Based on observation, interview, and facility policy review, the facility failed to ensure appropriate food storage in the kitchen's main freezer and the memory care unit refrigerators. The kitchen area had the potential to affect all residents receiving meals from the kitchen. The facility identified three residents (#36, #78, and #96) who had nothing by mouth (NPO) diet orders. The facility identified 24 residents (#16, #18, #19, #21, #24, #31, #37, #39, #50, #52, #55, #56, #59, #60, #66, #67, #69, #71, #72, #80, #83, #87, #90, and #95) on the memory care unit. The facility census was 115. Findings include: Observation on 07/22/24 from 8:15 A.M. to 8:30 A.M. with Assistant Director of Dietary Services #857 revealed the main freezer had an internal thermometer reading negative 19 degrees Fahrenheit. Inside the main freezer was significant amounts of frozen water drips across the ceiling of the freezer. There were ice crystals formed on boxes of stored food products along the top racks of the freezer. There was ice buildup noted on the two condensers. Assistant Director of Dietary Services #857 indicated she had previously put in a work order with maintenance; however, the freezer had not yet been inspected. There was a box of pretzel rolls spilled onto the floor of the freezer. All kitchen findings were verified at time of observation with Assistant Director of Dietary Services #857. Observation on 07/22/24 at 8:42 AM with Assistant Director of Dietary Services #857 on the secure memory care unit revealed a mini refrigerator freezer located in the nursing station. There was noted ice buildup in the freezer portion of the mini refrigerator freezer. There was a residential refrigerator with a freezer adjacent to the dining area on the memory care unit. There was a large, dried spill of an unidentified brown substance on the bottom shelf of the refrigerator. Assistant Director of Dietary Services #857 removed several staff lunches and beverages from the refrigerator including several bottled beverages, bagged lunches, a box of pizza, and a frozen dinner. The food and beverage products removed were not labeled with a name or date. Assistant Director of Dietary Services #857 indicated the refrigerator was only for resident foods, and staff were not permitted to store their food in the refrigerator. All findings were verified at time of observations with Assistant Director of Dietary Services #857. Review of the undated facility policy labeled Freezer Storage revealed all food would be stored to prevent freezer burn. The freezer should be maintained at a temperature of zero degrees to negative 10 degrees Fahrenheit. Review of the facility policy labeled Care and Monitoring of Unit Refrigerators, dated August 2017, revealed resident food or beverages brought in from the outside will be labeled with the resident's name, room number, and dated by nursing. The policy did not address cleanliness of unit refrigerators.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the nurse practioner was notified as ordered when Resident #145's blood sugar was elevated. This affected one of five residents reviewed for unnecessary medications. The facility census was 145. Findings include: Review of the record revealed Resident #145 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of an order dated 02/26/19 revealed the nurse practioner was to be notified if the resident's blood sugars were higher than 250. Review of the medication administration records for March and April 2019, where the resident's blood sugar results were recorded, revealed the blood sugar checks exceeded 250 on on 03/07/19 at 9:00 P.M. (275), 03/14/19 at 11:00 A.M. (267), 03/17/19 at 11:00 A.M. (257), 03/18/19 at 4:00 P.M. (285), 03/19/19 at 11:00 A.M. (300), 03/19/19 at 4:00 P.M. (261), 03/26/19 at 4:00 P.M. (276), 03/28/19 at 11:00 A.M. (274) and 03/31/19 at 7:00 A.M. (257). Her blood sugar also exceeded 250 on 04/02/19 at 4:00 P.M. (269), 04/12/19 at 11:00 A.M. (263), 04/12/19 at 4:00 P.M. (268) and 04/17/19 at 11:00 A.M. (271). A phone call to the nurse practioner, Registered Nurse RN #500, on 04/18/19 at 1:45 P.M. revealed she had been called about a few high blood sugars but could not remember specifics of when. She did verify she had not been called about the high blood sugars on 04/12/19 (two elevated levels) or the elevated level on 04/17/19. The assistant director of nursing, Licensed Practical Nurse (LPN) #400, verified on 04/18/19 at 2:00 P.M. that the record did not contain evidence the nurse practioner was notified as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #39's skin alteration prevention interventions were in place as ordered. This affected one (Resident #39) of two residents reviewed for skin conditions. Findings include: Resident #39 was admitted on [DATE] with diagnoses including but not limited to unspecified dementia with behavioral disturbance. Resident #39's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive two person assistance with bed mobility, transfers, and dressing. Resident #39's physician orders revealed on 04/24/17 she was ordered float heels off pillow when in bed as tolerated every shift, on 07/14/17 she was ordered Dermasavers (protective sleeves for fragile skin) to both upper extremities at all times as tolerated, on 12/01/18 she was ordered Dermasavers to both lower extremities at all times as tolerated, on 01/26/18 she was ordered bilateral soft heel boots when in bed as tolerated every shift to prevent breakdown, and on 11/08/18 she was ordered ace wraps to bilateral lower extremities in the morning and off at night. Resident #39's active comprehensive care plan revealed she was at risk of impaired skin integrity due to cognitive impairments, decreased mobility, edema, and fragile skin. Interventions to address this risk were ace wraps as ordered, bilateral soft heel boots when in bed, Dermasavers as ordered, and elevate heels off bed with pillow as tolerated. Observation on 04/15/19 at 2:20 P.M. and on 04/16/19 at 2:02 P.M. of Resident #39 lying in bed revealed her heels were not elevated with a pillow and she did not have Dermasavers, ace wraps, or soft heel boots on. Interview on 04/16/19 at 2:02 P.M. with Licensed Practical Nurse (LPN) #404 confirmed Resident #39's heels were not floated with a pillow, and she did not have Dermasavers to both lower extremities, ace wraps, or soft heel boots on as ordered. LPN #404 revealed the resident digs and digs at her legs. State Tested Nursing Assistant (STNA) #405 joined the interview and revealed Resident #39 did not have Dermasavers applied to her upper extremities. Observation on 04/17/19 at 7:30 A.M. of Resident #39's lower legs, revealed her right shin area had reddened areas and her skin was peeling. Interview on 04/17/19 at 7:35 A.M. with STNA #405 revealed there were not Dermasavers or heel boots in Resident #39's room on 04/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #103 was served her recommended diet and failed to offer timely assistance with eating. This affected one (Resident #103) of five residents reviewed for nutrition. Findings include: Resident #103 was admitted on [DATE] and readmitted on [DATE] with diagnoses including but not limited to nontraumatic subdural hemorrhage, need for assistance with personal care, dysphagia (difficulty swallowing), hypertension, anemia, history of urinary tract infections, and unspecified dementia without behavioral disturbance. Resident #103's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed she required extensive one person assistance with eating. Resident #103's active comprehensive care plan for an alteration in nutrition due to anemia, hypertension, dysphagia, hyponatremia, and weight loss revealed interventions to assist at meals to ensure adequate intake, encourage adequate fluid and oral intake, feed at meals to ensure adequate intake, and honor food preferences. Review of Resident #103's lunch meal ticket for service on 04/17/19 revealed she should receive four fluid ounces of cranberry juice and eight fluid ounces of whole milk with her meal. Observation on 04/17/19 at 12:35 P.M. revealed Resident #103 was served her meal and her head was down. The meal tray did not include four ounces of cranberry juice or eight ounces of whole milk. Observation on 04/17/19 at 12:53 P.M. revealed a staff member came to Resident #103's table but did not wake the resident up to eat. Resident #103 continued to sit with her head down and her food was untouched. Observation on 04/17/19 at 1:00 P.M. revealed a staff member questioned if everyone had ate, but did not come to observe Resident #103's plate that was untouched. Observation on 04/17/19 at 1:04 P.M. revealed a staff member was standing in the dining room, not attending to any resident needs, while Resident #103 continued to have her head down with food untouched. Observation on 04/17/19 at 1:10 P.M. revealed State Tested Nursing Assistant (STNA) #406 came to Resident #103's table to record meal intakes. Most resident were no longer in the dining room. STNA #406 woke Resident #103 up and offered to reheat her food, but the resident did not respond. STNA #406 offered the drink that was in front of the resident, and the resident stated not really. STNA #406 retrieved a nutritional mighty shake for the resident, and the resident put her head back down as if she were asleep again. From 12:35 P.M. to 1:10 P.M., no one had assisted the resident with her meal. Interview on 04/17/19 at 1:10 P.M. with STNA #406 confirmed Resident #103 had not touched her food, and confirmed she was not served cranberry juice or whole milk, according to her lunch meal ticket. STNA #406 revealed Resident #103 sometimes fed her self. Interview on 04/18/19 at 10:05 A.M. with Registered Dietician (RD) #501 and Dietary Technician #502 revealed Resident #103's level of feeding assistance had varied from needing a fair amount of assistance and