Based on interview, record review, and document review, the provider failed to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled resident (13) reviewed for facility-initiated transfer to the hospital. Findings include: 1. Interview on 9/30/24 at 5:10 p.m. with resident 13 revealed she had gone to the hospital recently, but did not remember why., 2. Review of resident 13's electronic medical record (EMR) revealed: *She was transferred to the hospital on 1/29/24. -Her power of attorney (POA) was notified of her transfer. -There was no documentation the bed hold information was given to the resident or her POA. *She was transferred to the hospital on 9/11/24. -Her POA was notified. -There was no documentation the bed hold information was given to the resident or her POA. 3. Interview with the facility's local ombudsman on 10/3/24 at 8:19 a.m. and again at 11:02 a.m. regarding resident 13's transfers to the hospital revealed: *She stated that she had not received notifications for either of resident 13's hospital transfers above. *She had spoken with social services designee (SSD) C and social services employee D in May 2024 about the regulation and did share a document with them at that time as well. 4. Interview on 10/3/24 at 9:11 a.m. with SSD C and social services employee D revealed: *The social services department was responsible for notifications to the ombudsman. -An email was often sent, however, sometimes we just call her. *They were not aware that they had to report every hospital transfer to the ombudsman. -They completed notifications to the ombudsman on day 5 if the resident was discharged . *No documentation was provided to verify the ombudsman was notified of resident 13's hospital transfers. 5. Review of the document shared with the provider by the Ombudsman revealed: *Notice before transfer. Before a facility transfers or discharges a resident, the facility must - (i) Notify the resident and the resident representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. That facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on record review, interview, and policy review the provider failed to ensure one of one sampled resident (1) had her as needed (PRN) lorazepam (antianxiety medication) order renewed for continued use beyond 14 days. Findings include: Review of resident 1's electronic medical record (EMR) revealed: *A physician's order on 8/1/24 for lorazepam 0.5 milligrams (mg) orally to be given every four hours as needed for increased anxiety and tooth pain. *Her revised care plan dated 8/6/24 indicated she used antidepressant/antianxiety medication related to depression and anxiety. *A pharmacist recommendation sheet for resident 1 dated 8/31/24 revealed: -PRN orders for psychotropic drugs are limited to 14 days. -Except if the attending or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. -He or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. -It was signed by director of nursing (DON B) and the consultant pharmacist. -The physician's response, had an X marked on the following area: --I would like to specify a duration of this PRN psychotropic as indefinitely and will document the rationale below. --Patient needs meds when has stressful event. --The physician's signature was dated 9/30/24. --DON B's signature was dated 10/2/24. *From 8/15/24 through 9/30/24 PRN lorazepam was administered 21 times. Interview on 10/2/24 at 3:30 p.m. with DON B and restorative licensed practical nurse (LPN) H regarding resident 1's PRN lorazepam revealed: *They knew PRN lorazepam orders had to be renewed by the physician every 14 days for continued use. *They were not aware the order had not been renewed. *They agreed the lorazepam order was not current. Review of the provider's July 2022 Psychotropic Medication Use policy revealed: *11. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. *12. Psychotropic medications are not prescribed on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration of the PRN order. (2) For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.

Based on observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (1) received a food prepared to correct temperature. Findings include: 1. Observation on 9/30/24 at 3:40 p.m. of the kitchen warming cabinet revealed: *The food warming cabinet thermometer was not functioning. *The dial for temperature control was set at 6.5 on 0-10 range. 2. Observation and interview on 10/1/24 at 12:00 with dietary manager E revealed: *She had pureed and placed resident 1's noon meal in the warming cabinet. *She stated the food had been pureed with warm broth. *The dial on the food warming cabinet was set at 5.5, the dial ranged 0 to 10. *She said that before the warming cabinet thermometer stopped working, this was the normal setting to keep food warmed to the appropriate temperature. *The taco meat used for the pureed meal was documented to be 176 degrees Fahrenheit (F)before being placed in the food warming cabinet. *The temperature of the pureed food was 113.7 degrees Fahrenheit. *She stated she would not recheck the temperature or reheat the pureed food before serving it to the resident. 3. Observation and interview on 10/2/24 at 4:33 p.m. with cook J revealed: *Hot chicken broth from the steamer was used to puree resident 1's. *After being pureed, the steamed vegetables were 113.3 degrees Fahrenheit. *After being pureed, the boneless pork rib was 107.9 degrees Fahrenheit. *After being pureed, the roasted potatoes were 107.9 degrees Fahrenheit. *Cook J stated that she would place pureed foods back in the warming cabinet until serving and she would not further heat the food. 4. Interview on 10/1/24 at 8:35 a.m. with dietary manager E revealed: *The food warming cabinet thermometer has been broken for two to three months. *The maintenance department is aware and has ordered a new food warming cabinet. *There was no internal thermometer placed in the warming cabinet to ensure safe food temperatures. 5. Interview on 10/2/24 at 8:40 a.m. with maintenance director F revealed: *He stated that he was made aware the food warming cabinet thermometer by dietary manager E on 5/20/24. *He stated there was a new food warming cabinet ordered on 10/1/24. 6. Interview on 10/3/24 at 9:40 with administrator A revealed: *She stated that she was recently made aware that the food warming cabinet was not functioning properly. *She stated that she told maintenance director F to order a new food warming cabinet the previous week. *She expected that the facility's food preparation and service policy would be followed. 7. Review of the facility's food temperature log revealed: *All cooked food's internal temperatures had been documented after cooking, before being placed in the food warming cabinet. *There was no record of food temperatures being documented after pureeing, before being served to the resident. 8. Policy review on 10/3/24 of the facilities food preparation and service policy revealed: *The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. *Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees Fahrenheit during preparation or they are reheated to 165 degrees Fahrenheit for at least 15 seconds.

