**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure resident assessments were accurately documented for two (2) residents (R)42 and R100. The findings include: Review of R42's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Psychosis [a mental disorder characterized by a disconnection with reality], cognitive communication deficit, major depressive disorder, and anxiety disorder. R42 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A review of the Physician's Order dated 8/27/24, for R42 read, Hydroxyzine HCl Oral Tablet [an antianxiety medication] 10mg [milligram], give 10mg by mouth at bedtime for sleep. Order Type: Antianxiety Orders. A review of R42's Annual Minimum Data Set (MDS) assessment, dated 2/5/25, revealed the resident was not coded for taking an antianxiety medication, which was considered a high-risk medication [medications that when used in error can cause significant harm and require careful monitoring] on the MDS. A review of R100's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, diabetes mellitus, osteoporosis, and a cognitive communication deficit. R100 had a BIMS score of seven (7), which indicated moderate cognitive impairment. A review of the Physician's Order, dated 11/7/24, for R100 read, Admit to [Name of Hospice Agency]. The Quarterly MDS assessment, dated 2/14/25, for R100, revealed the resident was not coded for receiving Hospice services under Special Treatments, Procedures, and Programs. During an interview, on 3/27/25 at 11:08 a.m., the MDS Coordinator (MDSC) reviewed the Annual MDS dated [DATE] for R42 and confirmed that the assessment for high-risk medications was not accurate. The MDSC stated, It should have been coded 'yes' under the antianxiety [medication] class on the MDS. [sic] The MDSC reviewed the Physician's Order, dated 8/27/24, and confirmed that R42 was prescribed an antianxiety medication during the Annual MDS assessment. For R100, the MDSC confirmed that Hospice was not coded on the Quarterly MDS assessment, dated 2/14/25. The MDSC stated, [R100 name] was on Hospice at the time of the Quarterly MDS assessment. S/he should have been coded for Hospice, but s/he wasn't. I'll have to modify the MDS. The MDSC confirmed that there was no facility policy for MDS assessments. The MDSC stated, I have the MDS 3.0 User's Manual, but I also use the online version of RAI [Resident Assessment Instrument] linked to the medical record, due to the constant updates. [sic] During an interview, on 3/27/25 at 12:42 p.m., the Administrator confirmed that resident assessments needed to be accurate on the MDS. The Administrator stated, I expect the assessments to be reported accurately when signing and submitting them. We don't have a policy for MDS or RAI, we use the online manual linked to the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that respiratory equipment was appropriately stored according to professional standards of practice for one (1) of one (1) resident sampled for respiratory care, Resident (R)54. The findings include: Review of the undated facility policy titled, Oxygen Administration, noted: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. d. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. e. Keep delivery devices covered in a plastic bag when not in use. [sic] A review of R54's clinical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease [a group of lung diseases that block airflow and make it difficult to breathe], Dementia, and malignant neoplasm of the nasal cavity [a cancerous tumor of the nasal cavity]. R54's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated moderate cognitive impairment. Review of the Physician's Order for R54, dated 11/20/24, read, Albuterol Sulfate Nebulization Solution [medication used in nebulizers to deliver medication into the lungs in the form of a fine mist] (2.5MG [milligram]/3ML [milliliter]) 0.083% [percent], 3ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath. [sic] During an observation, on 3/25/25 at 11:36 a.m., R54 was lying in his/her bed, awake. There was a nebulizer device on the right front corner of the nightstand against the wall to the right of the resident's bed. The nebulizer tubing was connected to the nebulizer device, uncovered and hanging down over the nightstand, and coiled up on the floor. The nebulizer mouthpiece was detached from the nebulizer tubing and laying on the nightstand uncovered. There was no nebulizer equipment storage container observed at the bedside or in R54's room. During an observation, on 3/26/25 at 1:45 p.m., R54 was lying in bed awake. There was a nebulizer device on the right front corner of the nightstand against the wall to the right of the resident's bed. The nebulizer tubing was connected to the nebulizer device, uncovered and hanging down over the nightstand, and