Based on review of facility policy, record review, observation, and interview, the facility failed to ensure that Resident (R)17 had an active order for the use of a Cervical Thoracic Orthosis (CTO) neck brace, for 1 of 1 resident reviewed for positioning/range of motion (ROM). Findings include: Review of the facility policy titled, Medication and Treatment Orders, with a last revision date of July 2016, documented, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility policy titled, Assistive Devices and Equipment, with a last revision date of February 2014, documented, Our facility maintains and supervises the use of assistive devices and equipment for residents. The policy also documented, The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment: a. Appropriateness for resident condition; b. Personal fit; c. Device condition; d. Staff practices. Review of R17's Face Sheet revealed that R17 was admitted to the facility with diagnoses including, but not limited to: Traumatic Subarachnoid Hemorrhage Without Loss of Consciousness, Intracranial Injury with Loss of Consciousness, Epidural Hemorrhage with Loss of Consciousness, Nontraumatic Subarachnoid Hemorrhage, Nondisplaced Fracture of the 2nd Cervical Vertebra, Multiple Fractures of Ribs, Left Side, Stable Burst Fracture of the Fourth Thoracic Vertebra, and Stable Burst Fracture of the Third Thoracic Vertebra. Review of R17's undated Care Plan documented ADL - [R17] relays a goal to improve her abilities in self-care. She has difficulties with movement, generalized weakness, and unsteady balance due to a recent hospitalization from a fall from her attic (about 15 feet) directly onto her head. This caused significant injuries, including subarachnoid hemorrhage, scalp laceration, left frontoparietal cranial fracture, epidural hematoma, left C2 lamina fracture, left rib fractures (1st, 3rd, 4th, 9th), left pneumothorax, L4 pars defect of unknown chronicity, and a three-column fracture at T3-T4. She has a CTO brace that should remain in place to prevent extreme changes in the position of the neck. She also prefers to lie flat for comfort, but this causes headaches. She was treated for her acute needs at the hospital but remains fatigued and restricted in her movements, requiring staff assistance with transfers, toileting, and incontinence care. She was referred to rehab to improve her functional activities without physical assistance, address impaired dynamic and static balance, and improve strength and balance. Review of the Prisma Health Progress Note with a visit date of 02/24/25, revealed the patient was admitted to the hospital for multiple traumas, including Traumatic Brain Injury (TBI), Subdural and Subarachnoid Hemorrhage (brain bleed), multiple broken ribs, and a spinal fracture. Additionally, the document revealed, 2/24/25 Continue CTO [Cervical Thoracic Orthosis] brace for 3 months. Review of R17's Orders on 03/10/25 at 3:00 PM, did not reveal an active order for the use and/or indication for a CTO brace. During an interview on 03/09/25 at 12:42 PM, R17 revealed that she suffered a head-first fall at home, resulting in multiple fractures to her spine, neck, and ribs. The resident stated she was hospitalized for treatment and sent to the facility for rehab. She was told to leave her neck brace on until she sees her spinal doctor and neuro team later in the week. The resident indicated that she wears the brace at all times except when bathing. During an interview on 03/11/25 at approximately 4:30 PM, with Registered Nurse (RN)1 and Interim Director of Nursing (DON). RN1 stated that it was her understanding that R17 should have her CTO brace on at all times. An observation was made with RN1 and the DON of the resident's current order set, and no active order could be found in regard to the use and rationale for the use of R17's CTO brace. The DON acknowledged that the lack of an order could potentially lead to safety concerns and possible harm to the resident. The DON also stated that an order should have been placed for the CTO brace use. During an interview on 03/11/25 at 5:23 PM, the Medical Director (MD)1 stated based on R17's hospital discharge instructions, the CTO brace should be worn at all times until the resident is seen by the neurosurgeon on 03/13/25. MD1 thought there was an order in place for R17's CTO brace in the electronic health record (EHR). MD1 explained that the resident should have an order for the CTO brace to ensure resident safety and protect the resident from further injury. MD1 further explained that typically, the admissions nurse is responsible for reviewing hospital discharge paperwork and transferring any relevant orders to the resident's EHR under the medical director's name. During an interview on 03/11/25 at 5:32 PM, RN2, who serves as the admissions nurse, stated that when a resident is admitted from the hospital, she is responsible for ensuring that any medications and treatment orders specified by hospital providers are entered into the resident's EHR. The admissions nurse will place the orders under the MD's name. RN2 