Based on South Dakota Department of Health (SD DOH) facility reported incidents (FRI) review, interview, and policy review, the provider failed to provide timely and thorough notification to SD DOH for two of two sample residents (2 and 6) who required evaluation at the emergency room, after sustaining an injury during a transfer (2), and after an unwitnessed fall (6). Findings include: 1. Review of the SD DOH FRI submitted on 3/01/24 at 9:30 p.m. revealed: *On 2/28/24 at 10:00 a.m. resident 2 reported she had heard a pop while staff transferred her from the toilet to her wheelchair. *She stated that her right knee was hurting. *No swelling or open sores noted to her R [right] knee. *The final report submitted on 3/4/24 stated: -Neither staff member heard anything, but they did report it to their nurse . -The nurse noted no redness or swelling at this time. *There was no indication that resident 2 had been sent to the emergency room for evaluation in the provider's FRI report. *There was no indication that resident 2 sustained a proximal right tibial fracture. *The assessment of pain and swelling did not match the progress notes (PN) in the residents' electronic medical record (EMR). Review of resident 2's EMR revealed: *On 2/28/24 at 10:00 a.m. there was no nurse progress note (PN) that indicated resident 2 had reported she had heard a pop while being transferred from the toilet to her wheelchair. *On 2/28/24 at 11:25 p.m. a PN indicated [Resident 2] Can't sleep. Right knee still hurts. -This was the first PN after the incident that mentioned her right knee. *On 2/28/24 at 11:29 p.m. a PN indicated Right knee swollen and was elevated on a pillow from day shift. Muscle rub applied to both knees. This writer tried to elevate HOB [head of bed] to give resident her meds. Resident cried out in pain with tears noted. Resident was reassured that knee is just stiff and joint inflammation is what's going on here. Resident was reminded that she hasn't walked for awhile. Resident also received ice pack to right knee. *On 2/28/24 at 11:59 p.m. a PN indicated CNA [certified nursing assistant] stated that resident also cries out in pain when turning over to have brief [incontinence product] changed. *On 2/29/24 at 4:07 p.m. a PN indicated This writer was not able to measure wound, C/O [complains of] knee pain and wasn't able to have leg moved, [telehealth provider] was contacted in reguards to knee pain. *On 3/1/24 at 9:34 a.m. a PN indicated knee pain rated a consistent 8. Pts [patient's] right knee is swollen to about double the size of her other knee, and it is discolored. -This information was omitted from the SD DOH FRI initial and final reports. *On 3/1/24 at 10:04 a.m. a PN indicated resident 2 had been transferred to the emergency room for evaluation of her right knee pain. -This information was omitted from the SD DOH FRI final report that was submitted on 3/4/24. *On 3/1/24 at 5:05 p.m. a PN indicated Pt was in the hospital today. *On 3/1/24 at 6:03 p.m. a telehealth provider note indicated Phone call to facility to speak with nurse. Fx [fracture] of tibia on the right side. She is back in LTC [long-term care] facility. *On 3/1/24 at 7:39 p.m. a PN indicated f/u [follow up] from [telehealth]. Gave them report of what happened at [hospital] with the Tibia break. -This information was omitted from the SD DOH FRI final report submitted on 3/4/24. *There was no PN that indicated the time that resident 2 returned to the facility. 2. Interview on 10/1/24 at 9:15 a.m. with resident 6 revealed she: *Had fallen about a month ago. *Stated she went for a scan but nothing was broken. *Reported she still had some pain. Review of the SD DOH FRI submitted on 9/16/24 at 2:15 p.m. revealed: *On 9/14/24 at 3:30 p.m. resident 6 was found sitting on the floor on her bottom with her feet stretched out in front of her. *Pain was a 2 on pain scale 0-10. *Resident 2 had stated, The invisible man pushed me down. *A telehealth visit had been completed. *The final report due 9/21/24 had not been submitted to SD DOH. *There was no indication that resident 6 had been sent to the emergency room for evaluation. Review of resident 6's EMR revealed: *On 9/14/24 at 3:30 p.m. there was no nurse PN that indicated resident 6 had fallen. *On 9/14/24 at 5:32 p.m. a PN indicated resident 6 stated, When are you going to send me to the doctor for mt [my] brittle bones? My bone on my bottom hurts. *On 9/15/24 at 2:45 a.m. a PN indicated follow up unwitnessed fall from 9/14/24 day shift. *On 9/16/24 at 1:20 p.m. a PN indicated resident 6's family wanted resident 6 to be seen for an x-ray. She is complaining of left side abdominal pain Ambulance here at 12:45 to transport resident to the ER [emergency room]. -This information was omitted from the SD DOH FRI initial report that was submitted on 9/16/24 at 2:15 p.m. Interview on 10/2/24 at 12:12 p.m. with director of nursing (DON) B revealed: *She had not reported resident 2's transfer to the emergency room or injury because: -We didn't have the information at that time. -[The resident's primary care physician] didn't think it was a fracture. *She was aware of the SD DOH FRI reporting guidelines. *She had fallen behind in reporting incidents to SD DOH. *She confirmed that the initial report for resident 2 had not been completed on time. *She had not reported resident 6's transfer to the emergency room or injury because: -Her family wanted her to be seen. -She always wants to go to the emergency room. She was fine. *She confirmed that the final report for resident 6 had not been completed on time. Review of the provider's 10/2/24 Reporting of injuries of Unknown Source and Reasonable Suspicion of a crime education packet revealed: *Review with all IDT [interdisciplinary team] team members and those designated to report to Department of Health Complaint office. *Copy of reporting guidelines given to each team member on this date. *IMMEDIATELY notify the Administrator of the Event, the 2 HOUR clock starts. *REPORT the reasonable suspicion not later than 2 HOURS after forming the suspicion. REPORT to: SD DOH COMPLAINT Coordinator . *CONDUCT a thorough internal investigation and Send in findings report within 5 working days. *DON B had signed that she was provided the above information.

