**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advanced Directive for 1 of 32 sampled residents (Resident #113) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, admission Process: Advance Directives, dated 10/2017, revealed .protect the resident's rights and resident choice to advance life support initiatives upon admission/readmission .advance directives .will be signed prior to admission . Review of the medical record, revealed Resident #113 was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure, Gastrostomy, Guillain-Barre Syndrome, and Convulsions. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #113 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of Resident #113's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. During an interview on 6/22/2022 at 5:29 PM, the Director of Nursing confirmed all residents should be provided the information regarding Advanced Directives on admission.

**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 the environment was free from accident hazards for 1 of 4 sampled residents (Resident #19) reviewed for accidents. The findings include: Review of the facility's undated policy titled, Accidents and Supervision, revealed .The resident environment remains as free of accident hazards as is possible .The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents . Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Heart Disease, Dementia, and Obesity. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #19 had moderately impaired cognition. Review of the Care Plan revised on 4/20/2022, revealed, .The resident's safety will be maintained . Observation in the Dining Room on 6/20/2022 at 9:18 AM and 12:32 PM, and on 6/21/2022 at 8:20 AM and 3:47 PM, revealed Resident #19 was sitting at a table that had torn jagged veneer on all sides. During an interview with 6/22/2022 at 8:38 AM, Licensed Practical Nurse #2 confirmed the table in the Dining Room had rough and jagged veneer and could be a safety hazard for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow the pharmacy recommendations in a timely manner 1 of 5 sampled residents (Resident #12) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled POLICIES AND PROCEDURE Pharmacy Services, dated 6/1/2021, revealed The consultant pharmacist documents activities performed and services provided on behalf of the residents and the facility. A written or electronic report of findings and recommendations resulting from the activities as described above is given to the, attending physician, director of nursing, medical director and others as may be appropriate (e.g. [example] administrator, regional manager .) monthly. The facility has a process to ensure that the findings are acted upon . Review of medical record, revealed Resident #12 was admitted on [DATE], and readmitted on [DATE], with diagnoses of Femur Fracture, Diabetes, Acute Failure Kidney, Dementia and Urinary Retention. Review of the significant change Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment and Resident #12 was receiving insulin. Review of the Consultant Pharmacist Communication to the Physician sheet dated 4/2022, revealed .Novolog is currently being given 3 times daily. Due to the fast-acting nature of this insulin and the risk of hypoglycemia, please consider adding a hold parameter to Novolog order so that dose will not be administered if blood sugar is too low or resident is not eating . The facility was unable to provide documentation that the 4/2022 Pharmacy recommendation was reviewed by a Physician or Nurse Practitioner until 6/2/2022. During an interview on 6/22/2022 at 4:05 PM, the Director of Nursing (DON) was asked what the process was for Pharmacy recommendations. The DON confirmed that Pharmacy recommendations should be addressed before the next month. During an interview on 6/23/2022 at 10:13 AM, Nurse Practitioner #1 was asked if a Pharmacy recommendation from 4/2022 should be addressed prior to 6/2022. Nurse Practitioner #1 confirmed the recommendations should be addressed timely.