recalled reading a note from the hospital that stated the resident needed to wear the brace at all times. RN2 explained that when the resident was admitted , she was handling four other admissions simultaneously, and the order for the CTO brace was not entered into the system, possibly because it was overlooked. RN2 believes the order for the CTO brace should have been placed upon admission. During an interview on 03/11/25 at 5:44 PM, the Executive Director (ED) confirmed that, based on the admissions nurse's role in ensuring that orders are properly placed during admission, proper procedures were not followed, and the order for R17's CTO brace should have been placed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to ensure proper handling and transportation of resident laundry for 1 of 1 residents observed. Findings include: Review of the facility policy titled, Laundry and Bedding, Soiled, documents, Policy Interpretation and Implementation Transport . 5. Separate carts are used for transporting clean and contaminated linen. Otherwise, carts that are used for transport of dirty linen are thoroughly cleaned and disinfected before being used to transport clean linen. 6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness . Storage 1. Clean linen is stored separately, away from soiled linens, at all times. During an observation on 03/11/25 at 11:35 AM, the Laundry Attendant removed covered dirty linen basket from room [ROOM NUMBER]. Laundry Attendant took the dirty linen basket to the hallway outside of the laundry room. The laundry attendant donned gloves and removed clean linen from the dryer. She folded a pair of pants and a blanket and placed the clean laundry on top of the resident's dirty linen basket. The laundry attendant did not clean and disinfect the dirty linen basket before placing the clean linen on top of the dirty laundry basket. The Laundry Attendant removed her gloves. She donned an apron and a new pair of gloves. She removed the soiled laundry from the dirty linen basket and placed it in the washing machine. The washing machine was started. The clean linen was transported back to the resident's room uncovered, on top of the dirty linen basket. The Laundry Attendant confirmed that she always transports linen like this. During an interview on 03/11/25 at 12:13 PM, the Director of Facilities revealed that dirty linen should be bagged, sealed off and transported. There should be a separate cart for dirty linen and a separate cart for clean linen. Both the clean and the dirty linen should be covered for transport because you do not know what kind of viruses are floating around. During an interview on 03/11/25 at 12:36 PM, the Executive Director revealed their expectations are that clean linen should never come in contact with dirty linen or dirty surfaces. Clean linen and dirty linen should be covered during transport.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and facility policy review, revealed the facility failed to date insulins when opened and moved to the medication cart for use on one (1) of two (2) medication carts. Findings include: Review of the facility's policy titled, Administering Medications, dated 12/2012, revealed the following: - Item #9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Observation of the medication cart on [NAME] Hall on 8/17/21 at 10:45 a.m. with Unit Manager (UM) #4, revealed five (5) insulin injection pens were not dated when removed from the refrigerator and placed on the cart. Continued observation revealed that these five (5) insulin injection pens were as follows: two (2) Humalog Kwik pen, one (1) Semglee insulin glargine injection pen, one (1) Tresiba insulin injection pen, and one (1) Toujeo Solostar insulin glargine injection pen. Interview on 8/17/21 at 2:30 p.m. with the Director of Nursing (DON) s/he stated that these insulins should have the date on them when placed on the medication cart for use. S/he stated it is the responsibility of the nurse that takes the insulin from the refrigerator to immediately date the insulin when they place it on the medication cart. Interview on 8/19/21 at 9:10 a.m. with the facility's pharmacist, s/he confirmed these insulins are to be dated when open or in use, s/he stated, these insulin injection pens containing prefilled insulin, are to be dated when removed from the refrigerator and placed on the medication cart. Once placed on the medication cart they have an expiration of 28 to 30 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to follow the menu for the items served and for the serving sizes for one (1) of one (1) meal observed. Findings include: Review of the Dietary Guide Sheet for 8/17/21 revealed the residents should receive hearty beef stew, mashed potatoes, braised stew vegetables, assorted breads, assorted desserts, and the salad of the day. Observation on 8/17/21 beginning at 12:03 p.m. and ending at 12:55 p.m. of Dietary [NAME] #2 serving the lunch meal on [NAME] Unit revealed the residents did not received the braised stew vegetables. Interview on 8/17/21 at 12:34 p.m. with