Based on observation, interview, record review, and policy review, the provider failed to provide the therapeutic diet prescribed by a physician for 16 of 21 (2,3,4,5,7,8,9,11,12,13,14,16,17,18,19,21) residents. Findings include: 1. Observation on 9/30/24 at 3:40 p.m. revealed: * Spaghetti had been served for the lunch meal instead of the approved scheduled menu item of Asian barbecue turkey. *There was no indication on the kitchen menu that the substitution was approved by the dietician or documentation that the substitution was made. *All residents received the same meal with no differentiation between their individually prescribed diets (regular, heart healthy, renal, consistent carbohydrate, and no added salt diets). 2. Observation on 9/30/24 at 4:45 p.m. revealed: *A ham salad sandwich on a slider-sized roll was served for the evening meal instead of spinach and cheese quiche that was listed on the approved scheduled menu. *There was no indication on the kitchen menu that the substitution was approved by the dietician or documented that the substitution was made. *All residents received the same meal with no differentiation between prescribed diets. 3. Observation on 10/1/24 at 11:40 a.m. revealed: *Taco burgers and chicken noodle soup with potato wedges were served for lunch instead of the approved scheduled menu item of ham steak with honey mustard sauce, twice baked sweet potato, sauteed Brussel sprouts, dinner roll/margarine, and pineapple with toasted coconut. *There was no indication on the kitchen menu that the substitution was approved by the dietician or documentation that the substitution was made. *All residents received the same meal with no differentiation between their prescribed diets. 4. Interview on 10/1/24 at 8:35 with dietary manager E revealed: *She stated that the kitchen made substitutions due to the lack of availability of the menu items. *She stated that she did not know what some of the items on the menu were. *She stated that she had not been documenting when and what substitutions had been made. *She stated that she made taco burgers every Tuesday because the residents liked them. *When asked if the substitutions had been approved by the dietician, she stated that they had not been. *When asked if an alternate menu option was available, she stated that if a resident doesn't like what is being served, they can have soup or cereal. 5. Interview by phone on 10/2/24 at 10:52 a.m. with registered dietician M revealed: *Her involvement with the facility is to review and approve the food menus for the facility. *She stated, They should be notifying me of the substitutions, but they are not. *She stated that she had previously voiced concerns about kitchen staff not following the menu. *She stated that she had previously asked for the menu substitution log but did not receive accurate substitutions menus. 6. Interview on 10/3/24 at 8:40 am with administrator A revealed: *She was aware that ordered menus were not being followed. *She stated there were challenges to following the menu due to residents not wanting to follow their prescribed diet. *She stated that there were times when elderly protection would complain on behalf of the resident and that was part of the reason that diets were not being followed. *There was no written documentation that residents refused to follow their prescribed diets. *She agreed that diets ordered by a physician should be followed but stated many of the residents would not follow their prescribed diet. 7. Record review on 10/2/24 of the provider's dietary orders revealed: *Residents 2,3,4,5,7,8,9,11,12,13,14,16,17,18,19, and 21 did not have specific dietary orders addressed. -Eight residents were ordered a consistent carbohydrate diet. -Five residents were ordered a heart healthy diet. -Six residents were ordered a no added salt diet. -Two residents were ordered a renal diet. 8. Review of the provider's April 2019 Frequency of Meals policy revealed: *Policy Statement: Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care. 9. Policy review of the provider's October 2017 Foods Brought by Family/Visitor policy revealed: *Policy Interpretation and Implementation, line 13, When meals or snacks are provided by family/visitors, the nurse will inform the dietician of these substitutions.

Based on observation, interview, record review and policy review the provider failed to ensure two of two sampled residents (2 and 18) with open wounds had been placed on enhanced barrier precautions (EBP). Findings include: 1. Observation on 10/1/24 at 8:00 a.m. of two unidentified staff entering resident 2's room with the Hoyer lift (a mechanical lift with a body sling used for transfers) revealed neither staff member had worn a gown prior to entering the room. Observation and interview on 10/2/24 at 10:03 a.m. with resident 2 revealed: *The door to her room was open and held an over-the-door rack that contained gowns and gloves. *There was a sign indicating the need for EBP on that side of the door. *That sign and those supplies had not been visible with the door open and were located outside that resident's room when that door was closed. *Resident 2 stated that the staff had not worn a gown or gloves when they transferred her with the mechanical lift or the gait belt. Interview on 10/2/24 at 10:09 a.m. with certified nursing assistant (CNA) K revealed: *Resident 2 required the use of the Hoyer lift and two CNAs for all transfers. *Resident 2 sometimes refused the Hoyer lift and could be transferred with a gait belt and two CNAs *She had not worn a gown when she completed any transfers with resident 2. Review of resident 2's electronic medical record (EMR) revealed Dressing to right lower extremity related to non-pressure chronic ulcer of unspecified part of right leg . 2. Observation and interview on 9/30/24 at 4:94 p.m. with resident 18 revealed: *There had not been any signage on the door or in the room that indicated EBP. *There had not been any gowns in the room or near the door. *She wore heel protector boots on both feet and stated she had an open wound on her left foot. *She stated that the staff did not wear a gown or gloves when they transferred her, but that they wore gloves when they had changed the bandage on her foot. Observation on 10/1/24 at 4:20 p.m. of licensed practical nurse (LPN) H, CNA K, with resident 18 revealed: *LPN H and CNA K transferred resident 18 from her bed to the wheelchair. -LPN H and CNA K had not worn a gown or gloves. Observation on 10/1/24 at 4:40 p.m. of licensed practical nurse (LPN) H, certified nursing assistant (CNA) K, with resident 18 revealed: *CNA K assisted resident 18 with a whirlpool bath. -CNA K wore gloves but did not wear a gown. *LPN H applied a bandage to resident 18's left foot. -LPN H wore gloves but did not wear a gown. Interview on 10/01/24 at 5:31 p.m. with LPN H revealed she: *Did not know the facility policy on EBP. *Confirmed she had not worn a gown when she transferred or completed wound care for resident 18. Review of resident 18's electronic medical record (EMR) revealed a dressing change was ordered to be completed every day shift for Ischemic injury to right great toe. Interview on 10/2/24 at 11:37 a.m. with LPN H revealed she: *Received training on EBP on 4/2/24 from administrator (Admin) A. -Had been told that only residents with a multi-drug resistant organism (MDRO) required EBP. -Hnad not been educated that all residents with open wounds require EBP *Stated, I did not know. *Stated resident 2 required EBP only when they changed her dressings on her leg due to the presence of an MDRO. Interview on 10/2/24 at 4:36 p.m. with infection control registered nurse (ICRN) G revealed: *Residents with wounds would have only had EBP in place if they had an MDRO or the wound was seeping and could not be contained. *She expected the nurse to have worn a gown to complete a dressing change for resident 2 but not for resident 18. *She had not expected staff to wear gowns with residents 2 or 18 when completing transfers or bathing. 