**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and interviews, the facility failed to maintain the dietary department in a sanitary manner on 2 of 2 observations, affecting 48 of 48 residents in the facility. Review of the facility's policy titled, Cleaning Kitchen Equipment, dated 8/1/2019, revealed, .Small appliances (such as mixers and food processors) will be cleaned and sanitized after and prior to each use .The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food services areas through compliance with a written, comprehensive cleaning schedule .The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department .A cleaning schedule will be posted for all cleaning tasks, and staff will initial the task as completed .Staff will be accountable for cleaning assignments . Review of the facility's undated policy titled, Sanitizing Buckets, revealed, .All surfaces and equipment will be cleaned and sanitized using red buckets .Clean spills as needed using a clean cloth and warm water .Test water and chemical mixture using strip .Test strip must read between 200-400 PPM [parts per million] .Document PPM on log sheet . Review of the Daily Cleaning Schedule Sample Form dated 8/8/2022 through 8/14/2022 revealed, .Item: Toaster, Can Opener, Stove, Mixer, Slicer, Counter Top, Floor, [NAME]. [beverage] Carts, Meal Carts, Sinks, Dish Machine, Microwave . were to be cleaned by assigned staff Monday through Sunday. All boxes were initialed the task had been completed. Continued review of the Monthly Cleaning Schedule Sample Form revealed, .Item: Behind Stove, Under Table, Drawers, Shelves, Ice Machine, Oven, Walls, Vents, Doors, Tray Line, Delime, Dishroom, Trayline . were to be cleaned by assigned staff monthly. All months from January 2022 through July 2022 were initialed the task had been completed. Observations in the kitchen on 8/15/2022 at 9:15 AM and 12:15 PM, revealed there was a moderate amount of debris on the floor throughout the kitchen. Further observation revealed dust and debris on the shelf above the stove, on top of the steamer, on the prep cart, the drip tray under the stove top, the sides of the stove, the sides of the steamer, underneath the steamer, on top of the tray cart, on the bottom shelf of the steam table, and on the top surface of the steam table. Observation in the kitchen on 8/16/2022 at 9:30 AM, revealed there were no sanitizer buckets prepared. The Certified Dietary Manager (CDM) prepared a sanitizer bucket with sanitizer solution and warm water. When tested with the test strips, the strips revealed the PPM of sanitizing solution was under the required 200 PPM. The CDM emptied that bucket and prepared another one, and the results were the same. She stated she would call her supplier immediately to find a solution to the problem. When asked how often they test the sanitizer buckets, she stated, At least once a week. During an interview on 8/15/2022 at 9:30 AM, the CDM confirmed there was debris on the floor throughout the kitchen, dust and debris on the shelf above the stove, on top of the steamer, on the prep cart, the drip tray under the stove top, the sides of the stove, the sides of the steamer, underneath the steamer on the stainless steel table, on top of the tray cart, the shelf under the steam table, and on the top surface of the steam table. She stated the dietary department has a daily and monthly cleaning schedule and she would expect the dietary employees to follow the cleaning schedule and the areas should have been clean, and were not. During an interview in the conference room on 8/16/2022 at 3:00 PM, the CDM confirmed the facility's policy stated test strips must read between 200-400 PPM, and it is to be documented on a log sheet. She confirmed the dietary staff did not keep a log of testing the sanitation buckets, and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses included Low Back Pain, History of Falling, Difficulity Walking, Need For Assistance With Personal Care, Repeated Falls, Unspecified Fracture Of The Sacrum, Wedge Compression Fracture Of Lumbar Vertebra, Unspecified Fracture Of The Lower End Of Right Radius, Hypothyroidism, Hypertension. Medical record review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 discharged to the hospital. Medical record review of the progress notes dated 9/7/18 revealed Resident #44 was discharged home with home health services. Medical record review of the Discharge summary dated [DATE] revealed Resident #44 was discharged home with home health services. Interview with the Registered Nurse #3/MDS Coordinator on 10/2/18 at 7:50 AM in her office confirmed she completed the discharge MDS for Resident #44. Further interview with MDS Coordinator confirmed .she made the mistake of entering hospital discharge instead of discharging home . Based on medical record review, review of facility