**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 were provided related to nail care, skin care, and facial hair for 4 of 6 sampled residents (Resident #27, #41, #58, and #115) reviewed for ADLs. The findings include: Review of the facility's policy titled, .Fingernails/Toenails, Care of, dated 10/2017, revealed .The proper care of fingernails .The purpose of this procedure is to clean the nail bed, to keep the nails trimmed, and to prevent infections. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Review of the facility's undated policy titled, .Activity of Daily Living ., revealed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .personal .hygiene . Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Heart Disease, Diabetes, Depression, and Dementia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #27 had moderately impaired cognition, had no behaviors, and required extensive assistance from staff for personal hygiene. Review of the Care Plan revised on 6/21/2022, revealed .Nail and oral care routinely and PRN [as needed] . Observation in the Dining Room on 6/20/2022 at 6:35 AM, 9:19 AM, and 12:34 PM, on 6/21/2022 at 3:45 PM, and on 6/22/2022 at 8:25 PM, revealed Resident #27 was sitting in a chair and her fingernails were long, dirty, and had a brown substance built up underneath them. During an interview on 6/22/2022 at 8:35 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #27's nails that needed to be cleaned and trimmed. Review of the medical record, revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Parkinson's Disease, Diabetes, and Dementia. Review of the Care Plan dated 2/4/2021, revealed .Check nail length and trim and clean on bath day and as necessary . Review of the quarterly MDS dated [DATE], revealed Resident #41 had moderately impaired cognition, no behaviors, and required extensive assistance from 2 staff for personal hygiene. Observation in the resident's room on 6/20/2022 at 7:38 AM, 9:39 AM, and 2:11 PM, on 6/21/2022 at 8:28 AM and 3:25 PM, and on 6/22/2022 at 3:08 PM, revealed Resident #41 was in bed, with long fingernails with a brown substance built up underneath them. During an interview on 6/22/2022 at 3:08 PM, LPN #3 confirmed Resident #41's nails needed to be trimmed and cleaned. Review of the medical record, revealed Resident #58 was admitted to the facility on [DATE] with diagnoses of Traumatic Brain Injury, Tracheostomy, Schizophrenia, and Paraplegia. Review of the quarterly MDS dated [DATE], revealed Resident #58 had severe cognitive impairment, had no behaviors, and was totally dependent on staff for personal hygiene. Review of the Care Plan revised on 5/28/2022, revealed, .Resident needs assist of 1-2 for personal hygiene . Observation in the resident's room on 6/20/2022 at 7:34 AM, 9:38 AM, and 2:10 PM, on 6/21/2022 at 8:25 AM and 3:53 PM, and on 6/22/2022 at 10:55 AM, revealed Resident #58 had long, curled, black chin whiskers. During an interview on 6/22/2022 at 10:55 AM, LPN #3 confirmed Resident #58 had long, curled, black chin whiskers and she should have been shaved. Review of the medical record, revealed Resident #115 was admitted to the facility on [DATE] with diagnoses of Diabetes, Dementia, Heart Disease, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #115 was cognitively intact, had no behaviors, and required extensive assistance from staff for personal hygiene. Review of the Care Plan revised on 6/21/2022, revealed Resident #115 required the assistance of one staff member for personal hygiene. Observation in the resident's room on 6/21/2022 at 3:15 PM, and on 6/22/2022 at 8:40 AM, 10:30 AM, and 3:08 PM, revealed Resident #115 was in the bed with long fingernails with a brown substance built up underneath them and dry flaky skin on his ankles, shins, and the tops of his feet. During an interview on 6/21/2022 at 8:31 AM, Resident #115 confirmed staff did not honor his request to trim and clean his fingernails. During an interview on 6/22/2022 at 3:08 PM, LPN #3 confirmed Resident #115 should have received care for the flaky skin on his ankles, shins, and feet and confirmed his fingernails needed to be trimmed and cleaned.

**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 enteral feedings with automatic flushes were infusing at the correct rate and failed to ensure enteral feedings and automatic flush bags were correctly labeled for 3 of 3 sampled residents (Resident #17, #65, and #94) reviewed for enteral feedings. The findings include: Review of the facility's undated policy titled, Care and Treatment of Feeding Tubes, revealed .Feeding tubes will be utilized according to physician orders .Open system feeding bags will be changed every 24 hours . Review of the medical record, revealed Resident #17 was admitted to facility on 2/24/2022 with diagnoses of Hemiplegia, Hemiparesis, Gastrostomy (a tube inserted into the stomach to administer liquid nourishment), and Cerebral Infarction. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #17 was assessed with a Brief Interview for Mental Status score (BIMS) of 1, which indicated Resident #17 was severely cognitively impaired, and received nutrition through a feeding tube. Review of the facility's Order Review History Report dated 5/23/2022 - 6/23/2022, revealed Resident #17 should receive automatic water flushes at 50 milliliters (ml) an hour for 20 hours and Glucerna 1.5 at 70 ml an hour for 20 hours. Observation in the resident's room on 6/20/2022 at 7:09 AM and 9:29 AM, on 6/21/2022 at 8:04 AM and 9:53 AM, and on 6/22/2022 at 8:57 AM, revealed Resident #17 had an enteral feeding pump (a pump used to deliver an enteral feeding) with Glucerna 1.5 infusing at 50 ml per hour and an automatic water flush infusing at 60 ml per hour. During an interview on 6/22/2022 at 3:33 PM, Licensed Practical Nurse (LPN) #1 confirmed the enteral feeding was set at an incorrect rate. LPN #1 confirmed the enteral feeding of Glucerna 1.5 should be at 70 ml per hour with the automatic water flush at 50 ml per hour. During an interview on 6/22/2022 at 4:20 PM, the Director of Nursing (DON) confirmed that an enteral feeding pump and the automatic water flush should be set at the rate ordered by the physician. Review of the medical record, revealed Resident #65 was admitted on [DATE] with diagnoses of Cerebral Infraction, Hemiplegia, Aphasia, Gastrostomy, Dysphagia, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #65 had a BIMS of 99, indicating severe cognitive impairment, and received tube feedings. Review of the Physician's Order dated 6/1/2022, revealed .every shift for caloric intake Enteral: H20 [water] Auto Flush feeding tube with 65 cc [cubic centimeters]/ [per]hr [hour] over 19hrs . Observation in the resident's room on 6/20/2022 at 12:07 PM, revealed Resident #65 had an enteral feeding pump with an unlabeled automatic flush bag. Observation in the resident's room on 6/22/2022 at 5:47 PM, revealed Resident #65 had an enteral feeding pump with an enteral feeding bag labeled with the resident's last name and dated 6/22/2022. An automatic water flush bag was labeled with the resident's first name, room #, a rate of 65, dated 6/22/2022, and labeled Jevity 1.5. During an interview on 6/22/2022 at 4:26 PM, the DON was asked what should be on the label of a tube feeding. The DON stated, The formula, patient's name, rate, and date it was started. The DON was asked what should be on the label on the flush. The DON stated, Should have patient's name, date, and the rate. Review of the medical record, revealed Resident #94 was admitted to the facility on [DATE] with diagnoses of Cerebrovascular Disease, Gastrostomy Status, Diabetes, and Dysphagia. Review of the Care Plan dated 4/7/2020, revealed .NPO [Nothing by Mouth] status requiring 100 percent (%) needs met via [by way of] peg [Percutaneous Endoscopic Gastrostomy] tube . Review of the quarterly MDS dated [DATE], revealed Resident #94 had a BIMS score of 9, indicating moderately impaired cognition and received 51 % or more of total calories, and 501 ml or more of fluids by a tube feeding daily. Review of the Order Summary Report dated 6/22/2022, revealed .every shift Enteral: H20 Auto Flush feeding tube with 40cc/hr x [times] 18 hrs .CHANGE AND DATE TUBE FEEDING, SYRINGE AND TUBING WHEN FEEDING IS STARTED one time a day . Review of the Medication Administration Record (MAR) dated 6/1/2022-6/30/2022, revealed the tube feeding, syringe, and tubing were signed as being changed on 6/19/2022 and 6/20/2022 at 1:00 AM. Observation in the resident's room on 6/20/2022 at 9:23 AM and 1:26 PM, revealed an enteral feeding pump with an automatic flush bag dated 6/18/2022 at 12:00 AM. During an interview on 6/22/2022 at 4:25 PM, the DON was asked how often enteral feeding flush bags and tubing should be changed. The DON stated, .every 24 hours . The DON was asked if it was acceptable for an automatic water flush bag, dated 6/18/2022 at 12:00 AM, to still be hanging and infusing water to a feeding tube on 6/20/2022. The DON stated, No, it should be changed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide the necessary respiratory care and services when a tracheostomy tubing condensation collection bag was lying on the floor, humidification bottles were on the floor, a dusty fan was blowing on a resident's tracheostomy, and there were no physician orders for oxygen for 4 of 4 sampled residents (Resident #23, #41, #44 and #45) reviewed for oxygen therapy. The findings include: Review of the facility's policy titled, .Trach [Tracheostomy] Care, dated 10/2017, revealed .Our policy is to provide care for the resident with a tracheostomy present to prevent nosocomial infections . Review of the facility's policy titled, .Oxygen, dated 12/2017, revealed .Oxygen therapy is administered to the resident only upon the written order of a licensed physician . Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure and Tracheostomy. Review of the Physician's Orders dated 6/22/2022, revealed .May suction trach [tracheostomy] . There was not an order for oxygen administration. Observation in the resident's room on 6/20/2022 at 7:32 AM, 9:37 AM, and 1:58 PM, revealed Resident #23's tracheostomy tubing condensation collection bag was lying in the floor. Review of the medical record, revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Anxiety. Review of a Care Plan revised 6/21/2022, revealed, .OXYGEN as ordered . Observation in the resident's room on 6/20/2022 at 7:38 AM, 9:39 AM, and 2:11 PM, revealed Resident #41's oxygen humidification bottle was lying on the floor. Review of the medical record, revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure and Anoxic Brain Damage. Review of a Physician's Order dated 6/22/2022, revealed, .O2 [Oxygen] .3 .LPM [Liters Per Minute] via [NAME] trach . Observation in the resident's room on 6/20/2022 at 7:29 AM, 9:41 AM, 1:58 PM, on 6/21/2022 at 8:37 AM and 3:37 PM, and on 6/22/2022 at 9:24 AM, revealed a fan, covered in dust, was blowing directly toward Resident #44's tracheostomy. During an interview on 6/22/2022 at 9:30 AM, Respiratory Therapist (RT) #1 confirmed a dusty fan should not be blowing on the resident's tracheostomy and confirmed the fan should be clean and free of dust. Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Asthma, and Shortness of Breath. Review of the Physician's Orders dated 6/12/2022, revealed there was no order for oxygen administration. Observation in the resident's room on 6/20/2022 at 6:44 AM, 9:32 AM, and on 6/21/2022 at 8:39 AM, 1:26 PM, and 3:18 PM, revealed Resident #45 was receiving oxygen through a binasal cannula in her nose and the oxygen humidification bottle was lying in the floor. During an interview on 6/22/2022 at 4:04 PM, the Director of Nursing (DON) confirmed there should be a physician's order for oxygen for a resident receiving oxygen therapy. During an interview on 6/22/2022 at 4:29 PM, the DON was asked if humidifier bottles should be lying on the floor of a resident's room. The DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by opened, unlabeled, undated food in the walk-in cooler and in the dry storage area, a mop lying in a bucket of dirty water near the stove during meal preparation, a dirty kitchen floor, a dirty deep fryer, a dirty convection toaster, a dirty food slicer, a scoop lying in the sugar bin, a Styrofoam cup lying in the raisin bran bin, carbon build-up on 2 sauté pans, opened, undated, unlabeled food items in the cooler, a dirty plate warmer, dirty 3-tiered cart, and a dirty tray line conveyor in the serving line area. The facility had a census of 133 with 105 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's undated policy titled, .Sanitation Inspection, revealed .It is the policy of this facility .to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations .All food services areas shall be kept clean, sanitary, free from litter, rubbish .The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation and daily inspections . Review of the facility's undated policy titled, .Dietary Department Guidelines, revealed .The facility must store, prepare, and distribute food under sanitary conditions .The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness .All items stored in the refrigerator will be covered and labeled with the contents and the date .All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner .Any piece of equipment, dish, or utensil will be discarded when it is cracked, broken, discolored, or abraded .cleaning equipment such as mops, buckets .will be stored in a separate janitorial area, away from the kitchen/food preparation areas . Review of the facility's undated checklist titled, .SANITATION INSPECTION - KITCHEN OBSERVATION, revealed .DRY STORAGE .All opened food items are labeled, dated, and in air tight containers .WALK IN COOLER .All items are covered, labeled, dated, and in air tight containers .MAIN PRODUCTION AREA .Floor is clean .near a meal time .Work tables are clean .Following equipment is clean .Food slicer .Fryer .Tray carts are clean .Pots and pans do not have excessive carbon build up . Observation in the Kitchen on 6/20/2022 at 5:28 AM, revealed the floor had black shoe marks, a shiny, slippery substance covering the floor, debris, and dirt build-up. A mop was sitting in a bucket of dark blackish-gray water beside the stove during breakfast preparation. Observation in the walk-in cooler in the Kitchen on 6/20/2022 at 5:32 AM, revealed the following: a. an undated, unlabeled pan of gravy b. an undated, unlabeled bag of pureed eggs c. an undated, unlabeled plastic bag of whole, cooked sweet potatoes d. an undated, unlabeled plastic bag of scrambled eggs e. an undated, unlabeled pan of ground sausage with 4 sausage patties lying on top of the ground sausage f. an undated, unlabeled plastic bag of dough Observation in the dry storage area of the Kitchen on 6/20/2022 at 5:42 AM, revealed: a. an opened, undated bag of hamburger buns b. an opened, undated bag of bread c. a scoop lying in the sugar bin d. an opened, undated gallon-size maple syrup e. an opened, undated, unsealed bag of sugar f. an opened, undated, unsealed package of cookies g. an opened, undated bag of vanilla wafers Observation in the food preparation area in the Kitchen on 6/20/2022 at 5:52 AM, revealed: a. carbon build-up on 2 sauté pans b. a Styrofoam cup lying in a plastic container of raisin bran cereal c. 3 opened, undated packages of gravy mix d. 1 opened, undated, unsealed bag of confectioner sugar e. a convection toaster with a thick build-up of crumbs and dust f. dried particles of a brown and black substance on the food slicer g. balls of thick, brown grease build-up and old shiny brown build-up on both sides of the deep fryer, extending down to the floor on both sides Observation in the cooler in the Kitchen on 6/20/2022 at 6:00 AM, revealed: a. 3 opened, undated, unlabeled plastic bags of lettuce and tomatoes b. 3 opened, undated, unlabeled bowls of salad During an interview on 6/20/2022 at 6:05 AM, the Dietary Manager (DM) looked in the cooler, saw the bags of lettuce and tomatoes and the salads and stated, .those were left from last night . Observation in the Kitchen on 6/20/2022 at 9:42 AM, revealed a piece of foil lying in an uncovered pan of tomato sauce, an opened, undated, unlabeled box of quick oats was on a shelf near the stove, thick, brown balls of grease build-up and old shiny brown build-up was on both sides of the deep fryer, extending down to the floor on both sides, and the floor had black shoe marks, a shiny, slippery substance covering the floor, debris, and dirt build-up. Observation in the walk-in cooler in the Kitchen on 6/20/2022 at 9:45 AM, revealed 13 unlabeled, undated packages of sandwich meat in a pan on a shelf. Observation in the dry storage area in the Kitchen on 6/20/2022 at 9:46 AM, revealed: a. an opened, undated bag of hamburger buns b. a scoop lying in the sugar bin c. an opened, undated gallon-size maple syrup d. an opened, undated unsealed package of cookies e. an opened, undated bag of vanilla wafers Observation in the Kitchen, with the Dietary Manager, on 6/22/2022 at 9:40 AM, revealed: a. an opened, undated bag of hamburger buns b. a scoop lying in the sugar bin c. an opened, undated gallon-size maple syrup d. an opened, undated unsealed package of cookies e. an opened, undated bag of vanilla wafers f. 13 unlabeled, undated packages of sandwich meat in a pan on a shelf of the walk-in cooler During an interview on 6/22/2022 at 9:42 AM, the DM confirmed all opened items should be labeled and dated. The DM confirmed the sandwich meat in the walk-in cooler should be labeled and dated. The DM confirmed the toaster needed cleaning due to the build-up of crumbs and confirmed an opened box of oatmeal should be sealed, labeled, and dated. The DM confirmed the scoop should not be lying in the sugar bin, and the Styrofoam cup should not be lying in the container of raisin bran. The DM confirmed there was build-up on the meat slicer, and it needed cleaning. The DM confirmed a mop should not be lying in a bucket of dirty water in the Kitchen during meal preparation. Observation in the serving line area of the Kitchen on 6/22/2022 at 11:45 AM, revealed the plate warmer had a dried yellow substance smeared across the front, a 3-tiered serving cart was dirty with old food crumbs, and white and gray particles, the tray line conveyor was dirty with old food crumbs and gray and white flakes, the deep fryer had a build-up of a shiny brown substance on both sides along with thick balls of a brown shiny substance, extending down to the floor, on both sides, and the floor had black shoe marks, a shiny, slippery substance covering the floor, debris, and dirt build-up. During an interview on 6/22/2022 at 3:10 PM, the DM confirmed the plate warmer, the 3-tiered serving cart, the tray line conveyor, and the deep fryer were dirty and needed to be cleaned. She confirmed the floor was not clean and stated, .it needs some work . The DM confirmed 2 sauté pans had carbon build-up and should not be in the cooking equipment area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, medical record review, and interview, the facility failed to ensure each resident was repositioned to promote comfort and provide pressure relief for 1 (Resident #22) of 4 residents reviewed for positioning. The findings include: 1. The facility's Repositioning policy documented, .A turning /repositioning program includes a continuous consistent program for changing the resident's position and realigning the body .Place the resident in a comfortable position in accordance with the resident's individualized care plan .The following information should be recorded in the resident's medical record .The position in which the resident was placed .The name and title of individual who gave the care .signature and title of the person recording the data . 2. Medical record review revealed Resident #22 was admitted on [DATE] with diagnosis of Encephalopathy, Gastro-esophageal Reflux Disease, Sepsis, Acute Kidney Failure, Pressure Ulcer Sacral Region Stage 4, Muscle Weakness, Dysphagia, Aphasia, Pressure Ulcer left Hip Unstageable, Dementia, Acute Deep Vein Thrombosis Lower Extremity. The Annual Minimal Data Set (MDS) dated [DATE] and a quarterly MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) 2 indicating severe cognitive impairment, extensive assistance with bed mobility. Observations of Resident #22 on 11/5/18 at 9:35 AM, in the resident's room revealed, the resident was lying in bed on her right side. Observations of Resident #22 on 11/6/18 at 7:43 AM, 11:40 AM, 12:04 PM, 1:09 PM, and 4:09 PM, in the resident's room revealed, the resident was lying in bed asleep on her right side with her head and neck in a bent position to the right. Observations of Resident #22 on 11/8/18 at 7:44 AM, in the resident's room revealed, the resident was lying in bed on the right side with head bent to the right. Interview with Licensed Practical Nurse (LPN) #1 on 11/6/18 at 4:25 PM, in the 800 Hall, LPN #1 was asked if Resident #22 was totally dependent on staff for turning and positioning. LPN #1 stated, Yes, she is . Interview with LPN #2, on 11/08/18 at 9:37 AM, in Resident #22's room, the LPN #2 was asked do you expect the resident to have support under her head. LPN #2 stated, .Yes I would . Interview with LPN #2 on 11/8/18 at 1:05 PM, at the 800 hall desk, LPN #2 confirmed that the documentation was incomplete for positioning.

Based on policy review, observation, and interview the facility failed to ensure practices to prevent the development and transmission of infection when 1 of 32 staff members (Certified Nurse Assistant (CNA) #1) handled food with their bare hands during 2 of 2 (11/5/18 and 11/6/18) meal observations. The findings include: The facility's Assistance with Meals (undated) policy documented, .3. All employees .will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Observations in the 600 hall dining room on 11/5/18 beginning at 12:14 PM, CNA #1 removed the bread from a plastic sandwich bag and placed it on a resident plate, picked up a piece of chicken off of a resident's plate, and pulled a piece of chicken apart with her bare hands. Observations in the 600 hall dining room on 11/6/18 beginning at 7:47 AM, CNA #1 dropped a paper package into a resident's cup of coffee and used her bare hands to remove the package from the cup. Interview with the assistant Director of Nursing (ADON) on11/8/18 at 9:40 AM, in the 800 hall, the ADON confirmed that staff should not touch food with their bare hands.

Based on policy review, observation, and interview, the facility failed to serve chicken at an acceptable holding temperature, ensure the microwave was clean for 2 of 2 days (11/5/18, and 11/6/18) of observation, and failed to ensure tea glasses was appropriately covered. This had the potential to affect 154 of the 190 residents receiving meal trays from the kitchen. The findings include: 1. The facility's Food Temperatures (undated) policy documented, .Foods should be served at proper temperature to insure [ensure] food safety and palatability .Acceptable serving temperatures* are: Meat, entrees .[sign for greater than or equal to]140 [degrees] . Observations on 11/6/18 at 12:25 PM, at the dining room steam table revealed the temperature of the chicken breast with cream of chicken soup was 120 degrees. The chicken was then reheated and brought back to the steam table and the temperature of the chicken was 135 degrees. The last reheat of the chicken before it was served was 145 degrees. 2. The facility's Microwave Oven (undated) policy documented, .Sanitation Of Equipment Frequency: Daily Wipe down inside . Observations on 11/5/18 at 9:15 AM and 11/6/18 at 12:05 PM, in the kitchen revealed food particles stuck to the inside top of the microwave. Observations on 11/6/18 at 12:10 PM, in the kitchen revealed a Dietary Aide #1, prepared tea glasses on a stainless table in the kitchen and took the tray of tea glasses to a room where trays were being served and stacked the tray on top of another tray of tea glasses twice. Interview with the Kitchen Manager on 11/6/18 at 12:06 PM, the Kitchen Manager confirmed the microwave was dirty and unacceptable. The Certified Dietary Manager (CDM) on 11/6/18 at 12:50 PM, confirmed the chicken had been reheated too many times and should not have been served to 2 residents and that stacking trays of tea glasses that were not covered was inappropriate and an infection control issue.