3. Review of the provider's 8/12/24 Enhanced Barrier Precautions policy revealed: *Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. *An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., Chronic wounds such as pressure ulcers diabetic foot ulcer's unhealed surgical wounds and chronic visa stasis ulcers) and/or indwelling medical devices . *High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, h. Wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 9/30/24 at 3:45 p.m. of unidentified CNA during the initial tour in the kitchen revealed: *CNA was making ham salad sandwiches for the residents' evening meal. *CNA was not using a measuring scoop to correctly portion the amount of salad put on each sandwich. *The bread used for the sandwich was a slider bun, approximately one-half the side of a standard hamburger bun. Observation on 10/2/24 at 4:13 p.m. of cook J revealed: *While preparing the cucumbers with ranch portions, she was not using a measuring utensil to measure the portion for each meal tray. *While preparing the three bean salad portions, she was not using a measuring utensil to measure the portion for each meal tray. Interview on 10/1/24 at 8:35 a.m. with dietary manager E revealed: *The CNA that was making the ham salad sandwiches was not part of the regular kitchen staff. -The CNA was helping due to short staffing. *She stated that she had trained the CNA to use the one-half cup scoop to portion the ham salad, but the thought the CNA must have been nervous because the surveyors were watching her. *When asked what options the resident would have if they did not like what was being served, she stated that the resident could have soup or cereal. There was no alternate meal prepared. Interview on 10/1/24 at 9:35 a.m. with resident 14 revealed: *This was the first time he had lived in a nursing home, and he had been there for a few months. *He stated that the food was good, but he did not get enough. *When asked if he was able to get more food if he asked for it, he stated, Sometimes. *When asked if he was offered an alternate option if he did not like what was being served, he stated No. *When asked if the staff brought him snacks between meals, he stated Sometimes. *When asked how often staff brought him snacks, he stated Maybe two to three times a day. Interview on 10/2/24 at 10:52 a.m. with registered dietician M revealed: *She was a contracted employee, and her role was to approve food menus. *She did not visit the facility. *She approved the menus the facility used, they were provided to the facility by US Foods, which was the facility's food distributor. *She stated that the facility should have been notifying her when substitutions were made, but that was not happening. *She stated the diet extensions should be used, but that was difficult when staff were not making food from the menu. Interview on 10/3/24 at 9:40 a.m. with administrator A revealed: *The kitchen had recently had a difficult time with adequate staff due to COVID-19 and staff turnover. *She acknowledged that substitutions were made regularly, and this was due to food availability and resident preference. *She stated that substitutions were allowed to be done but needed to be documented as to why they were being done and the dietician needed to be made aware of the substitution menus. *It was her expectation that serving sizes would be consistent by using appropriate serving utensils. *She stated that the facility planned to work with a new company that would be able to accommodate the resident's dietary needs as well as cultural food preferences. Review of the provider's April 2019 Frequency of Meals policy revealed: *Policy Statement: Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care. Based on observation, interview, record review, and policy review, the provider failed to serve a well-balanced diet that: A. Considered the food preferences for 3 of 3 sampled residents (6, 13, and 16). B. Contained dietician-approved nutritional equivalent food substitutions for 21 of 21 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) for one of one observed meal service. Findings include: 1. Observation and interview on 10/1/24 at 9:09 a.m. with resident 6 revealed: *She stated, You get what you get, when asked what she ordered for breakfast. *She had not received a menu of meals for the day. *She had not selected or been asked what she wanted to eat that day. *Menus had been posted in the hallway near the dining room, but it was not always accurate. *The residents had been quarantined in their rooms due to a COVID-19 outbreak and had not been able to check that menu. *She stated, If you refuse [the meal provided], you get soup. *She had requested softer foods because she did not wear dentures. -She stated, This fruit [[NAME] and grapes] is hard. Review of resident 6's electronic medical record revealed: *A 11/3/22 physician's order for Diet Regular diet, Mechanical Soft texture. *She had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. Observation and interview on 10/1/24 at 10:34 a.m. with resident 13 revealed: *There were uneaten pancakes with syrup and sausage on her plate that had been covered. *She had not liked what was served that day and wanted another choice. -She had wanted malt-o-meal. *She stated, You get what is provided. *If she had been given a choice she would have ordered something different. Review of resident 13's electronic medical record revealed: *A 4/13/2 physician's order for a Consistent Carbohydrate diet, Regular texture, Regular consistency. *She had a Brief Interview for Mental Status (BIMS) score of 12 which indicated she was moderately cognitively impaired. *Her diagnosis included Type 2 Diabetes Mellitus with Hyperglycemia. *Her care plan indicated: -Poor appetite. -Refuses to eat at times. -Monitor nutritional status. -Serve diet as ordered. Interview on 10/1/24 at 11:07 a.m. with resident 16 revealed she stated: *I don't care for a lot of things they have. *If I don't like what they bring me I can have soup. *They put it [the menu] up on the board. *I am tired of hamburgers. *You get what they bring. Review of resident 16's electronic medical record revealed: *A 12/1/23 physician's order for Diet Consistent Carb [carbohydrate], NAS [no added salt] diet, Regular texture, Regular consistency. *She had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. *Her diagnosis included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Essential (Primary) Hypertension. Interview on 10/1/24 at 8:00 a.m. with dietary manager (DM) E regarding an alternative menu revealed they did not have an alternative menu, but if the resident did not like what was served they would be able to have soup or hot/cold cereal.

