**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to date and label Percutaneous Gastrostomy (PEG) tube feedings for 1 of 2 sampled residents (Resident #15) reviewed for Peg Tube feedings. The findings include: Review of the facility's policy titled, Feeding Tubes, dated 1/1/2021, revealed .Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications . Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, Diabetes, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 rarely/never understands, had short and long term memory problems, and received nutrition through a feeding tube. Review of the Medication Administration Record (MAR) dated 6/1/2022 - 6/30/2022, revealed .Diabetisource .30ml/hr [milliliters/hour] . Observation in the resident's room on 6/27/2022 at 11:45 AM, 2:10 PM, and 4:35 PM, revealed Resident #15's tube feeding that was being administered was not labeled. There was no resident identifier, room number, rate, start date, or start time. During an interview on 6/30/2022 at 8:37 AM, Licensed Practical Nurse (LPN) #3 confirmed Resident identifiers should be on the peg tube feeding bags when infusing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to honor dietary preferences for 2 of 6 sampled residents (Resident #9 and #65) reviewed for food preferences. The findings include: Review of the facility's policy titled, Resident Food Preferences, dated 1/1/2021, revealed .Upon the resident's admission Dietary Manager or designee will identify a resident's food preferences .the resident's clinical record .will document the resident's likes or dislikes . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Diabetes, Dementia, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, and Insomnia. Review of the Resident Profile Details for food preferences dated 3/9/2022, revealed Resident #9 disliked broccoli, shrimp, and cauliflower. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of a Dietary Progress Note dated 3/25/2022, revealed .Updated dislike to include broccoli and cauliflower . Review of Resident #9's meal ticket dated 6/29/2022, revealed broccoli florets were on her meal tray. Observation and interview in the resident's room on 6/29/2022 at 5:25 PM, revealed Resident #9's meal tray contained broccoli florets. Resident #9 stated, They always bring me broccoli .I don't like it . During an interview on 6/29/2022 at 5:37 PM, the Registered Dietitian confirmed Resident #9 should not have had broccoli on her meal tray on 6/29/2022. Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes, Prostate Cancer, and Anxiety. Review of the Resident Profile Details dated 5/31/2021, revealed Resident #65 disliked broccoli and cauliflower. Review of the annual MDS dated [DATE], revealed Resident #65 had a BIMS score of 7, which indicated he had severe cognitive impairment. Observation and interview in the resident's room on 6/29/2022 at 5:38 PM, revealed Resident #65's meal tray contained broccoli florets. Resident #65's responsible party stated, He doesn't eat broccoli . During an interview on 6/30/2022 at 8:18 AM, the Certified Dietary Manager (CDM) confirmed Resident #65 should not have received broccoli on his meal tray on 6/29/2022.

Amended 8/4/2022 Based on review of the Blood Glucose Monitoring System User Instruction Manual (a system used to test the amount of sugar in the blood), policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not properly disinfected to prevent cross-contamination of bloodborne pathogens (an organism in the blood that can produce a disease) for 1 of 3 sampled residents (Resident #8) observed during medication administration. The findings include: Review of the BLOOD GLUCOSE MONITORING SYSTEM User Instruction Manual revealed, .Cleaning & [symbol for and] Disinfecting Guidelines .We suggest cleaning and disinfecting the meter between patient use .Cleaning and disinfecting can be completed by using a commercially available EPA [Environmental Protection Agency]-registered disinfectant detergent or germicide wipe .To disinfect the meter, dilute 1 ml [milliliter] of household bleach .in 9 ml of water to achieve a 1:10 dilution .The solution can then be used to dampen a paper towel .Then use the dampened paper towel to thoroughly wipe down the meter . Review of the facility's policy titled, Blood Glucose Machine Disinfection, revised 7/15/2020, revealed .Disinfection is a process that eliminates many or all pathogenic microorganisms .on inanimate objects .The facility will ensure blood glucose machines will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .The blood glucose machine should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV [Human Immunodeficiency Virus], Hepatitis C and Hepatitis B virus .Blood glucose machines should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use . Review of the facility's training sheet titled, PSTG [Private Sector Testing Group] BLOOD GLUCOSE SPECIMEN AND SANITATION-ANNUAL, dated 9/30/2021, revealed .Met .Preparation .obtain supplies .Met .blood glucose machine sanitation .Purple Top [Cleaning cloth with bleach] only for cleaning glucometer .Learners Name .[Named Licensed Practical Nurse (LPN) #1] . Observation at the High 100 Hall Medication Cart #1 on 6/28/2022 at 8:30 AM, revealed LPN #1 knocked and entered Resident #8's room and performed a blood glucose test, using a multi-use blood glucose meter. LPN #1 exited the room, returned to the medication cart, removed a 75 percent (%) alcohol disinfectant wipe from the medication cart, cleaned the multi-use blood glucose meter, and placed it in a plastic cup on top of the medication cart. LPN #1 failed to disinfect the glucose meter with an EPA approved disinfectant wipe. During an interview on 6/28/2022 at 11:55 AM, LPN #2 was asked what should be used to disinfect the blood glucose meters. LPN #2 stated, .we are supposed to use the bleach wipes. During an interview on 6/28/2022 at 11:55 AM, LPN #1 was asked what should be used to disinfect the multi-use blood glucose meter. LPN #1 stated, We are supposed to use the bleach wipes. LPN #1 was asked if that was what was used this morning during the observation of a blood glucose check. LPN #1 stated, No, but I should have .I used what I had. During an interview on 6/28/2022 at 6:14 PM, the DON confirmed the multi-use blood glucose meters should be disinfected with a bleach cleaner. During an interview on 6/30/2022 at 10:53 AM, the DON confirmed staff should use a bleach wipe to disinfect the multi-use blood glucose meters after every use. The DON confirmed that LPN #1 had been instructed and had performed a return demonstration on the proper procedure to disinfect a multi-use blood glucose meter in 10/2021, during the facility's yearly competency check. The DON was asked what instructions were given to staff during the competency check for disinfecting the multi-use blood glucose meters. The DON stated, It says wipe down the machine with an approved cleaning pad, removing visible dirt and blood. Using the sanitizing cloth, wipe down all surfaces of the machine allowing for proper contact time of the product, if necessary wrap the machine in 1 or more sanitizing cloths for the period of time necessary, and over to the side there is a section in our competency that says purple top only for cleaning the glucometer and wet time is 2 minutes, then clean the glucometer with 1 towel, then wrap the glucometer in 2 towels, and you may place it on the medication cart or use a cup, while the glucometer is wrapped .place clean glucometer in the cart and repeat the process after each use. The DON was asked if staff should collect all supplies prior to performing a blood glucose to ensure they had all the supplies needed to complete the process. The DON stated, Yes, I would expect them to ensure they have everything they needed .she just did not make sure she had the purple top . The DON was asked if she expected staff to follow the instructions that were given to them during their competency check and return demonstration for cleaning the multi-use blood glucose meter. The DON stated, I do .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide education for Advance Directives to residents or residents' responsible parties for 24 of 24 sampled residents (Resident #5, #8, #9, #11, #12, #14, #15, #17, #18, #26, #31, #32, #34, #35, #36, #44, #51, #62, #65, #67, #71, #224, #424, and #425) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated 1/1/2022, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .The facility will provide the resident or resident representative information, in the manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive .upon admission . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes, Aphasia, Sepsis, and Acute Kidney Failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had severe cognitive impairment. Review of Resident #5's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebral Infarction, Diabetes, End Stage Renal Disease, and Cardiomegaly. Review of the quarterly MDS dated [DATE], revealed Resident #8 had severe cognitive impairment. Review of Resident #8's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Diabetes, Dementia, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, and Insomnia. Review of the quarterly MDS dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of Resident #9's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Quadriplegia, Neurogenic Bladder, Cerebral Infarction, and Hyponatremia. Review of the quarterly MDS dated [DATE], revealed Resident #11 was cognitively intact with a BIMS of 15. Review of Resident #11's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Acute Posthemorrhagic Anemia, Cerebral Infarction, Congestive Heart Failure, Dementia, and Dysphagia. Review of the admission MDS dated [DATE], revealed Resident #12 was cognitively intact with a BIMS of 15. Review of Resident #12's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Anxiety, and Bradycardia. Review of the quarterly MDS dated [DATE], revealed Resident #14 had moderate cognitive impairment with a BIMS of 8. Review of Resident #14's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, Diabetes, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of the significant change MDS assessment dated [DATE], revealed Resident #15 rarely/never understands, and had short and long term memory problems. Review of Resident #15's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of Dementia, Psychotic Disorder, Anxiety, and Encephalopathy. Review of the admission MDS dated [DATE], revealed Resident #17 had severe cognitive impairment with a BIMS of 3. Review of Resident #17's medical record, revealed there was no documentation the resident or the legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Dehydration, Pneumonia, Alzheimer's Disease, and Hypokalemia. Review of the admission MDS dated [DATE], revealed Resident #18 had severe cognitive impairment with a BIMS of 2. Review of Resident #18's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Coronary Artery Disease, Parkinson's Disease, Dementia, and Anxiety. Review of the annual MDS dated [DATE], revealed Resident #26 had severe cognitive impairment. Review of Resident #26's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Dysphagia, Insomnia, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #31 had severe cognitive impairment with a BIMS of 6. Review of Resident #31's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advance Directive upon admission. Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Cerebral Atherosclerosis, Diabetes, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #32 had severe cognitive impairment. Review of Resident #32's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Cellulitis, Hypoxemia, Alcohol Abuse, Psychotic Disorder, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #34 was cognitively intact with a BIMS of 15. Review of Resident #34's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Hemiplegia, Hemiparesis, Cerebral Infarction, Psychotic Disorder, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #35 was cognitively intact with a BIMS of 15. Review of Resident #35's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Dementia, Sepsis, Atrial Fibrillation, and Cerebral Infarction. Review of the quarterly MDS dated [DATE], revealed Resident #36 had severe cognitive impairment with a BIMS of 3. Review of Resident #36's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Dementia, Dysphagia, Colon Cancer, and Congestive Heart Failure. Review of the quarterly MDS dated [DATE], revealed Resident #44 had severe cognitive impairment with a BIMS of 3. Review of Resident #44's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #51 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Dementia, Hypothyroidism, and Dysphagia. Review of the quarterly MDS dated [DATE], revealed Resident #51 had severe cognitive impairment with a BIMS of 4. Review of Resident #51's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advance Directive upon admission. Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dementia, Anxiety, and Dehydration. Review of the admission MDS dated [DATE], revealed Resident #62 had moderate cognitive impairment with a BIMS of 11. Review of Resident #62's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes, Prostate Cancer, and Anxiety. Review of the annual MDS dated [DATE], revealed Resident #65 had severe cognitive impairment with a BIMS of 7. Review of Resident #65's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dementia, Alcohol Abuse, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #67 was cognitively intact with a BIMS of 15. Review of Resident #67's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #71 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, End Stage Renal Disease, and Atrial Fibrillation. Review of the quarterly MDS dated [DATE], revealed Resident #71 was cognitively intact with a BIMS of 15. Review of Resident #71's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #224 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Anxiety, Dementia, Psychotic Disorder, and Insomnia. Review of the admission MDS dated [DATE], revealed Resident #224 had severe cognitive impairment with a BIMS of 2. Review of Resident #224's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #424 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia, Diabetes, Aphasia, and Gastrostomy. Review of the admission MDS dated [DATE], revealed Resident #424 had severe cognitive impairment. Review of Resident #424's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #425 was admitted to the facility on [DATE] with diagnoses of Diabetes, Gastritis, Hiatal Hernia, and Hypothyroidism. Review of the admission MDS dated [DATE], revealed Resident #425 was cognitively intact with a BIMS of 15. Review of Resident #425's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. During an interview on 6/28/2022 at 8:50 AM, the Administrator confirmed the facility did not have the Advanced Directives or documentation that education for Advanced Directives had been provided. The Administrator stated, .All I have is what I showed you [Physician's Orders for Scope of Treatment (POST) form] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to maintain a safe, sanitary, and homelike environment for 2 of 45 resident rooms (room [ROOM NUMBER] and #222) related to a torn fall mat on the floor and a dirty privacy curtain, and when 5 of 5 Lifts (Hoyer Lift #1, Hoyer Lift #2, Hoyer Lift #3, Stand Lift #1, and Stand Lift #2) had dirty grime build-up. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 3/20/2020, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control) recommendations in order to break the chain of infection .Multiple-resident use equipment shall be cleaned and disinfected after each use . Review of the facility's undated policy titled, .JOB TO BE DONE .CLEAN CUBICLE CURTAINS, revealed .If curtain is stained, remove immediately .Have spare curtains to replace dirty or torn curtains immediately . Observation in room [ROOM NUMBER] on 6/27/2022 at 9:17 AM, 2:39 PM, and 4:44 PM, on 6/28/2022 at 8:35 AM and 11:23 AM, and on 6/29/2022 at 2:42 PM, revealed the fall mat on the floor had torn, ripped areas, and the torn pieces were hanging off of the mat onto the floor. During an interview on 6/29/2022 at 6:40 PM, the Assistant Director of Nursing (ADON) confirmed the fall mat in room [ROOM NUMBER] was not in good condition. Observation in room [ROOM NUMBER] on 6/27/2022 at 10:19 AM, 1:55 PM, and 4:28 PM, on 6/28/2022 at 8:03 AM, 12:04 PM, and 5:24 PM, and on 6/29/2022 at 7:47 AM, revealed a privacy curtain near the entrance to the room had splatters of a brown substance on the curtain and a privacy curtain in the middle of the room had splatters of a reddish brown substance on the curtain. During an interview on 6/29/2022 at 7:58 AM, the Housekeeping Manager confirmed the privacy curtains in room [ROOM NUMBER] were stained and needed to be cleaned. Observation in the 100 Hall on 6/28/2022 at 9:00 AM and 11:25 AM, revealed Stand Lift #1 and Stand Lift #2 had gray and white flaky material covering the base of the stands, and the wheels on both lifts had a build up of dust, grime, and hair. Observation in the Activity Room on 6/29/2022 at 4:30 PM, revealed Stand Lift #1 and Stand Lift #2 had gray and white flaky material covering the base of the stands, and the wheels on both lifts had a build up of dust, grime, and hair. During an interview on 6/29/2022 at 4:30 PM, the Activity Director confirmed Stand Lift #1 and Stand Lift #2 needed to be cleaned. During an observation and interview in the Activity Room and the 100 Hall on 6/30/2022 beginning at 8:15 AM, the ADON confirmed Hoyer Lift #1, Hoyer Lift #2, Hoyer Lift #3, Stand Lift #1 and Stand Lift #2 were dirty and needed to clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to nail care and facial hair was provided for 4 of 18 sampled residents (Resident #14, #17, #18, and #35) reviewed. The findings include: Review of the facility's policy titled, Nail Care, dated 1/1/2021, revealed .for the provision of care to a resident's nails for good grooming and health .