coiled up on the floor. The nebulizer mouthpiece was detached from the nebulizer tubing and laying on the nightstand uncovered. There was no nebulizer equipment storage container observed at the bedside or in R54's room. During an interview, on 3/26/25 at 1:49 p.m., R54 stated, that's my breathing treatment equipment (pointing to the nebulizer device and equipment on the nightstand). I don't use it very often. I use it when I can't breathe. I haven't used it for a while. During an interview, on 3/26/25 at 1:50 p.m., Licensed Practical Nurse (LPN)3 entered R54's room and stated, Oh, that tubing shouldn't be on the floor like that. It needs to be in a bag when not in use. The mouthpiece shouldn't be left out like that. After a breathing treatment, the staff should rinse the container out and put it back in the bag with the tubing. The bag should be dated. We change the tubing and mouthpiece weekly on Sundays and as needed. I'm going to throw the tubing and mouthpiece away because it's contaminated. I'm not sure if s/he even needs the treatments anymore. [sic] During an interview, on 3/27/25 at 12:40 p.m., the Director of Nursing (DON) confirmed that nebulizer tubing should not be on the floor and that the nebulizer mouthpiece and tubing should be in a storage container when not in use to prevent contamination. The DON stated, the expectation is that the nebulizer tubing and mouthpiece be kept in a plastic bag when not in use. We change it out each week on Tuesdays, I think, and as needed. I don't require the staff to date the bag or tubing because we are consistent with changing the bag and supplies out each week. [sic]

Based on interview, record review and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three of three residents (Resident (R)7, R52, and R78) reviewed for no Minimum Data Set (MDS) assessment in over 120 days had a quarterly assessment successfully transmitted and accepted within the allotted time frame as stated in the RAI manual. Findings include: Review of the October 2019 RAI page 2-20 revealed: The MDS must be transmitted (submitted and accepted into the . system) electronically no later than 14 calendar days after the care plan completion date . Page 2-33 revealed: The Quarterly assessment is an . non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous . assessment of any type. The ARD . must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Page 5-5 revealed: Fatal Record Errors result in rejection of individual records by the . system. The provider is informed of Fatal Record Errors on the Final Validation Report. Rejected records must be corrected and resubmitted, unless the Fatal Error is due to submission of a duplicate assessment. Review of R7's electronic medical record (EMR) MDS tab revealed the last processed MDS was dated 07/20/23. A quarterly MDS with an Assessment Reference Date of 10/17/23, history showed the assessment was rejected on 11/06/23 and 11/28/23. Review of R52's EMR MDS tab revealed the last processed MDS had an ARD of 07/19/23. A quarterly MDS with an ARD of 10/17/23, history showed it was rejected on 11/06/23 and 11/28/23. Review of R78's EMR MDS tab revealed the last processed MDS had an ARD of 07/23/23. A quarterly MDS with an ARD 10/18/23 history showed it was rejected on 11/06/23 and 11/28/23. During an interview on 12/28/23 at 3:07 PM, the MDS Coordinator (MDSC) reviewed the three rejected MDS assessments on the 11/06/23 and 11/28/23 Final Validation Report and stated the Regional MDSC reviews the rejection reports and emails her what needs to be fixed and she would fix it, but she was not notified of the three assessments referenced. The MDSC confirmed the three MDS assessments did not have an accepted status and they are late. During an interview on 12/29/23 at 3:16 PM, the Director of Nursing (DON) expressed an expectation that MDS assessments should be completed within the time guidelines. When asked if any MDS assessments should be over 120 days between assessments, the DON responded Oh no.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to provide an accurate resident assessment regarding a Level II screening of a Pre-admission Screening and Resident Review (PASRR) on an admission Minimum Data Set (MDS) assessment for 1 of 2 residents (Resident (R) 28) reviewed for PASRR. Findings include: Review of the October 2019 RAI Manual, page A-22 and A-23 revealed: Coding Instructions .Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, ., Level II Preadmission Screening and Resident Review (PASRR) Conditions. Review of R28's printed admission Record in the electronic medical record (EMR) under the Profile tab showed an admission date of 06/07/21 with medical diagnoses including but not limited to: bipolar disorder and major depressive disorder. Review of R28's EMR Misc (Miscellaneous) tab showed a level I PASRR completed on 02/16/21; and a Level II PASRR that was also completed on 02/16/21. Review of the annual MDS from the EMR MDS tab showed the comprehensive assessment reference dates (ARD) of 03/05/23 which indicated, A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The question was coded No which disabled the next question as to R28's mental health needs. During an interview on 12/28/23 at 4:26 PM regarding R28's MDS dated 03/05/23 and the Level II PASRR screening question and response, the MDS Coordinator (MDSC) confirmed she was the one that completed section A. The MDSC reviewed R28's Level II PASRR, and stated, I didn't know he had a level II [PASRR] and confirmed the PASRR II should have been coded accurately on the MDS. During an interview on 12/29/23 at 3:16 PM regarding the Level II PASRR, the Director of Nursing (DON) stated, I expect assessments to be accurate, and that if there is a PASRR II, that it is coded accurately on the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, review of the Resident Assessment Instrument (RAI) Manual and interviews, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for 1 of 27 residents reviewed for care plans. Specifically, the facility failed to develop a care plan that addressed cognition/dementia health problems for Resident (R)76. Failure to develop the care plan could result in the resident not receiving care and services. Findings include: Review the undated facility policy titled, Comprehensive Care Plans provided by the facility indicated . The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. Review of the Minimum Data Set (MDS) 3.0 RAI Manual , dated 10/19, indicated, . The Care Area Assessment (CAA) process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident . Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment .it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as 'triggered care areas,' which form a critical link between the MDS and decisions about care planning . Review of a document provided by the facility titled admission Record for R76 indicated the resident was admitted to the facility on [DATE]. Review of R76's electronic medical record (EMR) titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/23 indicated the R76 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R76 was moderately cognitively impaired. Under the Care Area Assessment (CAA) the resident triggered for cognition/dementia and directed the clinical staff to develop a care plan. Review of R76's Care Plan provided by the facility, failed to contain evidence the resident was care planned for cognition/dementia. During an interview on 12/29/23 at 8:33 AM, the MDS Coordinator confirmed she did not develop a care plan for cognition/dementia for R76. During an interview on 12/29/23 at 8:39 AM, the Administrator, Regional Director of Clinical Services and the Director of Nursing stated it was their expectation to develop a care plan if the area was triggered on the resident's CAA.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure 1 (Resident (R)88) of 4 dependent residents reviewed for activities of daily living (ADL), was provided with adequate nail care. Findings include: Review of the undated facility policy titled Activities of Daily Living (ADLs) revealed: Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . During an observation and interview on 12/27/23 at 4:07 PM, R88 stated he has asked the staff to trim his fingernails. Observation of R88's hands revealed the fingernails were approximately 1/4 inch past the tips of his fingers. Review of R88's printed Care Plan from the electronic medical record (EMR) Care Plan tab revealed, ADL Care Plan: Focus: [R88's name] requires assist with ADLS R/T [related to] cognition, recent CVA [stroke] .Goal: Resident will have ADL needs met daily with appropriate assist through next review. Interventions: . Resident needs mod [moderate] assist of 1 for personal hygiene . During an observation and interview on 12/29/23 at 10:57 AM, R88's fingernails remained long and R88 stated he needed his fingernails trimmed. During an observation and interview on 12/29/23 at 11:00 AM, Certified Nurse Aide (CNA)3 looked at R88's fingernails and confirmed they were long. CNA3 stated, He's hospice. They do the showers and clean his nails. During an interview on 12/29/23 at 11:04 AM, Licensed Practical Nurse (LPN)4 stated, We do it and they do it. I know I asked him last Friday [12/22/23], and he refused care. During an observation and interview on 12/29/23 at 11:10 AM, LPN4 was trimming R88's left hand and stated, They need to be cut. During an interview on 12/29/23 at 11:50 AM, the Administrator stated an expectation that nail care was provided as needed and the facility had no specific policy on nail care. During an interview on 12/29/23 at 1:53 PM, the hospice team coordinator stated, I verified this with the Clinical Supervisor that we do not do that here. We are supplemental care and that nail trimming would be the facility's or family's responsibility. During an interview on 12/29/23 at 3:18 PM, the Director of Nursing (DON) stated, He came in with those nails. We expect that nail care is provided and if refused, staff should walk away and go back to attempt again.