Based on Certification and Survey Provider Enhanced Reports (CASPER) reporting data review, interview, and policy review, the provider failed to ensure their Payroll Based Journal (PBJ), (information of the provider's daily staffing hours for the appropriate care of the residents) had been complete and the data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four quarters (Quarter 1, 2024). Findings include: 1. Review of the provider's CASPER reporting data revealed no PBJ data had been submitted for the time period of October 1, 2023, through December 31, 2023. Interview on 10/1/24 at 3:47 p.m. with administrator A regarding the submission of PBJ data to CMS revealed: *She was aware the data had to have been submitted. *She knew there were deadlines to submit the data. *They had a vendor who kept track of payroll and PBJ data. *The vendor had missed the deadline for submitting the Quarter 1, 2024 PBJ data to CMS. Interview on 10/3/24 at 9:00 a.m. with administrator A and outsourced chief financial officer (CFO) L regarding the submission of PBJ data to CMS revealed: *Outsourced CFO L was responsible for ensuring the PBJ data was submitted to CMS. *His office would get the data from the provider and ensure it was submitted by the deadline. *A staff member from outsourced CFO L's office missed the deadline for submitting the data by one day. *It was both their expectations that the data would be submitted to CMS before the deadline each quarter. Review of the providers revised 1/4/23 Payroll Based Journal policy revealed, It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and diet manual review, the provider failed to: *Preserve the nutritive value of pureed foods for two of two sampled residents (5 and 8) by thinning the food items with plain water. *Provide a pureed substitute for a menu item of similar nutritive value for two of two sampled residents (5 and 8) who required a pureed diet for one of one observed meal service. Findings include: 1. Observation and interview on 8/2/23 from 4:18 p.m. to 5:32 p.m. with dietary staff in the kitchen revealed: *The menu for supper that day consisted of one cup shepherd's pie, one-half cup mixed vegetables, a brownie, and a dinner roll. *Cook F scooped about one and one-half cups of shepherd's pie into the blender. -She added about one-quarter to one-half cup of hot water to the blender. *She stated her goal for consistency was similar to yogurt, yet not too runny like soup. *She blended the shepherd's pie and water until it was smooth, yet it was runny. *She portioned the pureed shepherd's pie into two 5.5-ounce (oz.) clear plastic cups, filling the cups to the top. *She stated they usually serve about 5.5-oz. of the main pureed dish, 4-oz. of the side, and either a yogurt cup or a protein gelatin cup for dessert. *Cook F grabbed a clean blender and scooped about one and one-half cups of mixed vegetables into the blender. -She added about one-quarter cup of hot water, and two packets of liquid food thickener to the blender. --The food thickener label read, simplythick EasyMix Instant Food Thickener, Mildly Thick, Nectar Thick. --The directions read, Add to 4 fl. oz. [fluid ounces] of liquid. Stir briskly for 30 seconds. *She blended the vegetables until it was smooth, then she portioned the pureed vegetables into two 5.5-oz. clear plastic cups, filling the cups to the top. *Cook F indicated she was trained to use hot water for pureeing foods. -Sometimes she used milk for hot cereals and some desserts. *She had not pureed the brownie or the dinner roll for the supper meal service. *She prepared the plates of pureed food for residents 5 and 8 by grabbing two separate plates and placed the following onto each plate: -The clear plastic cup of pureed shepherd's pie. -The clear plastic cup of pureed mixed vegetables. -A strawberry yogurt cup in place of the brownie. --The yogurt had visible chunks of strawberries. -She had not provided a pureed alternate for the dinner roll. *She approved the plates that were to have been delivered to the residents. *When questioned about the strawberry yogurt, she had assumed the small chunks of strawberries were acceptable for a pureed diet. -She then replaced the strawberry yogurt with vanilla yogurt, which was smooth. *She again approved the plates and dietary aide S delivered those plates to residents 5 and 8. -There was no pureed alternate for the dinner roll. *When questioned about a pureed menu extension or a diet manual, cook F indicated she was not aware if they had either. Interview on 8/2/23 at 5:52 p.m. with dietary manager (DM) E about the above observations revealed: *They had no specific menu extension for the pureed diets. *She was not aware if there was a diet manual. -She instead brought the manual for food service policies and procedures, which had no descriptions of how to properly puree foods. *She expected staff to use milk for pureeing foods like cereal, and water for pureeing other foods. *She was not aware that water was not the proper liquid to use when pureeing food. -She agreed that water might lessen the flavor. Continued interview on 8/3/23 at 9:28 a.m. with DM E about pureed diets revealed: *She had spoken with registered dietitian consultant (RD) J about a pureed diet menu extension and RD J had indicated using the provider's copy of the [NAME] & Associates Diet and Nutrition Manual. -RD J had to explain to her where to find the diet manual, as she was not aware of it. Interview on 8/3/23 at 9:33 a.m. with RD J about the above observations revealed: *It was her expectation that staff should have used broth, gravy, milk, juice, or other liquids with nutritional value to puree foods. *The texture of the pureed foods should have been similar to mashed potatoes or pudding. *It was not the best practice to puree foods with plain water as it would alter the taste and decrease the nutritional value of the food. *She agreed the yogurts with chunks of fruit was not appropriate for someone who required a pureed diet. *She expected staff to provide pureed food for each item on the menu. *She said that the dietary staff should have provided an alternate for the dinner roll. -She indicated that the staff could have pureed the brownie with milk to make a pureed dessert, and the dinner roll with milk to make a slurried bread product. *She had not created a pureed menu extension. -It was her expectation for the dietary staff to utilize the diet manual for appropriate pureed alternates and serving suggestions. Review of resident 5's medical record revealed: *His diet order changed to pureed on 7/10/23. *He had not experienced significant weight loss in 30 or 180 days. Review of resident 8's medical record revealed: *On 7/28/23, her diet order was entered as Consistent Carbohydrate diet, Pureed texture, Nectar consistency. -The directions on the order read verbatim, Arginaid BID [twice a day] till wound healed. for Due to difficulty chewing. *She weighed 152# (pounds) on 1/29/23. *She weighed 144.2# on 7/31/23. -From 1/29/23 to 7/31/23, her weight decreased 7.8#, that was 5.15% weight decrease. --A decrease of 10% or greater in 180 days was considered significant. Review of the provider's 2014 copy of the Diet and Nutrition Manual by [NAME] & Associates, Inc. revealed: *There was a section titled Consistency Altered Diets. *Under the sub-section titled Dysphagia Puree (Level 1) Diet, -All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase. -For protein foods, 5-6 oz equivalent was the recommended amount each day. -For vegetables, [greater than or equal to] 2 [and] 1/2 cups or equivalent was the recommended amount each day. -For grains, [greater than or equal to] 6 oz equivalent was the recommended amount each day. -All foods must be the consistency of moist mashed potatoes or pudding. -Pureed Diet menus follow the foods on the Regular Diet as closely as possible with the main difference being food consistency. *Under the Foods Allowed chart: -Meats, eggs, and cottage cheese should be pureed to moist, pudding-like consistency . -Fruits, include any that are pureed to a smooth consistency with no pulp, seeds, skins or chunks. *All foods are the consistency of moist mashed potatoes or pudding. *The diet manual had no directions on how to properly puree foods.