documentation and interview, the facility failed to accurately assess falls for 1 of 8 residents (#13) with falls; and failed to accurately assess the discharge facility type for 1 of 3 discharged residents (#44) reviewed. The findings include: Medical record review revealed Resident #13 was readmitted to the facility on [DATE] with diagnoses included Dementia without Behavioral Disturbances, Repeated Falls, Difficulty Walking, Muscle Weakness, History of Falling, Unsteadiness on Feet, Seizures, Osteopetrosis, Major Depressive Disorder, Anxiety Disorder, Hypertension, Benign Prostatic Hyperplasia, and Restlessness and Agitation. Review of facility documentation revealed Resident #13 had falls with no injuries on 2/2/18, 2/3/18, 2/16/18, 2/23/18, 3/3/18, 3/26/18, 3/27/18, and 3/30/18. Medical record review of the Annual Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed the facility assessed the resident as having no falls when he had experienced 2 falls during the review period. Medical record review of the Quarterly MDS dated [DATE] for Resident #13 revealed the facility assessed the resident as having no falls when he had experienced 6 falls during the review period. Interview with Registered Nurse (RN) #3/MDS Coordinator, on 10/3/18 at 10:10 AM in her office confirmed the 2/14/18 and 5/17/18 MDS did not accurately assess the falls Resident #13 experienced during the review period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview and observation, the facility failed to obtain a physician's order for 3 of 27 residents (#31, #196, and #394) reviewed. The findings include: Review of facility policy, Physician Order, revised 11/2017 revealed, .Physician orders are obtained to provide clear direction regarding the care of the resident .A physician's order is required prior to the discontinuation of any current order . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses included Heart Failure and Encounter for Palliative Care. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had a Brief Interview Mental Status (BIMS) score of 15, indicating cognitively intact. Further review of MDS revealed Resident #31 had hospice care while a resident and while not a resident. Medical record review of a Hospice Communication Note dated 9/5/18 revealed hospice services to be discontinued on 9/5/18. Medical record review revealed no physician order to discontinue hospice services. Interview with Resident #31 on 10/2/18 at 2:12 PM in the resident's room confirmed she had hospice services upon admission to the facility but was discharged from hospice services a few days after admission. Interview with Licensed Practical Nurse (LPN) #1 on 10/2/18 at 2:32 PM at the nurse station confirmed there was no order for the discontinuation of hospice services for Resident #31. Medical record review revealed Resident #196 was admitted to the facility on [DATE] with diagnoses included Extended Spectrum Beta Lactamase (ESBL) Resistance, Dementia without Behavioral Disturbance, and Multiple Fractures Of Ribs. Medical record review of the Physician Order dated 9/30/18 revealed .Place EDPC (extended dwell peripheral catheter) for long term IV (intravenous) antibiotics . Further review revealed no orders for the care of the EDPC. Observation on 10/1/18 at 10:29 AM in Resident #196's room revealed EPDC to the right upper arm with a dressing date of 9/30/18. Interview with Registered Nurse (RN) #1 on 10/2/18 at 4:40 PM at the nurse station, revealed she only performed the dressing changes and did not put orders into the electronic health records. Further interview with RN #1 stated .when a resident comes on arrival I notate the dates and change the dressing 7 days from the date that is on the dressing or if it is actively needing to be changed I change it. I wasn't aware that a dressing needed an order . Further interview revealed RN #1 was not aware Resident #196 did not have an order for dressing changes. Interview with the Nurse Practitioner (NP) on 10/3/18 at 11:05 AM at the nurse station revealed, the wound care nurse changed out the dressing weekly and as needed. Further interview confirmed the NP was unaware that an order was not in place for the care of the EDPC. Medical record review revealed Resident #394 was admitted to the facility on [DATE] with diagnoses included Chronic Obstructive Pulmonary Disease, Anemia, Shortness of Breath, and Pneumonia. Medical record review of a Physician Order dated 10/2/18 revealed Oxygen at 2 liters per minute (lpm) per nasal cannula. Observations on 10/1/18 at 10:20 AM and 3:30 PM and on 10/2/18 at 7:17 AM and 2:05 PM in Resident #394's room revealed the resident with oxygen in use per nasal cannula at 2 lpm. Further observation revealed a Peripherally Inserted Central Catheter (PICC) (intravenous catheter for administration of medications or fluids that are unable to be taken by mouth) line to right upper arm with a transparent dressing in place dated 9/26/18. Interview with LPN #1 on 10/2/18 at 2:18 PM at the nurse station confirmed Resident #394 was wearing oxygen per nasal cannula on 10/1/18. Further interview confirmed Resident #394 did not have an order for oxygen until 10/2/18. LPN #1 stated, .He did not come in with an order for oxygen . Interview with RN #1 on 10/2/18 at 2:35 PM in Resident #394's room confirmed the resident had a PICC line to right upper arm, dressing intact and dated 10/2/18. Further interview confirmed she had changed Resident #394's PICC line dressing on 10/2/18 and she did all the PICC line care weekly. Further interview confirmed she did not obtain the physician's order for the PICC line care. Interview with RN #2 on 10/2/18 at 2:50 PM at the nurse station confirmed there was no physician order for PICC line care. She stated, .looks like he didn't come in with an order for PICC care and it's not listed on the discharge paperwork from the hospital . Further interview confirmed the admitting nurse needed to obtain the physician order for PICC line care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to appropriately place a resident on transmission based precaution on admission, and failed to store oxygen tubing when not in use for 1 of 9 residents (#13) receiving respiratory treatment. The findings include: Medical record review revealed Resident #196 was admitted to the facility on [DATE] with diagnoses included Extended Spectrum Beta Lactamase (ESBL) Resistance, Dementia without Behavioral Disturbance, and Multiple Fractures Of Ribs. Medical record review of the Hospital Discharge summary dated [DATE] revealed .Urinary tract infection .Pseudomonas species with extended spectrum beta lactamase activity . Further review revealed .Meropenenem 1 gram intravenous every 12 hours 7 days .Xifaxan 550 mg 1 tablet twice daily . Observation on 10/1/18 at 10:34 AM and 3:41 PM outside of Resident #196's room revealed no personal protective equipment (PPE) outside of the room. Interview with Licensed Practical Nurse (LPN) #2 on 10/1/18 at 3:39 PM at the nurse station, revealed Resident #196 was admitted on [DATE]. Further interview revealed LPN #2 was told to put Resident #196 on isolation on 10/1/18 by the Nurse Practitioner (NP). Further interview confirmed the . NP does not come on the weekends so that is probably why it got missed . Interview with the Director Of Nursing (DON) on 10/3/18 at 8:35 AM in her office confirmed .all residents are on contact (isolation) we just did not have an order for a formal isolation . Interview with the Nurse Practitioner (NP) on 10/3/18 at 11:05 AM at the nurse station stated, .I usually see them the next day or if on the weekend I see them on Monday . Further interview with the NP stated .in an ideal situation I would expect the nurses to call, but they don't need to call me to put a resident on isolation . Interview with the NP on 10/3/18 at 1:30 PM in the hall way revealed she found out on 10/1/18 Resident #196 had a diagnosis of ESBL by looking in her chart. Further interview revealed the NP would have been fine if the nurse put the resident on isolation or called to inform her of Resident #196 status. Medical record review revealed Resident #13 was readmitted to the facility on [DATE] with diagnoses included Dementia without Behavioral Disturbances, Repeated Falls, History of Falling, Seizures, Osteopetrosis, Major Depressive Disorder, Anxiety Disorder, Hypertension, Benign Prostatic Hyperplasia, and Restlessness and Agitation. Medical record review of the physician order dated 4/26/18 revealed Resident #13 was to receive oxygen at 2 liters per minute via nasal cannula as needed for oxygen saturation level less than 92% (percent). Observation on 10/1/18 at 10:19 AM, 11:06 AM, and 11:54 AM revealed Resident #13 was not in his room. Further observation revealed the oxygen concentrator had a nasal cannula attached. Further observation revealed the nasal cannula was draped over the top of the oxygen concentrator and hanging down the back of the concentrator. Observation on 10/1/18 at 3:57 PM, with LPN #3 present, revealed Resident #13 in his room. Further observation revealed the nasal cannula was in the same position as observed at 10:19 AM, 11:06 AM and 11:54 AM on 10/1/18. Interview with LPN #3 in Resident #13's room on 10/1/18 at 3:57 PM revealed the LPN was assigned to provide care to the resident. When the LPN was asked the facility practice for oxygen tubing storage when not in use stated .it's to be bagged . Further interview confirmed Resident #13's nasal cannula was not bagged and .should have been . Interview with the DON on 10/3/18 at 10:05 AM in the hallway by the Dining Room revealed the staff was expected to store the oxygen tubing or masks in a bag when not in use.