Based on observation, interview, and manufacturer's instructions for use (MIFU), the facility failed to ensure a medication administration error rate under five percent, with 2 errors for 2 (Residents (R)11 and R68) out of a possible 25 opportunities. This resulted in an error rate of 8 percent (%). Specifically, 2 Licensed Practical Nurses (LPN)1 and LPN2 failed to prime (to remove any bubbles from the needle and cartridge to ensure that the pen is working correctly so the insulin given is not too much or too little) insulin injection pens prior to the administration of the insulin. Findings include: Review of the MIFU for the glargine insulin pen documented: .STEP 3. PERFORM A SAFETY TEST Dial a test dose of 2 Units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle . Review of the MIFU for the Novolog documented: .Priming your NovoLog FlexTouch Pen: Step 7: Turn the dose selector to select 2 units Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter show 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. If you still do not see a drop of insulin, change the needle, and repeat steps 7 to 9. During a medication administration observation on 12/29/23 at 8:38 AM, LPN1 was observed to attach a needle to R11's insulin glargine (a long-acting modified form of medical insulin, used in the management of type I and type II diabetes) and dialed a 24-unit dose without priming the insulin injection pen. Review of the Order Summary from the electronic medical record (EMR) Reports tab showed a physician's order dated 10/18/23 for insulin glargine 24 unit of a 100 unit/milliliter solution twice a day for diabetes. During an interview on 12/29/23 at 8:44 AM, LPN1 stated, No, I don't prime. There are no air bubbles [showed insulin pen to surveyor] so I don't have to prime. During an observation of medication administration on 12/29/23 at 11:30 AM, LPN2 attached a needle to R68's Novolog (a fast-acting insulin used to manage blood sugar levels in adults with type 1 or type 2 diabetes) insulin pen and dialed a six-unit dose for a blood glucose of 354 without priming the insulin pen. Review of the Order Summary from the EMR Reports tab showed a physician's order, dated 04/12/23, for Novolog 100 units/milliliter solution with a sliding scale that showed for a blood glucose level of 354, six units Novolog should be administered for a diagnosis of diabetes. During an interview on 12/29/23 at 11:45 AM, LPN2 stated, I thought these were single use, the needle engages and when it's released it becomes a safety needle. So, I don't know how you would do that. LPN3, who was at the medication cart next to LPN2's medication cart stated, she means prime like this and dialed two units and depressed insulin pen injection button. When asked if the facility had taught her this, LPN3 stated, No, I knew that from another facility. It was verified with both LPNs, the facility had not instructed either LPN on priming insulin pen prior to use. During an interview on 12/29/23 at 3:20 PM, the Director of Nursing (DON) stated an expectation that staff follow manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 2 of 5 residents reviewed for pneumonia vaccinations (Resident (R) 21 and R60) and/or their representatives, the opportunity to be vaccinated in accordance with nationally recognized standards. Specifically, the facility failed to offer R21 and R60 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Prevnar 20 (PCV 20) in accordance with nationally recognized standards. The failed practice had the potential to increase the risk for these residents to contract pneumonia. Findings include: Review of the Center of Disease Control website under the link titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, last reviewed 01/24/22, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccination] one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults 65 years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . The CDC guidelines went into effect on 10/21/21 per recommendations from the Advisory Committee on Immunization Practices (ACIP). Review of the facility's undated policy titled Pneumococcal Vaccine (Series) indicated, .It is our policy to offer our residents . immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.The type of pneumococcal vaccine (PCV13, PPSV23/PPSC) offered will depend upon the resident's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations . 1. Review of a document provided by the facility titled admission Record, indicated R21 was admitted to the facility on [DATE]. The resident was [AGE] years of age at the time of admission. Review of a document provided by the facility titled Immunization Report indicated R21 received PPSV23 on 01/06/20. There was no evidence the resident was offered either the PCV15 or PCV20. 2. Review of a document provided by the facility titled admission Record indicated R60 was admitted to the facility on [DATE]. The resident was [AGE] years of age at the time of admission. Review of a document provided by the facility titled Immunization Report indicated R21 received PPSV23 on 10/23/20. There was no evidence the resident was offered either the PCV15 or PCV20. During an interview on 12/28/23 at 3:37 PM, the Medical Director stated he was not aware of the current CDC recommendations regarding pneumococcal vaccinations. During an interview with the Infection Preventionist (IP), Administrator, and Director of Nursing on 12/29/23 at 1:00 PM, the IP stated she was not aware of the current CDC recommendations for the pneumococcal vaccine.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure food was palatable for 9 out of 93 residents (Residents (R)76, R36, R38, R91, R89, R60, R69, and two residents who received pureed diets R59 and R44). Specifically, the vegetables for the regular diet were faded and soggy in appearance and residents did not receive salt, pepper, or margarine for their rolls. The pureed food was bland, pasty and lacked flavor. Residents reported the food was not served hot, the vegetables were overcooked, and condiments and margarine were not served. Findings include: Review of the facility's policy titled, Standardized Menus dated 2020 revealed, The facility shall provide nourishing, palatable meals to meet the nutritional need of the residents . The facility will make reasonable efforts to provide food that is appetizing . 1. Residents and/or families expressed concerns regarding the palatability of the food: a. During an interview on 12/27/23 at 1:36 PM, R76 stated the food did not taste good and was not hot. Review of R76's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/23 in the electronic medical record (EMR) under the MDS tab revealed R76 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. b. During an interview on 12/27/23 at 1:50 PM, a family member who wished to remain anonymous stated R36 received pureed foods, and the food was bland. Review of R36's admission MDS with an ARD of 11/29/23 in the EMR under the MDS tab revealed a BIMS score of 6 out of 15 which indicated the resident's cognition was severely impaired. c. During an interview on 12/27/23 at 12:30 PM, R91 stated the vegetables were soggy. R89 who was also present stated on 12/27/23 at 12:30 PM that the vegetables were too soft. Review of R91's admission MDS with an ARD of 11/24/23 in the EMR under the MDS tab revealed R91 was intact in cognition with a BIMS score of 15 out of 15. Review of R89's admission MDS with an ARD of 10/20/23 in the EMR under the MDS tab revealed R89 was intact in cognition with a BIMS score of 15 out of 15. 2. Review of the Resident Council Meeting Minutes dated 11/22/23 and provided by the facility revealed, Residents states when get food, it [sic] not warm. 3. Review of the Daily Spreadsheet, Week 2 Wednesday provided by the facility revealed lunch on 12/27/23 consisted of spaghetti noodles with meat sauce, Italian blend vegetables, dinner roll, margarine, brownie, and condiments (1 each packet of salt and pepper). During observations of the lunch meal service on the third floor on 12/27/23 from 12:06 PM -12:40 PM revealed, the Italian vegetables were faded in color with a soggy appearance. All menu items, consisting of spaghetti with meat sauce, Italian vegetables, dinner roll, were served on the same plate. Residents were not served margarine with their dinner rolls and only three residents were served salt and pepper. Thirty-two residents were noted having lunch on the third floor. During an interview on 12/27/23 at 12:15 PM, R60, who was eating in the dining room, stated if he wanted salt and pepper, he had to ask for it and R60 then verified he was not offered margarine with his roll but would eat it if offered. Review of R60's quarterly MDS with an ARD of 12/07/23 in the EMR under the MDS tab revealed R60 was moderately impaired in cognition with a BIMS score of 9 out of 15. During an interview on 12/27/23 at 12:17 PM, R69, who was eating in the dining room, stated the staff did not offer salt and pepper or margarine. Review of R69's admission MDS with an ARD of 12/15/23 in the EMR under the MDS tab revealed R69 was moderately impaired in cognition with a BIMS of 12 out of 15. During an interview on 12/27/23 at 12:17 PM, R38 stated although she liked margarine with rolls, she was used to not having it. R38 stated it would be nice if they offered it (margarine). 