Based on observation, interview, and policy review, the provider failed to ensure: *Two of three dietary staff (F and S) had performed proper hand hygiene and glove use during one of one meal service observation. *Potentially hazardous food was stored according to the manufacturer's guidelines. Findings include: 1. Observation on 8/1/23 at 9:46 a.m. in the kitchen revealed: *There was a clear plastic container of butter packets sitting on one of the counters. -The container felt like it had been sitting at room temperature, as it was not cold. Observation and interview on 8/2/23 from 4:18 p.m. to 5:32 p.m. with dietary staff in the kitchen revealed: *During the entire meal service observation, dietary aide S had not washed his hands. -He would instead change his gloves between tasks. *Dietary aide S had been wearing gloves while sweeping, then he started to put away clean dishes without changing gloves or performing hand hygiene. *Cook F had asked him to cut the brownies. Dietary aide S had not performed hand hygiene or changed his gloves after sweeping the floor and putting away the dishes. *While wearing those same potentially soiled gloves, dietary aide S had been cutting the brownies and his hands touched the brownies several times. -At one point, he had used the fingers on his left gloved hand to wipe off the brownie crust from the knife, and placed that brownie crust back onto the pan of brownies. *He changed his gloves without performing hand hygiene after he was finished cutting the brownies. -He blew air into each glove to inflate them prior to donning the gloves. *He started to set up the plates for supper service. -During that process, he walked from the kitchen to the dining room several times and touched the door each time he walked in and out. -He had not performed hand hygiene or changed his gloves. *Cook F prepared the pans of food for supper service. -She performed hand hygiene and donned a new pair of gloves prior. -The meal was shepherd's pie or a hot stuffed pepper, mixed vegetables, a brownie, and a dinner roll with a butter packet. -She had a spatula for the brownies, a measuring scoop for the vegetables, a pair of tongs for the peppers, and another measuring scoop for the shepherd's pie. -There was no serving utensil for the dinner rolls. *With her right gloved hand, she would touch the tongs, the spatula, and the measuring scoops. *With her left gloved hand, she would touch the plates, the brownies, the dinner rolls, and the butter packets. -The butter packets were stored in the clear plastic container. *Several times throughout the observation, she used both gloved hands to touch the food cart, the door handle to the warmer, the brownies as they had been stuck together, and the dinner rolls to open them up. *She had not changed her gloves or performed hand hygiene during the meal service. Continued interview with cook F and dietary aide S after the meal service had finished revealed: *Cook F confirmed that the butter packets were stored on the counter at room temperature. *She was not aware that the label on the packets of whipped spread had read perishable, keep refrigerated. *She usually would have used a serving utensil for each food item on the menu. -She stated that she was trying to get through the meal service as quickly as possible, so she used her gloved hands to serve the brownies and the dinner rolls. -She agreed she should not have done that. *Dietary aide S said he knew better, and he agreed he should have washed his hands and changed his gloves between each task. Interview on 8/2/23 at 5:52 p.m. with dietary manager (DM) E about the above observations revealed: *It was her expectation for staff to use a different utensil for each food item during meal service. -Staff should not have touched the food with their potentially contaminated gloves. *She agreed staff should have been performing hand hygiene and changing gloves between each task. *She was aware that the butter packets were stored at room temperature because, it gets too hard to spread when it's refrigerated. -She was not aware that the label on the whipped spread had read perishable, keep refrigerated. Review of the provider's 2017 Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy revealed: *Policy Statement: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. *1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. *6. Employees must wash their hands: -c. Whenever entering or re-entering the kitchen; -d. Before coming in contact with any food surfaces; -f. After handling soiled equipment or utensils; -g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or -h. After engaging in other activities that contaminate the hands. *9. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. *10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. Review of the provider's 2014 Food Receiving and Storage policy revealed: *Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. *9. Refrigerated foods must be stored below 41 [degrees Fahrenheit] unless otherwise specified by law. *The policy had not indicated anything about following the manufacturer's labels for proper storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 8/2/23 at 5:55 p.m. of resident 2's oxygen concentrator revealed: *The oxygen tubing was draped on top of the oxygen concentrator. *The nasal cannula tubing was not dated or stored in a bag when not in use. Review of resident 2's EMR and TAR revealed: *There was a physician's order for, Oxygen at two liters per nasal cannula to keep saturations greater than 90 percent every two hours as needed for shortness of breath to keep saturations above 90 percent. *No physician's order was found for changing the nasal cannula tubing. 3. Observation and interview on 8/1/23 at 11:30 a.m. with resident 30 regarding the nebulizer treatments revealed: *She had used the nebulizer to help with her breathing since she had part of her left lung removed. *The nebulizer machine had been setting on top of her dresser with other personal items. *The nebulizer setup was lying on top of the machine. *The nebulizer setup and tubing was not dated. Review of resident 30's EMR and July 2023 TAR regarding nebulizer treatment and tubing changes revealed: *She had a physician's order for an albuterol nebulizer 0.63 % every six hours as needed for shortness of breath. *There was no order to replace oxygen baggie, tubing, humidifier bottle with distilled water and mark with date and initials. *Clean oxygen concentrator. Clean nebulizer and change tubing also every night shift on Thursday. *She had no documented change regarding her tubing. Interview on 8/2/23 at 2:47 p.m. with staff development/infection preventionist H regarding the above resident's oxygen and nebulizer tubing changes revealed: *The oxygen and nebulizer tubing should have been changed every Thursday on the night shift. *Staff should have dated and initialed the baggie and the tubing at the time it was changed. *The oxygen tubing should have been placed in the baggie when not in use. 4. Observation on 8/2/23 at 5:55 p.m. of resident 23's oxygen concentrator revealed: *Oxygen canister contained water to humidify the oxygen and was dated 6/29/23. *Oxygen tubing was discolored and coiled on top of the concentrator. *Oxygen tubing was not dated and had not been placed in a baggie when not in use. Review of resident 23's EMR and June and July 2023 TAR revealed: *She used oxygen at two liters per nasal cannula at night and oxygen at two liters per nasal cannula to keep oxygen levels greater than 90%. *She had a physician's order to replace oxygen baggie, tubing, humidifier bottle with distilled water and mark with date and initials. *Clean oxygen concentrator. Clean nebulizer and change tubing also every night shift every on Thursday. *There was documented completion of the above order that had been initialed by staff on 6/29, 7/6, 7/13, 7/20, and 7/27/23. 5. Observation on 8/2/23 at 5:55 p.m. of resident 8's oxygen concentrator and oxygen tubing revealed: *The oxygen tubing had been coiled and was setting on top of the concentrator. *The oxygen tubing was not dated and was not placed in a baggie when not in use. Review of resident 8's EMR and July 2023 TAR revealed: *The oxygen had been ordered at two liters per nasal cannula to keep oxygen levels above 89%. *There was a physician's order to replace baggie, tubing, humidified bottle with distilled water and make with initials. *Clean oxygen concentrator every night shift on Thursday. *There was documented completion of above order that was initialed by staff on 7/6, 7/13, 7/20, and 7/27/23. 