according to the family the resident was able to feed her self now. RD #501 revealed the cranberry juice on the residents meal ticket was a preference. Dietary Technician #501 revealed on 03/13/19 Resident #103's milk was changed from two percent to whole milk because she was losing weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #54's record revealed an admission date of 01/31/17. Diagnoses included Alzheimer's disease. The significant change Minimum Data Assessment (MDS) assessment dated [DATE] revealed she had long and short-term memory problems and had severely impaired cognitive skills for decision making. Nurse's notes and physician's orders were silent for isolation precautions. Review of the change in condition assessment dated [DATE] revealed the hospice Certified Nurse Practitioner (CNP) confirmed a red, moist clustered rash under the left breast and back of Resident #54 was shingles. Observation on 04/15/19 at 5:05 P.M., of Resident #54's room revealed a yellow over the door isolation kit, a contact precaution sign outside the door, and a note on the door that read to see nurse prior to entering the room. Resident #54 was observed sitting in a Broda chair (a large padded wheelchair that can tilt) with a tray table in front of her. Stated Tested Nurse Aide (STNA) #409 was in the room without wearing a gown or gloves. Interview on 04/15/19 at approximately 5:06 P.M. with STNA #409 revealed she believed Resident #54 was on isolation precautions for shingles. STNA #409 stated she did not have to wear a gown when delivering trays, only if she was providing resident care. Review of the orange Contact Precaution sign on the door revealed, everyone must put on a gown and gloves at the door. Interview on 04/18/19 at 10:03 A.M. with Licensed Practical Nurse (LPN) #401 revealed the facility did not have a policy for contact precautions, but staff should be following the procedures on the sign. LPN #401 stated staff was supposed to wear a gown and gloves when entering a contact precaution room. Based on observation, interview, and record review the facility failed to follow transmission based precautions for Resident #151 and Resident #54. This affected two (Resident #151 and Resident #54) of six residents observed for transmission based precautions. Findings include: 1. Resident #151 was admitted on [DATE] with diagnoses including but not limited to intestinal obstruction, intestinal adhesions, incisional hernia with obstruction, diverticulitis, and surgical aftercare following surgery on the digestive system. Resident #151's Skilled Nursing Facility Admit/Readmit Screener admission assessment dated [DATE] revealed she had a right lower quad puncture wound. Resident #151's Skilled Nursing Observation dated 03/08/19 revealed a wound culture of abdomen was obtained. Resident #151's culture wound report dated 03/11/19 revealed she had heavy growth of enterobacter species carbapenem resistance enterobacteriaceae (CRE) and heavy growth of pseudomonas aeruginosa. Resident #151's Skilled Nursing Observation dated 03/11/19 revealed the resident was placed on contact precautions for enterobacter CRE bacteria in abdominal wound. Observation on 04/15/19 at 10:35 A.M. revealed Resident #115 had a personal protective equipment kit hanging over her door with a sign that indicated the need to see the nurse before entering the room. Interview on 04/15/19 at 10:35 A.M. with Registered Nurse #403 revealed Resident #115 had bacteria in her wound after a hernia mesh surgery and gown and gloves needed to be worn when in her room. Observation on 04/15/19 at 10:47 A.M. revealed State Tested Nursing Assistant (STNA) #402 walking into Resident #151's room without wearing any personal protective equipment. STNA #402 touched Resident #151's personal call pendant to turn it off. STNA #402 did not wash her hands with soap and water before leaving the resident's room. Interview with STNA #402 at this time confirmed she should have worn gown and gloves in Resident #151's room, but did not. Interview on 04/18/19 at 9:50 A.M. with Licensed Practical Nurse (LPN) #401, confirmed Resident #151 had contact precautions in place due to her wound culture showing enterbacter CRE, which was determined to be negative for carbapenemase production on 03/21/19. LPN #401 revealed on 03/25/19 it was discovered Resident #151 wound was colonized for both enterobacter and MRSA. LPN #401 revealed due to the size of the wound and the amount of organisms in her wound, she remained on contact precautions. LPN #401 confirmed Resident #151 had contact precautions in place on 04/15/19, and when in the resident's room a gown and gloves should be worn. LPN #401 revealed all individuals should wash their hands prior to exiting the room if they had contact with anything. LPN #401 revealed the facility did not have a specific transmission based precautions policy, as the precaution was posted on each resident's door that had precautions in place.

Based on observation, record review, and interview the facility failed to ensure the scoop sizes for the pureed food served from the servery for units one and two were correct according to the menu. This had the potential to affect seven residents, Residents #18, #68, #87, #32, #54, #60, and #73 who resided on unit two and received pureed foods. Findings include: Observation on 04/17/19 at 11:53 A.M. of the tray line service in the dementia unit servery for units one and two revealed;ed Dietary Aide (DA) #410 obtaining temperatures of the food on the steam table and Diet Technician (DT) #405 scooping approximately four small cups of pureed macaroni salad using a green handled scoop. Tray line service began a approximately 12:01 P.M. Observation at this time revealed DA #410 serve pureed corned beef sandwich using a green handled scoop and mashed potatoes using a gray handled scoop onto a plate. DA #410 handed the plate to the staff member to place on a tray on the cart for hall trays. DA #410 then grabbed one of the cups of pureed macaroni salads that was previously scooped and handed to the staff who placed it on the tray. Interview on 04/17/19 at approximately 12:16 P.M. with DT #405 verified both the green handled scoops in the pureed corned beef sandwich and pureed macaroni salad were #12. At this time review of the menu spreadsheet with DT #405 revealed the pureed corned beef sandwich should be served using a #6 scoop and the pureed macaroni salad should be served using a #8 scoop. DT #405 stated she was not sure if the pureed corned beef was just the meat or the whole sandwich. DT #405 stated she would get the correct scoop sizes and find out about the pureed corned beef. At approximately 12:20 P.M. DT #405 returned with the correct scoops and verified the pureed corned beef was the whole sandwich. At this time DA #410 indicated she had only served one pureed plate and would make it over using the correct scoops. Review of the facility's undated chart titled Scoop Sizes and Colors revealed the green handled scoop was a #12 which provided a three ounce serving and used for mechanical and pureed meat. The #6 scoop was a white handled scoop and provided a six ounce serving. The #6 scoop was used for casseroles and pureed sandwiches. The #8 scoop was gray handled scoop and provided a four ounce serving. The #8 scoop was used for starch and vegetables. Review of the facility's Resident Summary Report dated 04/17/19 revealed Residents #18, #68, #87, #32, #54, #60, and #73 resided on unit two and received pureed foods.

Based on observation, record review, and interview the facility failed to ensure the kitchen and nursing unit refrigeration were maintained in sanitary conditions and food was stored properly. This had the potential to affect all residents except one, Resident #128 who received nothing by mouth. Findings include: Tour of the kitchen on 04/15/19 from 9:22 A.M. to 9:52 A.M. with Chef Manager (CM) #408 and Diet Technician (DT) #405 revealed in the dry storage room a scoop was observed in a large clear container of dry brown rice. Two unopened loaves of frozen bread were observed on the freezer floor slightly underneath a rack. There was frost and ice buildup on the ceiling near both fans of the freezer. Observation of the Walk-in cooler revealed multiple squished grapes on the floor of the cooler near the back. There was an opened, unlabeled, and undated bag of green onions, red radishes wrapped in saran wrap that was undated and labeled, and a large size clear baggie of herbs that was unlabeled and undated. Interview with CM #408 on 04/15/19 between 9:22 A.M. to 9:52 A.M. verified the above findings. Tour of the nursing units on 04/15/19 from 9:56 A.M. to 10:16 A.M. with Dietary Manager #407 and DT #405 revealed on unit one the microwave behind the nursing station had a brownish spill. There was a large white refrigerator with a freezer. In the freezer was a large, opened container of ice cream that was half gone and a smaller container of ice cream. These containers of ice cream were not labeled or dated. DM #407 stated this refrigerator was for food brought in by visitors for the residents on the unit and should be labeled and dated. Observation of the unit three refrigerator revealed a sticky, clearish substance and multiple spill stains, a blue plastic bag of food that was undated and unlabeled, and two stands of dark colored hair on the bottom shelf of the refrigerator stuck in a sticky substance. Observation of unit four revealed the refrigerator had various dried food spills. The microwave located on the counter above the refrigerator was clean inside but underneath was a moderate amount of a dried, brownish stains and torn pieces of paper towel stuck in it. Observation of the unit five freezer revealed the it was full of frost and contained three, four ounce containers of ice cream that were covered in frost. The microwave located on the counter across from the freezer had dried food splatters. Interview on 04/15/19 between 9:56 A.M. to 10:16 A.M., DM #407 and DT #405 verified the above findings. DM #407 stated housekeeping was responsible for cleaning the nursing unit refrigerators and nursing was responsible for cleaning the microwaves. Review of the facility policy title Food Storage and Leftovers, reviewed 11/19/18 revealed both refrigerated and freezer storage units should be clean and free from moisture and ice buildup. All leftovers that were being stored for future service should be marked with a label that listed the food item and the date prepared. Review of the facility undated procedure for food storage titled How to Store Food Properly revealed best practices for storing food was to label and date all stored food.