4. Review of the Daily Spreadsheet, Week 2 Thursday provided by the facility revealed lunch on 12/28/23 consisted of roasted chicken, baked sweet potatoes, broccoli, dinner roll, margarine, sugar cookie, and condiments (one each). During observations of meal service on 12/28/23 from 12:40 PM - 1:24 PM on the first floor. The meal consisted of baked chicken, broccoli, yams, and roll, all served on the same dinner plate. The broccoli was faded and soggy in appearance, residents were not offered margarine, salt, or pepper with their meals. During an interview on 12:28/23 at 1:05 PM, R76 stated that her meal was hot today, which was unusual. She further stated there was no margarine offered and she would use it if she had it. On 12/28/23 at 1:15 PM a test tray of a regular diet and pureed diet was evaluated with the Dietary Manager (DM). The following was observed: The roll on the regular diet test tray was soggy/doughy due to the liquid on the plate from the broccoli. The broccoli was mushy and not flavorful. The DM stated the broccoli was overcooked and verified the roll was soggy. The pureed foods consisting of pureed chicken, pureed broccoli, and pureed yams were faded in color from the colors of the regular foods and were shiny in appearance. Each of the pureed foods lacked flavor of the original foods and were bland and unappetizing. The DM verified the observations of the pureed test tray and the taste of the food. The DM stated that too much thickener might have been added to the pureed foods. The DM stated the dietary staff did not use many seasonings when cooking. The DM verified neither salt, pepper, nor margarine had been served to residents on the first floor. She stated there were salt and pepper packets available and showed the Surveyor a container where they were stored in the dining room. The DM stated the dietary staff were supposed to send up individual margarine packets for the rolls, but she could not find any. The DM stated the nursing staff were supposed to serve the salt and pepper packets. Review of the quarterly MDS dated 11/22/23 in the EMR under the MDS tab revealed R59's BIMS score of 5 out of 15 indicating R59 had severely impaired cognition. Review of the Diet Orders report provided by the facility revealed R59 was prescribed a pureed diet. Review of the quarterly MDS dated 11/08/23 in the EMR under the MDS tab revealed R44's BIMS score of 0 out of 15 indicating R44 had severely impaired cognition. Review of the Diet Orders report provided by the facility revealed R59 was prescribed a pureed diet. During an interview on 12/28/23 at 1:24 PM, Certified Nursing Assistant (CNA)5 stated the CNAs only passed out salt and pepper packets to residents if the residents asked for them. Review of the Registered Dietitian (RD)'s Consultant Dietitian Report dated 06/28/23, provided by the facility revealed an identified concern which indicated: Consider vegetables in small bowl or roll served separately; dinner roll soggy due to broccoli. During an interview on 12/29/23 at 9:03 AM, CNA4, who worked on the third floor, stated she passed out salt and pepper packets to residents at meals only if they asked for them. CNA4 stated they did not offer or serve margarine with bread. During an interview on 12/29/23 at 1:01 PM, the RD stated concerns with food temperatures had come to her attention and issues with the availability of nursing staff to serve had been identified. The RD stated she received palatability complaints and worked with individual residents and dietary staff to address their preferences. The RD further stated she had made a recommendation for the dietary staff to serve bread/rolls on a separate plate or in a manner so the rolls would not become soggy from the water with the vegetables. The RD concluded that everything on the menu directed to be served including margarine packets, salt and pepper packets should be included on each resident's tray.