6. Observation on 8/2/23 at 5:55 p.m. of resident 9's oxygen concentrator and oxygen tubing revealed: *The oxygen tubing was lying on the floor next to the oxygen concentrator. *The oxygen tubing had not been dated or in a baggie while not being used. Review of resident 9's EMR and July 2023 TAR revealed: *She had a physician's order for oxygen at two liters continuously at night and at two liters as needed to keep oxygen levels greater than 90%. *She had an order to replace baggie, tubing, humidified bottle with distilled water and make with initials. *Clean oxygen concentrator every night shift on Thursday. *There was documented completion of above order that was initialed by staff on 7/6, 7/13, 7/20, and 7/27/23. Interview on 8/3/23 at 1:26 p.m. with director of nursing (DON) B regarding following physician's orders for changing oxygen and nebulizer tubing revealed: *She was not aware that staff had not been initialing and dating the tubing and baggies. *She stated that they should have followed up and ensured the orders had been followed. *She stated that she had entered the resident's rooms who used oxygen and she admitted she noticed that there were no baggies to store oxygen tubing when not in use. *Staff should have followed the physician's orders and the policy. *The policies were available for all staff to access and follow. Interview on 8/3/23 at 2:11 p.m. with administrator A regarding the orders for oxygen and nebulizer tubing changes revealed: *She had spoken to DON B about the physician's orders that were placed on the residents TAR. *If oxygen and nebulizer tubing change orders had been written on the TAR, staff need to follow the order. Review of the provider's undated Respiratory Therapy Prevention of Infection related to oxygen administration revealed: *Change the oxygen cannula and tubing every seven days and as needed. *Store the tubing in a plastic bag, marked with the date and resident's name between use. *Keep the oxygen cannula and tubing used prn {as needed} in a plastic bag when not in use. *Store the nebulizer set-up in a plastic bag , marked with the date, and resident's name between use. *Discard administration set-up every seven days. Based on observation, interview, record review, and policy review, the provider failed to ensure nursing staff followed physician orders for oxygen use and nebulizer tubing changes for six of six sampled residents (16, 2, 30, 23, 8, and 9) who received oxygen and nebulizer therapy. Findings include: 1. Observation on 8/1/23 at 1:06 p.m. in resident 16's room revealed: *The resident was lying in bed with his eyes closed, oxygen on, and his oxygen concentrator set at two liters via a nasal cannula. *His oxygen concentrator had a canister that contained water to humidify the oxygen with a handwritten date of 6/29/23. *The oxygen tubing was not marked with a date. *His nebulizer machine was placed on top of a dresser with the tubing and mask placed directly on top of the machine. -There was no date on the nebulizer tubing and that tubing was not stored in a plastic bag. Additional observations on 8/2/23 at 9:05 a.m. and again on 8/2/23 at 3:03 p.m. in resident 16's room revealed: *Oxygen tubing and the concentrator was in the same condition as above with a date of 6/29/23 on the water canister of the oxygen concentrator. *Nebulizer machine and tubing in the same position and condition as above. The date of 6/29/23 indicated that it had not been changed for four weeks, yet all weekly entries had been initialed by staff as changed on the treatment administration record (TAR) for July 2023. Review of resident 16's electronic medical record (EMR) revealed: *His diagnoses included chronic obstructive pulmonary disease (COPD), history of malignant neoplasm of the bronchus and lung, history of chronic pulmonary embolism, hypoxemia, history of Covid-19, traumatic brain injury, depression, and dementia with behavioral disturbance. *His medications included the following: -Albuterol Sulfate Hydrofluoroalkane Aerosol Solution 108 micrograms (mcg): inhale two puffs orally every four hours as needed for shortness of breath (SOB) related to COPD. -Budesonide-Fomoterol Fumerate Aerosol 160-4.5 mcg: inhale two puffs orally one time a day related to COPD. -Ipratropium Albuterol Solution 0.5-2.5 milligram (mg) 1 applicator inhale orally via a nebulizer every four hours as needed for SOB and or wheezing for COPD. -Two liters of oxygen via nasal cannula to keep saturations above 92 percent; oxygen concentrator set at two liters every day and night shift related to COPD with exacerbation. *A 7/28/22 physician's order to replace the oxygen baggie, tubing, humidifier bottle with distilled water and mark with date and initial. Clean the oxygen concentrator. Clean the nebulizer and change tubing every night shift on Thursday's. *He had an acute upper respiratory infection diagnosed on [DATE]. The resident was seen by his physician and diagnosed with an acute respiratory infection and placed on a steroid and an antibiotic due to increased SOB. Review of resident 16's July 2023 Treatment Administration Record (TAR) revealed: *Nebulizer tubing, oxygen tubing, water canisters, and plastic bags for tubing storage had been initialed by staff as changed on the following dates: -7/6/23. -7/13/23. -7/20/23. -7/27/23. Interview on 8/2/23 at 3:53 p.m. with certified nursing assistant (CNA) Z regarding the procedure for nebulizer tubing, oxygen tubing, and concentrator water canister changes revealed: *The night nurses were responsible to ensure the nebulizer tubing, oxygen tubing and water canisters were changed and dated every Thursday night. *Normally the nurses added purified water to the concentrator water canisters when low, but the CNAs would if the nurses were busy. *Every week the nursing staff were to change the oxygen and nebulizer tubing along with the water canister and mark them with the new date. Interview and observation on 8/2/23 at 5:30 p.m. with licensed practical nurse (LPN) Q regarding the procedure for nebulizer tubing, oxygen tubing, and concentrator water canister changes for resident 16 revealed: *The day nurses were not responsible for changing and dating the tubing or canisters for all residents with nebulizers and oxygen concentrators. *The night nurses had that responsibility. *The tubing and canisters were to have been changed each week on Thursdays for all residents who had used a nebulizer and/or oxygen therapy. *LPN Q followed the surveyor into the resident 16's room and agreed: -The nebulizer machine tubing and oxygen tubing was not dated. -The nebulizer machine tubing was not stored inside a plastic bag. -The date on the water canister was 6/29/23 which indicated it had not been changed as ordered. -The TAR should not have been signed off if the physician's order was not followed through as written. Interview and observation on 8/02/23 at 5:40 p.m. with infection preventionist H regarding the procedure for nebulizer tubing, oxygen tubing, and concentrator water canister changes for resident 16 revealed: *She confirmed: -The nebulizer machine tubing had not been dated and placed in a bag to store in between use. -The oxygen tubing had not been dated to indicate when it had last been changed. -The water canister had a date of 6/29/23 which indicated it had not been changed for four weeks. *The resident had COPD, a history of lung cancer and pneumonia and it would have been important for his nebulizer tubing, oxygen tubing, and water canisters to have been changed as ordered because of his vulnerable lungs. *Her expectation would have been for nursing staff to follow the physician's order and the procedures for changing and dating the nebulizer tubing, oxygen tubing, and water canisters weekly and then initial the TAR when the order was completed. Interview on 8/3/23 at 1:29 p.m. with director of nursing (DON) B regarding resident 16's oxygen tubing, nebulizer tubing and oxygen concentrator canister revealed: *She was not aware of