the Certified Dietary Manager (CDM) regarding why the residents did not receive the braised stew vegetables, he/she was unaware the vegetables were not being served. The CDM then asked Dietary [NAME] #2 the same question. Dietary [NAME] #2 stated the vegetables were in the stew, plus they received mashed potatoes. Dietary [NAME] #2 also stated he/she did not usually make/serve additional vegetables if something else being served contained vegetables. Review of the Diet Guide Sheet for 8/17/21, revealed the residents that received a regular diet should receive eight (8) ounces of the beef stew, and four (4) ounces of the mashed potatoes, braised stew vegetables and salad. The residents that received a pureed diet should receive eight (8) ounces of the pureed hearty beef stew and four (4) ounces of the pureed mashed potatoes, braised stew vegetables, and soft mixed vegetables (in place of the salad). The residents that received a ground diet would receive eight (8) ounces of the ground hearty beef stew, four (4) ounces of the mashed potatoes and braised stew vegetables and four (4) ounces of the mixed vegetable (in place of the salad). Further observation on 8/17/21 of the lunch meal on [NAME] Unit beginning at 12:03 p.m. and ending at 12:55 p.m. revealed Dietary [NAME] #2 used a four (4) ounce scoop to serve the beef stew and number 12 scoops to serve the mashed potatoes, pureed spinach (in place of the lettuce salad), and pureed beef stew. Dietary [NAME] #2 did not measure the lettuce salad. Interview with Dietary [NAME] #2 on 8/17/21 at 12:25 p.m. revealed he/she did not know how many ounces a number 12 scoop was. Further interview with the CDM on 8/17/21 at 12:34 p.m. confirmed the staff should serve the residents eight (8) ounces of the beef stew and instructed Dietary [NAME] #2 to serve the eight (8) ounces and serve four (4) ounces of the mashed potatoes, and pureed spinach. Further observation on 8/17/21 at 12:35 p.m. revealed Dietary [NAME] #2 served four (4) additional residents only four (4) ounces of the beef stew. The CDM on 8/17/21 at 12:41 p.m. provided documentation that a #12 scoop size was only 2 and 3/4 ounces and not the four (4) ounces documented for the mashed potatoes and the pureed vegetable. Further observation of the lunch meal on 8/17/21 beginning at 12:03 p.m. and ending at 12:55 p.m. on [NAME] Unit revealed the residents that received a pureed diet did not receive the pureed bread. Observation on 8/17/21 from 12:58 p.m. to 1:30 p.m. of the lunch meal on [NAME] Unit revealed, Dietary [NAME] #2 did not measure the pureed spinach when serving the residents that received a pureed or ground diet. Dietary [NAME] #2 also served five (5) residents four (4) ounces of the beef stew before serving the required amount of eight (8) ounces. Interview with the CDM during the observation of the lunch meal on 8/17/21 at approximately 1:00 p.m., as to why the residents that received a pureed or ground diet did not receive the pureed bread revealed the CDM did not know and then asked Dietary [NAME] #2. Dietary [NAME] #2 stated they were out of the pureed bread mix. The residents on the [NAME] Unit also did not receive the braised stew vegetables as listed on the Diet Guide Sheet. Interview with the CDM on 8/19/21 at 2:45 p.m. revealed the Registered Dietician (RD) told him/her the facility did not have a policy for following the menu or scoop sizes. The RD stated staff should follow the spreadsheet (Diet Guide Sheet). Interview with the RD via phone on 8/20/21 at 9:15 a.m. confirmed the staff should follow the spreadsheet for the items served and the serving size.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of facility policy, the facility failed to prepare and serve food and store kitchen dishware and pans in a sanitary manner and failed to discard leftovers within the scheduled timeframe during two (2) of two (2) observation days of the dietary department. Findings include: Review of the policy titled, Food Preparation and Service, dated 10/2017 revealed food preparation staff would adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Review of the policy titled, Dry Storage-Dishes and Utensils, dated 2/1/12 revealed, dishes must be stored to promote air drying i.e., use dish racks or trays with plastic mesh that allow air to circulate, and air dry the dishes. Review of the policy titled, Trayline Refrigerated Leftover Storage, dated 2014 revealed, leftover foods should not be saved and re-used for human consumption if there was any doubt of wholesome quality. The timeframes listed were not only used to control sanitation but the quality of the food also. Observation during the initial tour of the kitchen on 8/17/21 from 10:58 a.m. to 11:50 a.m. revealed the staff stored the serving and cooking utensils uncovered and upright directly above the three (3) compartment sink. Interview with the Executive Chef at that time revealed the staff used the three (3) compartment sink to clean the serving trays and the beverage dispensers. The Executive Chef confirmed the storage of the utensils above the three (3) compartment sink. Observation at 11:20 a.m. revealed a random sample of 38 steam table pans stacked together with water and/or dried food present inside the pans. Observation at 11:31 a.m. revealed a staff member drying a storage container with a towel. Interview with the Executive Chef at that time revealed he/she did not know that staff should not dry the dishes or cooking utensils. Further observation during the initial tour of the kitchen on 8/17/21 from 10:58 a.m. to 11:50 a.m. revealed the walk-in cooler contained two (2) packages of salami, one (1) package of swiss cheese and one (1) package of turkey with labels documenting the shelf life (day to discard) as 8/15/21; a container of liquid chicken stock with a label indicating the shelf life as 8/16/21; container of blue cheese with the label indicating the shelf life of 8/11/21; an uncovered steam table pan of black beans with no label; a steam table pan of panini pasta with the plastic covering the pan torn and not labelled; uncovered and unlabeled steam table pan of cut onions; steam table pan of corn with the shelf life of 8/12/21; and a plastic container of bow tie pasta with the shelf life of 8/12/21. Observation of the dry storage area revealed a container of batter mixture with the opened date of 5/1/21. The facility's label on the container documented the mixture was good for 90 days. Interview with the Executive Chef on 8/17/21 at 11:18 a.m. revealed he/she was responsible for ensuring the leftovers were discarded by the shelf-life date. The Executive Chef also stated if the leftovers were cooked, they would keep them for seven (7) days and if the leftovers were uncooked, they were kept for three (3) days. He/she confirmed the items listed above should have been discarded by the shelf-life date. Observation of the kitchenette on the [NAME] Unit on 8/17/21 at 11:57 a.m. revealed 27 out of 27 plastic cups stacked together with water between them and five (5) plates or bowls with dried food present where the food would be placed. Observation on 8/17/21 at 12:03 p.m. of the kitchenette on the [NAME] Unit revealed 27 out of 27 glasses stacked together with water between them. Observation on 8/17/21 during the lunch meal service on the [NAME] Unit revealed at 12:12 p.m. the Certified Dietary Manager (CDM) placed his/her ungloved finger inside a salad bowl being used. At 12:29 p.m. Dietary [NAME] #2 with gloves on touched the menu list, Styrofoam containers, microwave buttons and handles, counters and itched his/her arm and then without changing gloves pushed the lettuce down into the bowls. Further observation during the lunch meal from 12:47 p.m. to 12:55 p.m. revealed Dietary [NAME] #2 pushed his/her glasses up, held his/her hands on the back of his/her shirt, touched his/her pen and then touched the inside of the plate where food was placed without changing his/her gloves. Observation on 8/19/21 from 11:34 a.m. to 11:48 a.m. revealed Dietary [NAME] #2 prepared the pureed food. Further observation revealed with gloved hands Dietary [NAME] #2 pulled up his/her mask, touched the recipe book, the thickener container, warmer cabinet handles and without changing his/her gloves, touched the robot coupe's (industrial blender) beaters prior to making the pureed tortellini. Dietary [NAME] #2 also, without changing his/her gloves, placed spinach that had landed on the rim of the robot coupe into the robot coupe. Interview with Dietary [NAME] #2 on 8/19/21 at 11:48 a.m. regarding the dietary training he/she had received, revealed the Registered Dietician (RD) came to the facility one (1) time a month. The RD would test them on different things, such as sanitization or making ground or pureed diets. Interview with the CDM on 8/19/21 at 11:52 a.m. confirmed the Dietary [NAME] should change gloves after touching other items and then touching the food or items that came in contact with the food. The CDM stated the RD came monthly and on occasion the RD would do training for the staff. He/she further stated on hire the new kitchen staff would shadow someone in the kitchen that held the same position as the new person would have. The CDM stated there was no formal list as to what the new person was trained on. Further observation on 8/19/21 at 11:52 a.m. revealed the dietary staff were preparing and plating food and two (2) females in street clothes with no hair nets on, entered the kitchen and went to the beverage area. Upon the surveyor asking, the CDM stated the females were activity staff and confirmed that they should not be in the kitchen without hair nets on. Observation revealed no staff approached the activity staff until the surveyor continued to ask questions about them being in the kitchen without hair nets on. The CDM then called a dietary staff member over and by that time the activity staff had left the kitchen. Interview with the RD via phone on 8/20/21 at 9:15 a.m. revealed the facility did the training for the kitchen staff. The RD stated he/she utilized a company wide sanitization check-off sheet when assessing the kitchen and dietary staff.