Based on observation, interview, record review, review of the Food Code U.S. Food and Drug Administration, manufacturer's guidance and facility policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and sanitation practices were in place to prevent the potential spread of food borne illness to 92 out of 93 residents (one resident received nutrition via a feeding tube). Specifically, dietary carts, buckets, garbage can had a heavy accumulation of food or grime; a plastic basin, located under the handwashing sink had an accumulation of dirt and green tinged water within the basin; shelves for the storage of clean pots were rusted; plastic bags of leftovers were in the refrigerator were not labeled with the food item in the bag or the date the food was placed in the refrigerator; the cook used unlabeled undated leftover food as alternates on the steam table; the dietary aide was not aware of the amount of time to immerse the pots and pans in the third compartment sink sanitizer solution; and the cook directly touched the rolls with a gloved hand that had been contaminated by touching other surfaces in the kitchen while adding the roll to the resident's plate during a meal observation. Findings include: The facility policy for glove use in the dietary department was requested on 12/28/23. No policy for glove use was provided. Review of the undated facility's policy titled, Handwashing Guidelines for Dietary Employees revealed, Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses . Frequency of handwashing: Dietary employees shall clean their hands . after engaging in any activity that may contaminate the hands . Review of the undated facility's policy titled, Sanitation Inspection provided by the facility revealed, All food service areas shall be kept clean, sanitary, . Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, . daily . b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. Review of the Food Code U.S. Food and Drug Administration dated 2022, 3-6 Food Identity, Presentation, and on Premises Labeling, 3-602 page 102, revealed, Food Labels. (A) Food packaged . Label information shall include: (1) the common name of the food . Review of the Manufacturer's Quick San 10 Specification Sheet found at https://support.sunburstresults.com/wp-content/uploads/sites/2/2018/09/Quick-San-10_Spec-Sheet_V11_Haz.pdf, revealed the food contact surface sanitizing performance time requirement was one minute. 1. During the initial kitchen inspection on 12/27/23 from 9:38 AM through 10:05 AM, the following concerns noted: a. A small utility cart with bottom and upper shelves was observed to be heavily soiled with accumulated food and beverage residue covering approximately one third of the surface of both the upper and lower shelves. Boxes and opened cans of food were observed on the cart. The cart was in the pot washing area. b. Two shelves, located near the pot washing area, were observed to be rusted along the edges and surfaces of the shelves. There were inverted pots and pans resting directly on the rusted surfaces. c. A plastic basin located on the floor underneath the handwashing sink. It was heavily soiled with black grime and residue. d. The garbage can lid for the garbage can in the handwashing sink area was heavily soiled with food spills, splatters, and accumulated grime and dust. e. A plastic bucket located on the floor under the pot washing sinks that was heavily soiled with black residue on the interior and exterior surfaces. f. Observation and interview with Cook1 revealed, Cook1 was preparing lunch and there were several Ziploc bags with leftovers on the counter. Cook1 stated these were going to be the alternates for lunch today. One of the bags contained noodles and Cook1 stated it was chicken noodle casserole. There was no label on the bag indicating what the contents were or when it had been placed in the walk-in or when the use-by date was. Cook1 verified there was no date on the bag and stated she thought it had been in the walk-in a few days. Cook1 stated it should have been labeled with the food item and date. g. Inside the walk-in refrigerator, there was a food storage container in which diced red peppers in liquid were observed. The date on the container was 12/17/23. h. There was a full-sized steamtable pan with cubed chicken in broth covered with plastic wrap. There was a large chunk of ham that had been opened and had been wrapped in plastic wrap on top of the plastic wrap. The ham had fallen into the solution of chicken and broth. The ham was partially submerged in the chicken and broth. 2. A follow up kitchen inspection was conducted on 12/28/23 from 11:28 AM through 12:25 PM with the Dietary Manager (DM) present, and the following concerns were noted: a. A plastic basin, located under the handwashing sink, was observed with accumulated dirt, and green tinged water within the basin. b. The utility cart observed on 12/27/23 continued to be heavily soiled with the same food residue covering approximately one third of the horizontal surfaces. There were boxes and opened cans with the food contents removed from the cart. The DM stated the cart was used to transport garbage. The cart was in the pot washing area. c. The rusted shelves in the pot washing area continued to be rusted and had inverted pots and pans touching the rusted surfaces. The DM stated contact paper had been applied but had worn though. The DM verified the pots and pans were sitting directly on the rusted surface and that