have been checked on the assessment. She thought it was an oversight that she missed the coding on the prognosis question. On 3/30/22 at 3:53 PM an interview was completed with the Administrator. She indicated the facility had corporate support who assisted with monitoring/auditing the accuracy of MDS assessments. Based on observations, record reviews, resident and staff interviews, the facility failed to accurately assess and code the minimum data set for 1 of 3 sampled residents (Resident #26) reviewed for range of motion/positioning; 1 of 6 sampled residents (Resident #40) reviewed for nutrition; and 1 of 2 sampled residents (Resident #11) reviewed for hospice services. Findings included: 1. Resident #26 was admitted to the facility on [DATE] re-admitted : 9/27/21 with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting her right dominant side. The quarterly minimum data set (MDS) dated [DATE] indicated Resident #26 was moderately, cognitively impaired; required extensive assistance with bed mobility and transfers; required supervision when eating; and had no impairments with range of motion of her upper and lower extremities. On 3/28/22 at 11:47 a.m., Resident #26 was observed in the dining room feeding herself. The resident was using her left hand to hold the fork. The resident revealed her right hand was her dominant hand but was unable to use it due to difficulty with straightening the fingers of her right hand. During an interview on 3/30/22 at 2:30 p.m., MDS Coordinator #1 acknowledged Resident #26 had a diagnosis of right sided hemiparesis of her upper and lower extremities. She stated that section G0400 A and B of Resident #26's MDS were incorrectly coded as no impairment due to human error. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses which included: hypertensive heart and chronic kidney disease, congestive heart failure, and diabetes mellitus with diabetic peripheral angiopathy. The quarterly minimum data set (MDS) dated [DATE] indicated Resident #40 was cognitively intact, eating occurred only 1-2 times with setup; had no weight loss; and received a mechanical altered diet. During an interview on 3/29/22 at 2:43 p.m., MDS Coordinator #2 indicated Resident #40 was independent with eating. She revealed she referred to and documented using the nursing assistants' tracking information for the period of 1/18/22 -1/24/22 when coding the MDS for eating function. She stated that a corrected MDS should have been re-submitted and the nursing assistant's error of the resident's eating assessment should have been documented in the nurse's note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to follow care planned interventions for 1 of 2 residents (Resident #10) reviewed for accidents. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, an autoimmune disease, diabetes mellitus II, chronic kidney disease, pressure ulcers of the right and left heels with a history of falls. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had severe cognitive impairment, required extensive assistance of one staff for activities of daily living (ADL) care and total assistance with dressing. The assessment revealed the Resident had a fall with minor injury since the last assessment. The care plan had a focused area for falls that read, Resident #10 had the potential to fall down and hurt herself because she had decreased safety awareness and mobility with a goal to stay safe while she was moving about to avoid injury. An intervention was added on 10/29/2021 that read, bilateral fall mats and bolsters to the bed were added. The intervention was still active at the time of the investigation. A review of the physician orders revealed an order that read, floor mats to both sides when in bed for safety due to multiple falls with continuous use. An observation was conducted of Resident #10, on 3/27/2022 at 3:36 PM, lying in bed with a fall mat on the right side of the bed, between the wall and the bed, and not on the left side of the bed. An observation was conducted of Resident #10, on 3/28/2022 at 3:47 PM, lying in bed with a fall mat on the door side of the room and no fall mat on the window side of the bed. An observation was conducted of Resident #10, on 3/29/2022 at 11:52 AM, lying in bed with a fall mat between the bed and the wall with no fall mat on the window side of the bed. A review of the Medication Administration Record (MAR) for the date of 3/29/2022 revealed the order for the bilateral floor mats had been signed as complete and in place by Nurse #4. An interview was conducted with Nurse #4 on 3/29/2022 at 11:54 AM and she revealed that she had signed the MAR today that Resident #10 had bilateral fall mats in place. She then observed Resident #10 in bed and stated the Resident only had one fall mat on the wall side of the bed and she did not see a second fall mat anywhere in the room. She denied seeing a second fall mat prior to signing the MAR. She added she would try to acquire a second mat as soon as possible. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed when an order was written and care planned for a resident, such as the order for bilateral fall mats for Resident #10, it was his expectation that the order or care planned intervention be followed as written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and Nurse Practitioner interviews the facility failed to provide the interventions for fall prevention for 1 of 2 residents (Resident #10) reviewed for falls. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, an autoimmune disease, diabetes mellitus II, chronic kidney disease, pressure ulcers of the right and left heels with a history of falls. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had severe cognitive impairment, required extensive assistance of one staff for activities of daily living (ADL) care and total assistance with dressing. The assessment revealed the Resident had a fall with minor injury since the last assessment. A review of the fall incident reports revealed Resident #10 had an incident on 9/16/2021 that documented the Resident was observed on the floor with a fall from the bed. A review of the fall incident reports revealed Resident #10 had an incident on 9/17/2021 that documented the Resident was observed on the floor in the Resident's room with a fall from the bed. A review of the fall incident reports revealed Resident #10 had an incident on 10/11/2021 that documented the Resident was observed on the floor in the Resident's room. A review of the physician orders revealed an order, dated 10/27/2021, that read, floor mats to both sides when in bed for safety due to multiple falls with continuous use. A review of the fall incident reports revealed Resident #10 had an incident on 10/29/2021 observed in the floor next to the bed on a floor mat. The care plan had a focused area for falls that read, Resident #10 had the potential to fall down and hurt herself because she had decreased safety awareness and mobility with a goal to stay safe while she was moving about to avoid injury. An intervention was added on 10/29/2021 that read, bilateral fall mats and bolsters to the bed were added. The intervention was still active at the time of the investigation. An observation was conducted of Resident #10, on 3/27/2022 at 3:36 PM, lying in bed with a fall mat between the bed and the wall and there was no fall mat on the window side of the bed. An observation was conducted of Resident #10, on 3/28/2022 at 3:47 PM, lying in bed with a fall mat on the door side of the room and no fall mat on the window side of the bed. An observation was conducted of Resident #10, on 3/29/2022 at 11:52 AM, lying in bed with a fall mat between the bed and the wall with no fall mat on the window side of the bed. A review of the Medication Administration Record (MAR) for the date of 3/29/2022 revealed the order for the bilateral floor mats had been signed as complete and in place by Nurse #4. An interview was conducted with Nurse #4 on 3/29/2022 at 11:54 AM and she revealed that she had signed the MAR today that Resident #10 had bilateral fall mats in place. She then observed Resident #10 in bed and stated the Resident only had one fall mat on the wall side of the bed and she did not see a second fall mat anywhere in the room. She denied seeing a second fall mat prior to signing the MAR. She added she would try to acquire a second mat as soon as possible. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed when an order was written and care planned for a resident, such as the order for bilateral fall mats for Resident #10, it was his expectation that the order or care planned intervention be followed as written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and nurse practitioner interviews the facility failed to prevent a urinary catheter bag from encountering the floor to reduce the risk of infection or injury for 2 of 2 residents (Resident #10 and #29) reviewed for urinary catheter care. The findings included: A review of the facility policy, titled: Catheter care, Urinary from the manual, LSC Nursing Services, under the section, Urinary and Renal Conditions, was conducted. On page 1, under infection control, the policy read: The catheter tubing and drainage bag should be kept off the floor. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, an autoimmune disease, diabetes mellitus II, chronic kidney disease, chronic use of steroid medications and a history of infection. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had severe cognitive impairment, required assistance of one staff for activities of daily living (ADL) care and total assistance with dressing. The assessment revealed the Resident had a urinary catheter. A review of the care plan dated 10/19/2021 revealed a focused area that read: Resident #10 had a urinary catheter because she had chronic kidney disease with a goal that she would be free from a urinary tract infection. Interventions included to provide care to the catheter, monitor for signs and symptoms of infections, take care of the catheter equipment. A review of the physician orders revealed an order to provide catheter care every shift, dated 2/1/2022. An observation was conducted on 3/28/2022 at 3:47 PM of Resident #10 lying in bed with a urine catheter bag hanging on the bed frame at the foot of the bed with the lower half of the bag on the floor. The bed was in the lowest position. An interview was conducted on 3/28/2022 at 3:50 PM with Nursing Assistant (NA) #3 and he revealed when a resident had a catheter bag, the bag should not touch the ground because it was not sanitary. An interview was conducted on 3/28/2022 at 3:45 PM with NA #4 that was assigned to Resident #10 and #29 and she revealed when she has a resident with a urine catheter bag she hangs the bag on the side of the bed and likes to make sure the bag was emptied at the first of her shift and the end of her shift. She added that she had already made rounds and emptied the catheters for this shift. An observation was then conducted inside Resident #10's room with NA #4 and she stated she observed the urine catheter bag lying on the ground with the bed in the lowest position and the bag should not be touching the ground because this will cause the bag to leak urine. She raised the bed to take the bag off of the ground and stated the bed was to be in the lowest position but the bag touches. An interview was conducted with the Staff Development Coordinator (SDC) on 3/28/2022 at 4:03 PM and she revealed the facility expectation was for a urinary catheter bag to not touch the floor in order to prevent bacteria from entering the system through the tubing and causing the potential for infection. She stated she would follow up with NA #4 and provide education. She added that NA #4 was a new NA and had only been certified a brief time period. An observation was conducted on 3/29/2022 at 9:55 AM of Resident #10 lying in bed with half of the urine catheter bag lying on the floor. The bed was in the lowest position. An interview was conducted with Nurse #4 on 3/29/2022 at 10:01 AM in Resident #10's room and Nurse #4 revealed she observed the urinary collection bag lying on the floor with half of the bag on the floor. She stated it was her expectation that the bag be off the floor. She stated the bed was to be in the lowest position for the fall safety intervention for the Resident and something needs to be thought of to go between the floor and the collection bag for the Resident. She stated she was going to think of something and place it as a barrier. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed, in regard to a urine catheter collection bag touching the floor, the catheter bag was a direct line to the bladder and an increased risk for infection when it touches the floor. He added that Resident #10 was a high risk for infection from the amount of steroids she was ordered to take due to her disease process. He stated it was his expectation that the catheter bags be kept off of the floor. 2. Resident #29 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, chronic kidney disease stage 3, atrial fibrillation, and chronic congestive heart failure with a history of urinary tract infections. A significant change MDS, dated [DATE], revealed Resident #29 had severe cognitive impairment and required total assistance of one staff member with toilet use and personal hygiene. The assessment revealed the Resident had an indwelling urinary catheter. The care plan for Resident #29 revealed she had a focused area that read, she had a catheter because she had chronic kidney disease and was on Lasix with a goal to be free from urinary tract infections with the catheter functioning properly with adequate fluid intake. The interventions included to have catheter care, ensure the catheter was not kinked, monitor for signs and symptoms of infections, and have the NAs provide care to the catheter equipment and skin. An observation was conducted on 3/28/2022 at 3:44 PM with Resident #29 lying in bed with the urinary catheter collection bag hanging on the bed frame at the foot of the bed with the bag sitting on the floor. An interview was conducted on 3/28/2022 at 3:50 PM with Nursing Assistant (NA) #3 and he revealed when a resident had a catheter bag, the bag should not touch the ground because it was not sanitary. An interview was conducted on 3/28/2022 at 3:45 PM with NA #4 that was assigned to Resident #10 and #29 and she revealed when she has a resident with a urine catheter bag, she hangs the bag on the side of the bed and likes to make sure the bag was emptied at the first of her shift and the end of her shift. She added that she had already made rounds and emptied the catheters for this shift. At 4:00 PM an observation was conducted with NA #4 of Resident #29's urine collection bag touching the floor and she stated she would raise the bed immediately. An interview was conducted with the Staff Development Coordinator (SDC) on 3/28/2022 at 4:03 PM and she revealed the facility expectation was for a urinary catheter bag to not touch the floor in order to prevent bacteria from entering the system through the tubing and causing the potential for infection. She stated she would follow up with NA #4 and provide education. She added that NA #4 was a new NA and had only been certified a brief time period. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed, in regard to a urine catheter collection bag touching the floor, the catheter bag was a direct line to the bladder and an increased risk for infection when it touches the floor.

Based on observations and staff interviews, the facility failed to maintain sanitary conditions in the kitchen by not labeling and dating resealed food items; by failing to store food items off the floor; by failing to ensure kitchen equipment was clean and free from debris; by not correctly storing food service cleaning supplies; by not ensuring hair covering was worn by anyone entering the kitchen; and by not ensuring food items served at acceptable temperatures. Findings included: 1. During the initial tour on 3/27/22 at 10:32 a.m., 6-cases of food items were observed stacked in the middle of the floor in the dry storage room in the kitchen. There were multiple cases of food items stacked on the floor in the walk-in freezer. During an interview on 3/27/22 at 11:00 a.m., the Dietary Manager (Assistant DM) revealed food deliveries to the kitchen were on Wednesdays and Fridays. She indicated the items observed on the floors in the dry storage room and in the walk-in freezer were delivered on Friday (3/25/22). 2. On 3/27/22 at 10:50 a.m., during observations of the refrigeration units in the kitchen the following were observed: a dietary staff did not ensure the door to the walk-in cooler was completely closed (the door remained approximately six inches open for five minutes until this Surveyor entered the cooler); stored in the walk-in cooler was a stainless-steel container of a prepared food item, covered with cellophane wrap and dated 3/25 with no identifying label; stored in the reach-in refrigerator were 1-unopened (33 ounce) plastic bottle of water, 1-unopened (16.9 ounce) plastic bottle of water, and 1-unopened (16.9 ounce) plastic bottle of tea (all with the date of 3/27). The dietary cook revealed these 3-bottles belonged to the second shift cook. The dry storage room contained 1-resealed bag of croutons, 1-resealed bag of dry milk, and 1-resealed bag of batter stored on the storage racks but were not dated. 3a. On 3/27/22 at 11:05 a.m. during the kitchen observation, the 2-filters and vents of the ice machine were observed with thick, dark gray lint. The outside and outside of the food warmer was stained with dark brown substances and the stainless-steel trays inside the warmer contained food crumbs. The lid of the flour bin was stained, and the handle of the scoop stored in the bin was stained with a yellow-brown substance. The lid of the sugar bin was covered with sugar particles. The 6-brooms in the broom/mop closet were stored against the wall with the bristle heads on the floor of the closet. 3b. During a follow-up observation in the kitchen during meal preparation on 3/30/22 at 11:55 a.m., a food vendor deliveryman was observed transporting cases of food items through the kitchen to the storage areas. The deliveryman's hair was not covered. Also observed in the kitchen were dirty and wet pans were stacked on the storage rack: 1-(1/2 sized) steamtable pan stained with yellow particles, 1-(2 inch deep) steamtable pan, and 1-large muffin pan with yellow/white particles. There was 1-(2 inch deep) steamtable pan stacked wet on the storage rack. In the dry storage room, the lid of the sugar bin was covered with fine white particles. 3c. On 3/30/22 at 12:17 p.m., during the 500/600 hall satellite kitchen observation, the 2-filters and vents of the ice machine were observed with thick, dark gray lint. 4. During an observation of the meal tray line service in the 500/600 hall satellite kitchen on 3/30/22 at 12:25 p.m., a pan of tuna with cheese sandwiches (alternate entrée) was observed on the counter, next to the steamtable. The temperatures of the tuna with cheese sandwiches in the pan were 90 degrees Fahrenheit. The meal tray service consisting of one of the tuna sandwiches was stopped by this Surveyor before it was served to a resident. The Dietary Manager removed the sandwiches from the meal serving line and stated that she was unsure if the tuna sandwiches were to be served cold or hot but acknowledged the 90-degree Fahrenheit temperature was not acceptable for a food item to be served cold (41 degrees Fahrenheit or below) or a food item to be served hot (135 degrees Fahrenheit or above).