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .Routine nail care, to include trimming and filing, will be provided on a regular basis .Nails should be kept smooth to avoid skin injury . Review of the facility's policy titled, Activities of Daily Living . dated 1/1/2021, revealed .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 . Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Anxiety, and Bradycardia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated she had moderately impaired cognition, and required extensive assistance from staff for personal hygiene. Review of the Care Plan dated 4/4/2022 revealed .The resident needs activities of daily living assistance .PERSONAL HYGIENE . Observation in the resident's room on 6/27/2022 at 2:36 PM and 4:45 PM, on 6/28/2022 at 8:38 AM, 11:28 AM, and 2:08 PM, and on 6/29/2022 at 8:50 AM, revealed Resident #14 had long jagged fingernails with a brown substance under the nails and had long whiskers on her chin and upper lip. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of Dementia, Psychotic Disorder, Anxiety, and Encephalopathy. Review of the admission MDS dated [DATE], revealed Resident #17 had a BIMS score of 3, which indicated she had severe cognitive impairment, and required extensive assistance from staff for personal hygiene. Review of the Care Plan with a revised date of 5/11/2022, revealed Resident #17 required assistance from staff for personal hygiene. Observation in the resident's room on 6/27/2022 at 10:29 AM, 12:00 PM, and 2:57 PM, on 6/28/2022 at 8:16 AM, on 6/29/2022 at 9:05 AM and 4:12 PM, and on 6/30/2022 at 8:20 AM, revealed Resident #17 had gray and black whiskers on her chin and upper lip. During an interview on 6/30/2022 at 8:22 AM, in Resident #17's room, Licensed Practical Nurse (LPN) #1 confirmed Resident #17 had facial whiskers and needed to be shaved. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Dehydration, Pneumonia, Alzheimer's Disease, and Hypokalemia. Review of the Care Plan dated 5/20/2022, revealed Resident #18 required assistance with activities of daily living (ADLs). Review of the admission MDS dated [DATE], revealed Resident #18 had a BIMS of 2, which indicated she had severe cognitive impairment, and required extensive assistance from staff for personal hygiene. Observation in the resident's room on 6/27/2022 at 9:17 AM, 2:39 PM, and 4:44 PM, on 6/28/2022 at 8:35 AM, and on 6/29/2022 at 2:42 PM, revealed Resident #18 had long jagged fingernails with a brown substance under the nails and whiskers on her chin and upper lip. During an interview on 6/29/2022 at 2:43 PM, LPN #1 confirmed Resident #18 had whiskers that needed to be shaved and needed to have her nails cleaned and trimmed. Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Hemiplegia, Hemiparesis, Cerebral Infarction, Psychotic Disorder, and Depression. Review of the annual MDS dated [DATE], revealed Resident #35 had a BIMS of 15, which indicated she was cognitively intact, and required extensive assistance from staff for personal hygiene. Review of the Care Plan dated 5/16/2022, revealed Resident #35 required staff assistance for ADLs. Observation in the resident's room on 6/27/2022 at 9:15 AM and 2:35 PM, on 6/28/2022 at 9:33 AM, 12:02 PM, and 5:35 PM, and on 6/29/2022 at 9:02 AM and 2:20 PM, revealed Resident #35 had long fingernails with a brown substance under the nails. During an interview on 6/29/2022 at 2:22 PM, LPN #1 looked at Resident #35's nails and confirmed they needed to be cleaned and trimmed. During an interview on 6/30/2022 at 11:28 AM, the Director of Nursing (DON) confirmed female residents should not have facial hair and their nails should be trimmed and cleaned.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when opened, unlabeled, undated food was in the Kitchen and the dry storage area, black, shiny build-up was on the stove, frying pans, and ovens, a shiny yellow build-up was observed on the vent-a-hood, thick, dark gray dust was observed on the fan in the walk-in-cooler, dark, brown build-up was observed on the tea makers, 9 serving trays were wet-nested, 6 metal pans were wet-nested, and 1 of 6 dietary staff (Dietary Aide #2) used a dirty dish rack to push a clean dish rack out of the ware-washer and failed to perform hand hygiene when she went from the dirty side of the ware-washer to the clean side. The facility had a census of 77 with 73 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's policy titled, .Food Storage: Cold, dated 5/2014, revealed .The Food Service Director/Cooks(s) ensures that all food items are stored properly in covered containers, labeled and dated . Review of the facility's policy titled, .Manual Warewashing, revised on 9/2017, revealed .All serviceware and cookware will be air dried prior to storage . Review of the facility's policy titled, .Environment, revised on 9/2017, revealed .All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces . Review of the facility's policy titled, .Food Preparation, revised on 9/2017, revealed .All staff will practice proper hand washing techniques and glove use .Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination . Review of the facility's policy titled, .Equipment, revised on 9/2017, revealed .All non-food contact equipment will be clean and free of debris . Observation in the in the Kitchen on 6/27/2022 at 9:15 AM, revealed: a. 2 open, undated packages of dry seasoning mix b. 1 open, undated, unsealed bag of confectioner sugar Observation in the in the Kitchen on 6/27/2022 at 9:15 AM and 2:00 PM, and on 6/28/2022 at 8:36 AM, revealed: a. two tea makers with a dark brown substance on the metal area above the tea bag holder b. a shiny black substance on 6 gas stove burners c. a shiny gold accumulation on the stove's vent-a-hood Observation in the walk-in cooler on 6/27/2022 at 9:21 AM and 2:08 PM, revealed a thick, dark gray ball of dust on the exhaust fan. Observation in the dry storage area of the Kitchen on 6/27/2022 at 9:27 AM, revealed: a. an opened, undated bag of toasted oats cereal b. an opened, undated bag of confectioner sugar During an interview on 6/27/2022 at 2:00 PM, the Dietary Manager (DM) observed the stove and stated, .It will always look like that. The stove is 7 years old . Observation in the Dishwashing Area on 6/27/2022 at 2:10 PM, revealed Dietary Aide #2 used a dirty rack of dishes to push a clean rack of dishes out of the ware-washer. Dietary Aide #2 removed her soiled gloves, failed to perform hand hygiene, went to the clean side of the ware-washer, lifted the handle, and opened the ware-washer with soiled hands. Dietary Aide #1 entered the dish room, removed serving trays from a clean rack, dried the trays with a disposable towel, and failed to allow the trays to air dry. Observation in the Dishwashing Area on 6/27/2022 at 2:18 PM, revealed 9 wet-nested serving trays stacked on a shelf. Observation in the Kitchen on 6/28/2022 at 8:36 AM, revealed a black, shiny build-up inside the upper and lower ovens on the base and sides. Observation in the dry storage area in the Kitchen on 6/28/2022 at 8:39 AM, revealed: a. an opened, undated bag of hot dog buns b. an opened, undated package of sliced bread Observation in the Dishwashing Area on 6/28/2022 at 8:43 AM, revealed a black, shiny build-up on the outer surface of a frying pan on a metal shelf. Observation in the Dishwashing Area on 6/28/2022 at 11:25 AM, revealed the following on a metal shelf: a. two wet-nested 6-inch quarter metal pans, b. two wet-nested 4-inch full metal pans, c. two wet-nested 6-inch half metal pans, and d. black, shiny build-up on the outer surface of a frying pan. During an interview on 6/29/2022 at 3:29 PM, the Registered Dietician (RD) confirmed opened foods should be dated and labeled, the stove should not have carbon or grease build-up, the vent-a-hood should not have grease build-up, staff should not use a dirty rack of dishes to push a clean rack of dishes out of the ware-washer, staff should sanitize their hands after removing gloves, staff should not use their soiled hands to lift the handle on the clean side of the ware-washer, tea makers should be clean, all serving trays and metal pans should be air dried and not wet-nested, skillets should be free of carbon build up, the exhaust fan in the walk-in cooler should be free of dust, and the oven should be clean.