a rusted surface could not be adequately cleaned. d. The soiled plastic basin continued to be located under the handwashing sink. The DM stated the sink had leaked at one time and although it no longer leaked, the basin had not been removed. e. The garbage can lid for the garbage can in the handwashing area continued to be heavily soiled with food, beverage residue and grime. The DM stated it needed to be cleaned. f. The container of diced red peppers dated 12/17/23 remained in the walk-in refrigerator. The DM stated all leftovers should be identified by the name of the food and there should be two dates documented, the date it was placed in the walk-in and the date it should be used by. The DM stated leftover should be used within three days. g. The interior of the microwave oven was observed to have a significant amount of rust along the inside seams. This was verified by the DM. h. Dietary Aide (DA)1 initiated washing pots and pans using the three compartment sink, wash, rinse, and sanitize method. DA1 washed utensils, pots, and pans for several minutes by washing in the first sink, dunking in the second rinse sink, and dunking in the third sanitizer sink. DA1 stated on 12/28/23 at 12:22 PM, that there was no requirement to immerse the pots and pans in the sanitizer solution for any specific period. DA1 continued to wash pots and pans for several more minutes using the same procedure until the DM was interviewed. The DM stated at 12:25 PM, that pots and pans should sit in the sanitizer solution for a minute or two; however, there was no specific time requirement regarding how long was necessary to adequately sanitize. 3. During an observation on 12/28/23 from 12:40 PM through 1:10 PM, the first-floor steam table meal service was observed for 24 residents who resided on the first floor. Cook1 plated all the foods onto residents' plates from the steamtable which included chicken, broccoli, yams, and rolls. There was no utensil to serve the rolls. Cook1 served all the rolls with a gloved hand. With the same gloved hand, she touched the utensil handles, paper tray cards, plates, counter, and other surfaces in between touching each roll. In addition, Cook1 touched pieces of chicken with the same gloved hand to center them on the plates. The rolls and chicken were ready to eat food items. At the end of tray line meal service at approximately 1:10 PM, Cook1 was interviewed and verified she touched the rolls and multiple other things (scoops, tray cards, etc.) with the same gloved hand and this created the potential for cross contamination. The DM was interviewed and verified there was no utensil for serving the rolls observed on the tray line and stated tongs should be used for serving the rolls. During an interview on 12/28/23 at 1:11 PM, the Registered Dietitian (RD) stated ready to eat foods such as rolls should be served using tongs, if the same gloves touched other objects besides the rolls. The RD stated she had conducted inspections in the kitchen for sanitation occasionally when she had time. The RD further stated she had identified sanitation concerns in the dietary department which she had documented in her reports. During a follow up interview on 12/29/23 at 1:01 PM, the RD stated she had observed sanitation issues in the kitchen on her inspections including unclean equipment, areas of grime and dirt, and issues with labeling and dating foods. The RD stated leftovers should be discarded within three days after being placed in the walk-in refrigerator. The RD verified rust was not a cleanable surface and that microwaves had been discarded on the nursing units due to being rusted inside. Review of the RD's Consultant Dietitian Report dated 06/28/23 and provided by the facility revealed correction was needed for cleanliness of the stove, floor, shelves, walk-in refrigerator, walls, fans/vent/ducts, and ice machine. Additionally, the report revealed bacon was not dated and foods should be labeled when opened. Review of the undated Kitchen Cleaning Schedule provided by the facility revealed the carts should be deep cleaned once a week; the walk-in refrigerator dates and labels should be checked daily; the trash cans and lids should be cleaned once a week; carts should be cleaned weekly; and the kitchen should be swept and mopped daily. Review of the Kitchen Cleaning Schedule for November 2023 and December 2023 (through 12/28/23) revealed the sign off assignments was completed approximately half of the time in November and two thirds of the time in December 2023. The remaining assignments were blank. During an interview on 12/28/23 at 5:20 PM, the Administrator stated there had been issues with dietary staff completing the cleaning schedules/cleaning in kitchen. The Administrator stated the December cleaning schedule was still incomplete.