resident 16's physician's orders had not been followed. *The procedure was for the nursing staff to change the nebulizer tubing, oxygen tubing, and concentrator water canisters for each resident with nebulizers and oxygen therapy each week. *Nebulizer and oxygen tubing should have been placed inside a plastic bag when not in use for proper storage in between use. *She agreed that the 6/29/23 date on resident 16's water canister would indicate it had not been changed as ordered and had been missed for four weeks. *The TAR should not have been initialed by staff if it had not been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of resident 15's medical record revealed the: *Paper medical record had been a form titled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions. -This form indicated he chose to have CPR. -His legal representative gave permission over the phone on [DATE]. -It had been signed by him with two witnesses and the physician on [DATE]. *Electronic medical record indicated he chose not to have CPR. *Care plan indicated he had not wanted CPR. 4. Review of resident 17's medical record revealed the: *Paper medical record had been a form titled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions. -This form indicated he chose not to be resuscitated. -His legal representative gave permission over the phone on [DATE]. -It had been signed by him with two witnesses on [DATE] and the physician on [DATE]. *Electronic medical record indicated he chose not to be resuscitated. *Care plan indicated he wanted CPR. Interview on [DATE] at 5:49 p.m. with licensed practical nurse (LPN) G about how she would find a resident's code status revealed she: *Would look at either the paper chart or the electronic medical record. *Had expected both the paper chart and the electronic medical record to be the same. Interview on [DATE] at 5:55 p.m. with social services director (SSD) D regarding the residents code status revealed: *A new form for code status had been initiated and code status for all residents had been reviewed and updated using the new form. *She agreed that the paper chart and the care plan should match signed code status form in the paper chart. *She had not realized all areas of residents medical record did not get updated. Interview on [DATE] at 6:00 p.m. with administrator A revealed: *She expected nurses to look at the electronic medical record for a resident's code status. *When the new code status form had been signed by the physician it should have been treated like a physician order and: -Entered into the electronic medical record -Updated on the care plan. Review of Provider's [DATE] advance directive policy revealed: *7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. *10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. *19. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. Based on record review, interview, and policy review, the provider failed to ensure the code status for four of sixteen sampled residents (5, 8, 15, and 17) documented in three areas of the medical record had been the same in all three areas. 1. Review of resident 5's medical record revealed the: *Paper medical record had been a form titled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions. -This form indicated he chose to have cardiopulmonary resuscitation (CPR). -It had been signed by his guardian on [DATE]. *Electronic medical record indicated he chose to not have CPR. *Care plan indicated he had not wanted CPR. 2. Review of resident 8's medical record revealed the: *Paper medical record had been a form titled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions. -This form indicated he chose not to be resuscitated. -It had been signed by him with two witnesses on [DATE] and the physician on [DATE]. *Electronic medical record indicated he chose to have CPR. *Care plan indicated he wanted CPR.

Based on observation, interview, and policy review, the provider failed to ensure dietary staff had: *Appropriately tested the sanitizer levels in the dishwasher and in the three-compartment sink. *Ensured expired food had been removed from the refrigerator. *Ensured food stored in the refrigerator had been appropriately labeled and dated. Findings include: 1. Interview on 4/6/22 at 1:45 p.m. with dietary aide (DA) F regarding testing the sanitizer in the dishwasher revealed: *He checked the levels of the cleaning products and sanitizer for the dishwasher daily to ensure they were not running low. *There was a warning light on the dishwasher that would light up when it was low on soap or sanitizer. *He did not check the sanitizer to see if it was in an acceptable range to ensure the dishes were sanitized. *He stated they used to have some test strips to test the sanitizer but they had run out about a week ago. *There had not been a log used to record the sanitizer levels. Interview and observation on 4/6/22 at 1:46 p.m. with cook E regarding testing the sanitizer revealed: *She had not ever seen test strips for the three compartment sink so she did not test to see if it was in an acceptable range. *Agreed there had been an instruction sheet on the wall above the three compartment sink on how to test the sanitizer. *She had been in the kitchen the day the dishwasher was installed and remembered being trained to use the test strips to see if the sanitizer was in an acceptable range. -The dishwasher had been installed about a year ago. -The person who installed the dishwasher had left testing strips, and they were to last about one year. *She thought they had run out of the test strips about one week ago. Interview on 4/6/22 at 1:47 p.m. with dietary manager (DM) C regarding testing the sanitizer revealed she: *Was not aware the sanitizer levels of the dishwasher and the three-compartment sink needed to be tested. *Did not know there had been no test strips available to the staff. *Agreed they did not have a log for documenting the sanitizer levels for the dishwasher or the three-compartment sink. On 4/6/22 at 2:00 p.m. surveyor had requested a policy for testing the sanitizer levels for the dishwasher and the three compartment sink. *Received a policy dated 4/6/22. *DM C had stated they did not have a policy so they had written one after it had been requested. Review of the Ecolab Oasis 146 Multi-Quat Sanitizer instructions that had been posted above the three compartment sink revealed it: *Gave instructions on how to test the levels and an acceptable range of 150 - 400 part per million. *Did not state how often to check the levels. *Did not give instructions on what to do if the level was not in acceptable range. 2. Observation on 4/4/22 at 12:20 p.m. in the kitchen of the three door refrigerator revealed: *One carton of lactose-free one percent milk with an expiration date of 3/11/22. *A small plastic container with a piece of fresh pineapple, it had a use by date of 3/29/22. *A small plastic bag containing a fresh piece of white onion, it was not dated. *A re-usable plastic container of green olives in a liquid, it was not dated. *A re-usable plastic container with food that appeared to be breaded chicken strips, it was not dated. *A large open bag of what appeared to be bits of cooked meat, such as bacon, it: -Did not have a date or label on it. -It was open and not sealed. Interview on 4/4/22 at 12:45 p.m. with the cook E revealed: *It was every one in the dietary departments responsibility to remove food from the kitchen when it was expired. *She had not noticed the above items were expired or not label appropriately. *She was going clean out the refrigerator. Observation and interview on 4/6/22 at 10:00 a.m. in the kitchen of the three door refrigerator with DM C revealed: *She had expected the dietary staff to dispose of food that was expired. *Residents were not to be served food that was expired. Interview on 4/6/22 at 1:15 p.m. with administrator A regarding the above observations and interviews revealed: *She had expected dietary staff to dispose of expired food and not to serve it to the residents. *There had not been residents with signs or symptoms of gastrointestinal upset. Review of the providers 2014 Refrigerators and Freezers policy revealed: *7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. *8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes.