**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 1 resident (Resident #5) reviewed for self-administration of medication. The findings include: 1. Review of the facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer dated 10/2010, revealed .The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Ask the resident to hold the mouthpiece gently between his/her lips .Instruct the resident .Encourage the resident to cough and expectorate .Administer therapy until medication is gone .When the treatment is complete, turn off nebulizer . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Rheumatoid Arthritis, Atrial Fibrillation, Heart Failure, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #5 was cognitively intact. Review of the Physician Order Sheet January 2025, revealed .IPRATROPIUM/ALBUTEROL [used for shortness of breath] INH [inhalation] SOLN [solution] 1 inhalation .inhale orally four times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Observation in the Resident's room on 2/3/2025 at 2:30 PM, revealed Resident #5 was sitting up in the wheelchair with the nebulizer mouthpiece sitting in the resident's lap and still running. There was no nurse present during the administration of the medication. Observation in the Resident's room on 2/3/2025 at 2:39 PM, revealed the nebulizer remains on and in the Resident's lap and no nurse present. Observation in the Resident's room on 2/3/2025 at 3:04 PM, revealed the nebulizer remains on and in the Resident's lap and no nurse present. During an interview on 2/3/2025 at 3:19 PM the Director of Nursing (DON) confirmed a nurse should be present with the Resident while medication administration and the nebulizer should be put away when the treatment is complete. She also stated that she was unable to provide an evaluation for medication self administration for Resident #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to report an allegation of sexual abuse to all appropriate local and state agencies for 1 of 1 (Resident #57) sampled residents reviewed for abuse. The findings included: 1. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/2022, revealed All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations .Findings of all investigations are documented and reported .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying licensing the facility; the local ombudsman; The resident's representative; Adult protective services .Law enforcement officials, The resident's attending physician, and the facility's medical director .Immediately is defined as .within two hours of an allegation involving abuse .Verbal/written notices to agencies are submitted via [by way of] special carrier, fax, e-mail, or by telephone .Upon receiving any allegation of abuse . 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Hypertension, Dementia, Hemiplegia, Seizure Disorder, Anxiety, and Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #57 was cognitively intact. Resident was dependent on staff for toileting, bathing, bed mobility, and transfers. During an interview on 2/3/2025 at 8:52 AM, Resident #57 stated that she had reported a sexual assault to the Assistant Director of Nursing (ADON) last month. Resident #57 stated, .During my bed bath CNA (certified Nursing Assistant) D started playing with my boob and said they are really soft. Review of the undated witness statement revealed [named ADON] ADON brought to administrator a complaint by [named resident] against CNA [named CNA D]. Stated he was a pervert and said during bed baths he said her boobs were so soft and patted her on the butt. When interviewing [named CNA D] CNA r/t [related to] allegation stated it was her bed bath day and he had to lift her breast to clean under it, but he never made any comments as such. Additionally when asking about patting on the butt he stated when was done cleaning one side he tapped her and asked her to help roll so he could get the other side. In an effort to appease [named resident] we removed [named CNA D] from her assignment. ADON and Admin [Administrator] followed up with [named resident] and when explained what he was doing she agreed yeah you're right. that makes sense. I just don't want him in there anymore. During an interview on 2/5/2025 at 3:36 PM, the Administrator confirmed that she was the Abuse Coordinator. The Administrator was asked the process of reporting allegations of abuse. The Administrator stated, For a true allegation an initial investigation is going to be completed before reporting to State Agency. The Administrator was asked, what is a true allegation. The Administrator stated, If we have a true suspicion then it is reported, and CNA D was interviewed and denied the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate allegations of sexual abuse for 1 of 1 (Resident #57) sampled resident reviewed for abuse. The findings included: 1. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, revealed .All reports of resident abuse .are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by the facility management. Findings of all investigations are documented and reported .The administrator initiates investigations .Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete .The individual conducting the investigation as a minimum .reviews the documentation and evidence .reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident .observes the alleged victim, including his or her interactions with staff and other residents .interviews the person reporting the incident .interviews any witness to the incident .interviews the resident .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .interviews the resident's roommate, family members, and visitors .interviews other residents to whom the accused employee provides care or services .reviews all events leading up to the alleged incident .documents the investigation completely and thoroughly .The investigator notifies the ombudsman that an abuse investigation is being conducted . 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Hypertension, Dementia, Hemiplegia, Seizure Disorder, Anxiety, and Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #57 was cognitively intact. Resident was dependent on staff for toileting, bathing, bed mobility, and transfers. During an interview on 2/3/2025 at 8:52 AM, Resident #57 stated that she had reported a sexual assault to the Assistant Director of Nursing (ADON) last month. Resident #57 stated, .During my bed bath CNA [certified nursing assistant] D started playing with my boob and said they are really soft. During an interview on 2/3/2025 at 1:00 PM, The Administrator was asked if Resident #57 reported an allegation of sexual abuse against CNA D. The Administrator replied, Yes, we had a conversation with her (Resident #57) and interviewed her (Resident #57) and him (CNA D). I will bring you the soft file. On 2/3/2025 at 4:17 PM, the Administrator brought in the soft file for the allegation of sexual abuse which consisted of a one-page undated witness statement. The Administrator was asked the date of the witness statement. The Administrator stated, It happened a couple of months ago, I think. Review of an undated witness statement revealed [named ADON] ADON brought to administrator a complaint by [named resident] against CNA [named CNA D]. Stated he was a pervert and said during bed baths he said her boobs were so soft and patted her on the butt. When interviewing [named CNA D] CNA r/t [related to] allegation stated it was her bed bath day and he had to lift her breast to clean under it, but he never made any comments as such. Additionally when asking about patting on the butt he stated when was done cleaning one side he tapped her and asked her to help roll so he could get the other side. In an effort to appease [named resident] we removed [named CNA D] from her assignment. ADON and Admin [Administrator] followed up with [named resident] and when explained what he was doing she agreed yeah you're right. that makes sense. I just don't want him in there anymore. On 2/5/2025, the facility provided additional documents which consisted of an undated document titled, Resident Interviews, and skin assessments dated 11/26/2024. During an interview on 2/5/2025 at 3:36 PM, the Administrator was asked what the facility's process for allegations of abuse. The Administrator stated, .if there is allegation any suspicion .an initial investigation is done . The Administrator was asked what the facility did in relation to Resident #57's allegation of sexual abuse. The Administrator stated, We interviewed the resident [Resident #57] and the CNA [CNA D] .we instructed the CNA [CNA D] to stay out of her room . The Administrator was asked if she felt the facility completed a thorough investigation for the allegation of sexual abuse. The Administrator stated, .If it was written down, I feel like we took the appropriate steps .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering for 2 of 2 sampled residents (Resident #41 and #45) reviewed for ADLs. The findings included: 1. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated 03/2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 2. Review of the medical record review revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Disorders of the Brain, Chronic Obstructive Disease, Major Depressive Disorder, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 had a Brief Interview for Mental status (BIMS) score of 9, which indicated Resident #41 was moderately cognitively impaired. Resident #41 required partial/moderate assistance with bathing. During an interview on 2/4/2025 at 10:45 AM, Resident #41 was asked about her bathing and showering habits, she takes a calendar off her wall and shows me where she writes her shower dates and bowel movements . daily, she confirmed this is how she keeps up with her personal things. Resident #41 stated, I did not receive a shower for 2 whole weeks in January . Review of the facility Shower Schedule form revealed Resident #41 should get a shower on Tuesday, Thursday, and Saturday. Review of the Aide Bathing Task for January 2025 and February 2025 revealed Resident #41 did not receive a shower on 1/7/2025, 1/9/2025, 1/11/2025, 1/16/2025, 1/21/2025, 1/23/2025, 1/25/2025, 1/28/2025, 1/30/2025, and 2/4/2025. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Heart Failure, Dementia, Diabetes, and Arthritis. Review of the annual MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident #45 was cognitively intact. Resident #45 required partial moderate assistance with bathing. During an interview on 2/3/2025 at 2:54 PM, Resident #45 was asked about her showers, Resident #45 confirmed she does get showers, but it may be 2 weeks in between times. Review of the facility Shower Schedule form revealed Resident #45 should get a shower on Monday, Wednesday, and Friday. Review of the Aide Bathing Task for January 2025, revealed Resident #41 did not receive a shower on 1/1/2025, 1/3/2025, 1/6/2025, 1/8/2025, and 1/13/2025. During an interview on 2/6/2025 at 4:01 PM, the Director of Nursing (DON) confirmed residents should be receiving their showers on the dates assigned to them. The DON confirmed there should not be any missing dates.

**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 infection control practices were followed during medication administration when 1 of 3 nurses Registered Nurse (RN) B failed to wear PPE (personal protective equipment) during the administration of medication by way of peg tube and when 1 of 1 Certified Nursing Assistant (CNA) C failed to perform hand hygiene during foley catheter care. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated 3/2024, revealed Enhanced Barrier Precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .Gloves and gown are applied prior to performing the high contact resident care activity .EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .Indwelling medical devices include central lines, urinary catheters, feeding tubes . Review of the facility policy titled, Handwashing/Hand Hygiene, dated 10/2023, revealed This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Perform hand hygiene before applying non-sterile gloves .When removing gloves, pinch the glove .Perform hand hygiene. 2. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Multidrug-Resistant Organism, Urinary Tract Infection, Malnutrition and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #26 was severely cognitively impaired. Resident was dependent on staff for eating, toileting, bathing, bed mobility, and transfers. Resident was assessed for an indwelling catheter. Review of the Treatment Administration Record dated 12/2024, revealed .Catheter site care one time daily starting 11/22/2024 with soap and water . Observation in the Resident's room on 2/6/2025 at 11:12 AM, revealed CNA C performed catheter care and removed soiled gloves, donned gloves without performing hand hygiene. CNA C emptied basin in the resident's bathroom, removed gown and gloves, and took soiled linens to the biohazard room on the 300 Hall before performing hand hygiene. 2. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Wernicke's Encephalopathy, Diabetes, Dysphagia, Gastrostomy, and Respiratory Failure. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #39 was cognitively intact. Resident was assessed for a feeding tube. Review of the Physician's Order dated 12/30/2024, revealed .Enhanced Barrier Precautions every shift . Observation during medication administration on the 300 Hall on 2/5/2025 at 10:22 AM, revealed RN B administered medications to Resident #39 via Peg-Tube without wearing a gown for enhanced barrier precautions. During an interview on 2/6/2025 at 10:58 AM, the Director of Nursing (DON) confirmed that staff should wear gown and gloves for medication administration with Peg Tube residents in enhanced barrier precautions. During an interview on 2/6/2025 at 11:34 AM, the DON confirmed that staff should perform hand hygiene before and after the removal of gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 11 of 24 (Resident #5, #11, #15, #29, #31, #41, #45, #52, #53, #58 and #60) residents reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled, Advance Directives, dated September 2022, revealed .Prior to or upon admission of a resident, the social services director or designee inquires of the resident , his/her family members and/or his or her legal representatives, about the existence of any written advance directives .The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives . 2. Review of the medical record revealed Resident #5 was admitted on [DATE], with diagnoses including Rheumatoid Arthritis, Atrial Fibrillation, Heart Failure, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #5 was cognitively intact. Review of the .Consent and Authorizations, dated 6/5/2024, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 3. Review of the medical record revealed Resident #11 was admitted on [DATE], with diagnoses including Dementia, Anxiety, Hypertension, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #11 had a BIMS score of 3, which indicated Resident #11 was severely cognitively impaired. Review of the .Consent and Authorizations, dated 9/8/2022, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 4.Review of the medical record revealed Resident #15 was admitted on [DATE], with diagnoses including Heart Failure, Anxiety, Depression, and Polyneuropathy. Review of the quarterly MDS assessment dated 12/272024, revealed a BIMS score of 4, which indicated Resident #15 was severely cognitively impaired. Review of the .Consent and Authorizations dated 5/8/2024, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 5. Review of the medical record revealed Resident #29 was admitted on [DATE], with diagnoses including Alzheimer's Disease, Dementia, and Osteoarthritis. Review of the quarterly MDS assessment dated [DATE], revealed Resident #29's BIMS score was unable to be assessed due to being cognitively impaired. Review of the .Consent and Authorizations dated 3/13/2019, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 6. Review of medical record revealed Resident #31 was admitted on [DATE], with diagnoses including Dementia, Diabetes, Chronic Kidney Disease, Depression, and Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 7, which indicated Resident #31 was severely cognitively impaired. Review of the .Consent and Authorizations dated 7/8/2024, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 7. Review of medical record revealed Resident #41 was admitted on [DATE], with diagnoses including Cerebral Infarction, Chronic Obstructive Pulmonary disease, Dementia, and Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #41 was moderately cognitively impaired. Review of the .Consent and Authorizations, dated 3/6/2023, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 8. Review of the medical record revealed Resident #45 was admitted on [DATE], with diagnoses including Multiple Sclerosis, Heart Failure, Atrial Fibrillation and Diabetes. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #45 was cognitively intact. Review of the .Consent and Authorizations, dated 2/2/2023, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 9. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Rheumatoid Arthritis, Morbid Obesity, Osteoarthritis, and Pain. Review of the annual MDS assessment dated 12/26 2024, revealed a BIMS score of 15, which indicated Resident #52 was cognitively intact. Review of the .Consent and Authorizations, dated 3/3/2023, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 10. Review of medical record revealed Resident #53 was admitted on [DATE], with diagnoses including Depression, Hemiplegia and Hemiparesis, Chronic Respiratory Failure, and Aneurysm of Other Precerebral Arteries. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #53 was cognitively intact. Review of the undated .Consent and Authorizations, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 11. Review of the medical record revealed Resident #58 was admitted on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Congestive Heart Failure, and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated that Resident #58 was cognitively intact. Review of the .Consent and Authorizations dated 3/14/2024, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 12. Review of the medical record revealed Resident #60 was admitted on [DATE], with diagnoses including Traumatic Brain Injury, Subdural Hematoma, Congestive Heart Failure and Anxiety. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 5, which indicated Resident #60 was severely cognitively impaired. Review of the .Consent and Authorizations dated 7/8/2024, revealed Each section of the form must be reviewed with, initialed and signed . There were no initials that the resident or the resident representative was given information or had an Advanced Directive or wished to formulate one. 13. During an interview on 2/05/2025 at 1:54 PM, the Administrator confirmed that the Consent and Authorizations should be initialed that the Resident or Responsible Party received education about Advance Directives .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, dish machine log, emergency menu, and interview, the facility failed to ensure that food was stored, handled, prepared, and served under sanitary conditions. The facility failed to recognize the low temperature dishwasher log had low temperatures for the wash cycle and when the emergency menu food items were not in stock. The facility had a census of 68 with 68 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility undated policy titled, Sanitation, revealed .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining rooms shall be kept clean, free from litter and rubbish and protected from .other insects .all counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from cracks and chipped areas . Review of the facility undated policy titled, Dishwasher Use, revealed .Food Service will be trained in all steps of dish machine use by the supervisor or a designee in all aspects of proper use and sanitation .Low temperature dish machines must maintain the following wash and rinse temperatures .120 F (Fahrenheit) for stationary rack, single temperature machines .The operator will check temperatures using the machine gauge with each dish machine cycle and will record the results in a facility approved log .Inadequate temperatures will be reported to the supervisor and corrected immediately .If water temperatures .do not meet requirements, cease use of dish machine immediately . 2. Observation in the kitchen with Dietary Manager (DM) on 2/3/2025 at 8:25 AM, and 4:25 PM, revealed the following: a. 17 cartons of grape juice with dirt, debris and a dead insect on the top of one carton. b. A pink plastic container filled with individual cracker packages and the container had sticky brown debris on top of lid. c. A plastic peanut butter container with peanut butter on the outside of the container. d. An oven that had brown build-up with food particles in the doors of the oven. e. A grease trap tray under the stove filled with a large amount of grease and filled with dried and new grease. f. A vent hood that was greasy and dirty on the outside edges and the arms of the lights had grease build-up. g. A juice and coffee station cabinet with shelving underneath with dirty, sticky food debris. h. Undated and unlabeled sugar and corn meal in large containers that were dirty, and sticky with food debris. i. A cabinet with 3 utensil drawers storing tools for cooking, difficult for staff to open and close, with rust in the drawers and around the drawers. The outside of the cabinet had brown and white dried streaks with food particles on the cabinet. j. Pimento cheese container in the walk-in cooler with pimento cheese food particles on the outside of the container. k. [NAME] slaw in walk in cooler with [NAME] slaw food particles on the outside of the container. j. 3 white milky liquid areas in walk-in cooler on the floor. 3. Observation in the kitchen on 2/4/2025 at 1:20 PM, revealed the following: a. A pink plastic container filled with individual cracker packages and the container had sticky brown debris on top of lid. b. An oven that has brown build-up with food particles in the doors of the oven. c. A grease trap tray under stove filled with large amount of grease, filled with dried and new grease. d. A vent hood that was greasy and dirty on the outside edges and the arms of the lights had grease build-up. e. A juice and coffee station cabinet with shelving underneath with dirty, sticky food debris. f. A cabinet with 3 utensil drawers storing tools for cooking, difficult for staff to open and close, with rust in drawers and around the drawer. The outside of the cabinet had brown and while dried streaks with food particles on the cabinet. g. Pimento cheese in walk-in cooler with pimento cheese food particles on outside of the container. h. [NAME] slaw in walk in cooler with [NAME] slaw food particles on the outside of the container. 4. During an observation on 2/4/2025 at 1:20 PM, observed a 110 F wash cycle while a dietary staff member was operating the low temperature dish machine . Review of the February 2025 High Temp (temperature) Dish Machine Daily Temperature Log, revealed the following: 1. 2/1/2025 at breakfast a wash temp of 115, lunch 110, and supper 110. 2. 2/2/2025 at breakfast a wash temp of 110, lunch 110, and supper 110. 3. 2/3/2025 at breakfast a wash temp of 110, lunch 110, and supper 115. 4. 2/4/2025 at breakfast a wash temp of 115, lunch 75. 5. During an observation and interview on 2/5/2025 at 12:00 PM, with the Registered Dietician (RD) revealed missing foods from the menu that were not in the Emergency Food section. The RD confirmed there was not enough food in storage for a 72-hour emergency and needed to order additional meats and milk. Review of a (Named) Shop order dated 2/5/2025 revealed an order of additional foods needed for Emergency Menu. During an interview on 2/6/2025 at 9:30 AM, with the Registered Dietitian (RD) and the DM confirmed the kitchen should not be dirty, there should not be dirt, dust or bugs on containers, cabinets or counter-tops, food should not have food particles on the outside of their containers, the vent hood should be wiped down monthly so grease does not build up, all food items shall be dated and labeled in clean containers, utensils for cooking should not be stored in rusty drawers. The RD and DM confirmed the low temp dish machine temperatures were not adequate for washing dishes, and all wash cycles should be at least 120 degrees, with staff re-education completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation, and interview, the facility failed to provide a nourishing and well-balanced diet that meets each resident's daily nutritional and dietary needs for 3 of 5 (Residents #2, #5 and #16) residents reviewed for nutrition. The facility had a census of 78, with 76 of those residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility's policy titled, Dietary: Menus and Adequate Nutrition, dated 7/25/2024, revealed .The purpose of the policy is to assure menus are developed and prepared, based on reasonable efforts, to provide each resident choices that reflect their nutritional, religious, cultural, and ethnic needs, while using guidelines and considering resident preferences .shall ensure that menus .Meet the nutritional needs of residents .Be followed . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Coronary Artery Disease, Anxiety and Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 with a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #2 was moderately cognitively impaired, was coded for weight loss, and required staff to set up his meals. Review of Resident #2's Care Plan dated 10/23/2024, revealed .Problem . is at risk for weight loss .had 5% [percent] weight loss in last 30 days .Interventions .Diet as ordered. See MD [Medical Doctor] orders for current diet/interventions .Monitor meal intake and offer substitutes prn [as needed] .Please see current MD orders .Adhere to food preferences . Review of the November 2024 Physician's orders revealed, .Diet - Regular . Review of the WEIGHT CHANGE ASSESSMENT dated 11/7/2024, revealed .Assessment due to continual weight loss/gain monitoring is needed .Previous Weight .178 [pounds] .Current weight .157 [pounds] .Weight change Percentage: 11.0 .Weight Change in Pounds: 21 .Timeframe for WT [weight] change 90 days .Diet Regular, with large portions at breakfast and lunch (11/11) [11/11/2024]. Inserviced staff on offering alternatives (11/6) [11/6/2024] .Sandwich at 3:00pm .Mirtazapine 7.5 mg [milligram] [to cause weight gain .it can make you feel hungrier than normal] QHS [every night at bedtime] loss of 11% . Review of the Registered Dietician Clinical Notes dated 11/12/2024, revealed 3.17% wt [weight] loss x [times] 30 days. 10.78% wt loss x 90 days. 14.57% wt loss x 180 days. Diet ordered regular with large options at breakfast and lunch added on 11/11 [11/11/2024]. a. Observation and interview in Resident #2's room on 12/9/2024 at 2:15 PM, revealed Resident #2 to be neatly dressed, and playing his keyboard. Resident #2 was asked if he had any concerns with the meals at the facility. Resident #2 stated, .it [the kitchen problems] was bad .cook didn't come .it [the kitchen problems] got in a mess .the Administrator was trying to cook, run her office. I felt so sorry for her .couldn't get nobody up here to cook . b. Review of the lunch menu for 12/10/2024, revealed residents should have received the following: 6 oz of ham and potato casserole. 4 oz Lima beans. 1 roll. 2 chocolate chip cookies. c. Observation and interview in Resident #2's room on 12/10/2024 at 11:48 PM, revealed the resident to be sitting in the recliner, in his room. Certified Nurse Assistant (CNA) N delivered the resident's lunch meal tray containing 1 piece of ham, 1 pureed vegetable and an oatmeal pie. CNA N confirmed the resident didn't receive double portion for lunch and stated, .I will go to the kitchen now . CNA N returned in a few minutes with 2 pieces of ham, 2 pieces of bread and 2 small cups of strawberry ice cream and stated, .didn't have any other vegetable . Review of Resident #2's meal ticket dated 12/10/2024 revealed, .LUNCH .DIET: Regular, DOUBLE PORTIONS . The facility was unable to provide the ham and potato casserole, lima beans and 2 chocolate chip cookies, the menu had to be changed due to the food truck not coming in time for lunch. Resident #2 was not served double portions as prescribed. 4. Review of the breakfast menu for December 10th, for a regular breakfast residents should have received the following: 2 oz egg 2 oz sausage 6 oz cereal 1 waffle Observation and interview in the kitchen of the breakfast tray line on 12/10/2024 at 7:17 AM, revealed residents in the main dining room, 200 and 300 hall that received a regular tray got one piece of bacon, eggs, oats or cereal and 1 biscuit and the residents on the 100 hall received 2 pieces of bacon. Dietary [NAME] #O was asked why the residents now are receiving 2 pieces of bacon. Dietary [NAME] O stated, .because we had some left over .if a resident had a mechanical diet they only got scramble egg, oats and a biscuit .supposed to get sausage but we don't have any . a regular diet receives 2 oz scramble egg, 1 piece of bacon, bowl of 6oz oats, and 1 biscuit . a puree diet, receives 2 oz of pureed egg, puree meat, and puree bread. Dietary [NAME] #O confirmed waffles were on the menu for breakfast, but the facility didn't have any and stated, Truck is coming today . 5. Random observation and interview in Resident #16's room on 12/10/2024 at 12:00 PM, revealed the resident to be dressed, and sitting up in her bed. Staff delivered her lunch tray, containing 1 piece of ham, 1 vegetable of sweet potatoes, 1 bread roll and 1 [NAME] butter bar. Resident #16 was asked about her meals. Resident #16 stated, .lousy for 2 or 3 months .1 tiny biscuit, 1 bacon, egg .one time it was 2 o'clock before lunch was served. 6. Random observation and interview in Resident #5's room on 12/10/2024 at 12:05 PM, revealed the resident to be dressed, sitting in his room, in front of his computer. Resident was asked how her breakfast was this morning. Resident #5 stated .it [breakfast] was lacking [not enough food and the food was not good] . 7. During a telephone 12/19/2024 at 3:25 PM, Family Nurse Practitioner (FNP) P was asked if she had concerns about kitchen. FNP P stated, I know they have been short staff .in there .meal later than usual on some days .I have heard complaints of the small portion . FNP P confirmed they are pulling from the floor and the Administrator is working in the kitchen and stated, They don't have a dietary manager .I think they need consistency [in kitchen staff] .she is the administrator not dietary and it makes a difference .there should be standard serving size across the board . During a telephone interview on 12/19/2024 at 3:43 PM, FNP Q stated, I have overheard residents say their breakfast and lunch has been late . FNP Q confirmed she provided care to Resident #2, he should had received double portion with his meal as order and stated, .I would absolutely expect them to honor that .if it was my mom or father I would be pretty upset if they didn't receive what they were supposed to .I know they have had a lot of issue with staffing in the kitchen .I would be upset . FNP Q confirmed nutrition is very important for residents. During a telephone interview on 12/19/2024 at 4:07 PM, the previous Registered Dietician (RD) stated, I would expect everything on that menu to be on that tray . The previous RD was asked if a resident didn't get a complete meal would it meet the nutritional needs. The previous RD stated, .in my expertise, no . During an interview on 12/23/2024 at 7:40 AM, the Housekeeping and Laundry Supervisor stated, .I have helped out with lunch .was calling for beef noodles and I didn't know where that stuff was .it was supposed to be hamburger helper and I said well I'm sorry they got beef and noodle .what I have been told, regular tray .gets eggs, 1 sausage, oatmeal or dry cereal, biscuit .if its bacon they should receive 2 pieces of bacon .a couple of times didn't have enough bacon to give them 2 pieces . The Housekeeping and Laundry Supervisor confirmed sometimes residents didn't get sausage and just got 1 piece of bacon. During an interview on 12/23/2024 at 8:38 AM, Housekeeper I stated, .sometimes a person is supposed to receive double portion but we don't have enough for them to have double portion . Housekeeper I confirmed residents are supposed to receive 2 pieces of bacon and stated, If they have enough that day .if not receive 1 piece .they aren't ordering enough food .it's all disorganized . Housekeeper I was asked if residents are receiving the appropriate meal. Housekeeper I stated, Not really .would only get a meat and one vegetable and .like yesterday they had breakfast, it was bacon, eggs and muffin .grits . the resident got the meal, wanted pancakes .they didn't have pancakes and just sent out what they had . During an interview on 12/23/2024 at 9:08 AM, The Director of Nursing (DON) was asked about complaints from residents or families of the food portions being small, that the food is cold and inedible. The DON stated, I have heard all three .I think that goes back to not having leadership in the kitchen and not doing the planning .I don't know who is doing the ordering . The DON confirmed if a resident was supposed to receive double portion the orders should be followed, and they should receive double portions. The DON was asked if 1 piece of ham and 1 vegetable was a double portion. The DON stated, .it should have been double meat and double portion of the 2 vegetables .double portion of everything . The DON was asked what her concerns are in the kitchen. The DON stated, .the kitchen needs guidance, leadership and thorough training . During an interview on 12/23/2024 at 11:30 AM, the Administrator confirmed physician orders should be followed, residents should receive a full nutritional meal, residents should had received 2 pieces of bacon. The Administrator was asked had she had complaints from residents or families, that there is not enough food in the kitchen. The Administrator stated, Yes ma'am .when our truck didn't deliver due to the transition .I went to the store and bought groceries to make it through for the truck to be delivered the next day . During a random interview on 12/23/2024 at 1:00 PM, Resident #10 stated, Can you get us some more food .get one scoop of egg .one sausage and one biscuit .won't give us anymore until everyone is served .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure a Registered Dietician (RD) or Qualified Nutritional Professional was employed to provide oversight of the kitchen sanitation, kitchen staff competencies, residents' prescribed diets, and meals served in a timely manner. The findings include: 1.Review of the policy titled, Dietary-Dining Services, dated 3/28/2024, revealed .CART DELIEVERY TIMES .Meals shall be delivered to the residents in a timely fashion . Review of the facility's policy titled, Dietary: Menus and Adequate Nutrition, dated 7/25/2024, revealed .The purpose of the policy is to assure menus are developed and prepared, based on reasonable efforts, to provide each resident choices that reflect their nutritional, religious, cultural, and ethnic needs, while using guidelines and considering resident preferences .shall ensure that menus .Meet the nutritional needs of residents .Be followed . Review of the facility policy titled, Dietary-Cleaning, dated 7/25/2024, revealed .Adequate cleaning and sanitizing shall minimize the risk of food borne illnesses .Cleaning surfaces, equipment or utensils involves the use of hot water and detergent which removes soil, grease, food and odors .Sanitizing can occur by applying heat and/or chemicals for enough time to reduce bacterial count on counters, dishware .pots and pans .The CDM/Kitchen Supervisor shall audit the cleaning schedule for completeness .shall conduct sanitation / safety inspection / kitchen observations . Review of the facility policy titled, Dietary-Mechanical Dish Washing, revised on 10/9/2023, revealed .to ensure dishes and utensils are cleaned under sanitary conditions. Dishes shall be cleaned and sanitized after each use .The temperature of the dish machine shall be recorded three (3) times a day .Wash and rinse temperatures shall be observed and recorded at each meal service .Low temperature machines should be between 120-140 F [Fahrenheit] .Dish machine sanitizer must be tested and recorded before each meal when using a low temp machine .Employees should initial after completion . 2. The facility failed to provide a nourishing and well-balanced diet that meets each resident's daily nutritional and dietary needs as follows: a. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Coronary Artery Disease, Anxiety and Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 with a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #2 was moderately cognitively impaired, was coded for weight loss, and required staff to set up his meals. Review of Resident #2's Care Plan dated 10/23/2024, revealed .Problem . is at risk for weight loss .had 5% [percent] weight loss in last 30 days .Interventions .Diet as ordered. See MD [Medical Doctor] orders for current diet/interventions .Monitor meal intake and offer substitutes prn [as needed] .Please see current MD orders .Adhere to food preferences . Review of the November 2024 Physician's orders revealed, .Diet - Regular . Review of the WEIGHT CHANGE ASSESSMENT dated 11/7/2024, revealed .Assessment due to continual weight loss/gain monitoring is needed .Previous Weight .178 [pounds] .Current weight .157 [pounds] .Weight change Percentage: 11.0 .Weight Change in Pounds: 21 .Timeframe for WT [weight] change 90 days .Diet Regular, with large portions at breakfast and lunch (11/11) [11/11/2024]. Inserviced staff on offering alternatives (11/6) [11/6/2024] .Sandwich at 3:00pm .Mirtazapine 7.5 mg [milligram] [to cause weight gain .it can make you feel hungrier than normal] QHS [every night at bedtime] loss of 11% . Review of the Registered Dietician Clinical Notes dated 11/12/2024, revealed 3.17% wt [weight] loss x [times] 30 days. 10.78% wt loss x 90 days. 14.57% wt loss x 180 days. Diet ordered regular with large options at breakfast and lunch added on 11/11 [11/11/2024]. Observation and interview in Resident #2's room on 12/9/2024 at 2:15 PM, revealed Resident #2 to be neatly dressed, and playing his keyboard. Resident #2 was asked if he had any concerns with the meals at the facility. Resident #2 stated, .it [the kitchen problems] was bad .cook didn't come .it [the kitchen problems] got in a mess .the Administrator was trying to cook, run her office. I felt so sorry for her .couldn't get nobody up here to cook . Review of the lunch menu for 12/10/2024, revealed residents should have received the following: 6 oz of ham and potato casserole. 4 oz Lima beans. 1 roll. 2 chocolate chip cookies. Observation and interview in Resident #2's room on 12/10/2024 at 11:48 PM, revealed the resident to be sitting in the recliner, in his room. Certified Nurse Assistant (CNA) N delivered the resident's lunch meal tray containing 1 piece of ham, 1 pureed vegetable and an oatmeal pie. CNA N confirmed the resident didn't receive double portion for lunch and stated, .I will go to the kitchen now . CNA N returned in a few minutes with 2 pieces of ham, 2 pieces of bread and 2 small cups of strawberry ice cream and stated, .didn't have any other vegetable . Review of Resident #2's meal ticket dated 12/10/2024 revealed, .LUNCH .DIET: Regular, DOUBLE PORTIONS . The facility was unable to provide the ham and potato casserole, lima beans and 2 chocolate chip cookies, the menu had to be changed due to the food truck not coming in time for lunch. Resident #2 was not served double portions as prescribed. b. Review of the breakfast menu for December 10th, for a regular breakfast residents should have received the following: 2 oz egg 2 oz sausage 6 oz cereal 1 waffle Observation and interview in the kitchen of the breakfast tray line on 12/10/2024 at 7:17 AM, revealed residents in the main dining room, 200 and 300 hall that received a regular tray got one piece of bacon, eggs, oats or cereal and 1 biscuit and the residents on the 100 hall received 2 pieces of bacon. Dietary [NAME] #O was asked why the residents now are receiving 2 pieces of bacon. Dietary [NAME] O stated, .because we had some left over .if a resident had a mechanical diet they only got scramble egg, oats and a biscuit .supposed to get sausage but we don't have any . a regular diet receives 2 oz scramble egg, 1 piece of bacon, bowl of 6oz oats, and 1 biscuit . a puree diet, receives 2 oz of pureed egg, puree meat, and puree bread. Dietary [NAME] #O confirmed waffles were on the menu for breakfast, but the facility didn't have any and stated, Truck is coming today . c. Random observation and interview in Resident #16's room on 12/10/2024 at 12:00 PM, revealed the resident to be dressed, and sitting up in her bed. Staff delivered her lunch tray, containing 1 piece of ham, 1 vegetable of sweet potatoes, 1 bread roll and 1 [NAME] butter bar. Resident #16 was asked about her meals. Resident #16 stated, .lousy for 2 or 3 months .1 tiny biscuit, 1 bacon, egg .one time it was 2 o'clock before lunch was served. d. Random observation and interview in Resident #5's room on 12/10/2024 at 12:05 PM, revealed the resident to be dressed, sitting in his room, in front of his computer. Resident was asked how her breakfast was this morning. Resident #5 stated .it [breakfast] was lacking [not enough food and the food was not good] . e. During a telephone 12/19/2024 at 3:25 PM, Family Nurse Practitioner (FNP) P was asked if she had concerns about kitchen. FNP P stated, I know they have been short staff .in there .meal later than usual on some days .I have heard complaints of the small portion . FNP P confirmed they are pulling from the floor and the Administrator is working in the kitchen and stated, They don't have a dietary manager .I think they need consistency [in kitchen staff] .she is the administrator not dietary and it makes a difference .there should be standard serving size across the board . During a telephone interview on 12/19/2024 at 3:43 PM, FNP Q stated, I have overheard residents say their breakfast and lunch has been late . FNP Q confirmed she provided care to Resident #2, he should had received double portion with his meal as order and stated, .I would absolutely expect them to honor that .if it was my mom or father I would be pretty upset if they didn't receive what they were supposed to .I know they have had a lot of issue with staffing in the kitchen .I would be upset . FNP Q confirmed nutrition is very important for residents. During a telephone interview on 12/19/2024 at 4:07 PM, the previous Registered Dietician (RD) stated, I would expect everything on that menu to be on that tray . The previous RD was asked if a resident didn't get a complete meal would it meet the nutritional needs. The previous RD stated, .in my expertise, no . During an interview on 12/23/2024 at 7:40 AM, the Housekeeping and Laundry Supervisor stated, .I have helped out with lunch .was calling for beef noodles and I didn't know where that stuff was .it was supposed to be hamburger helper and I said well I'm sorry they got beef and noodle .what I have been told, regular tray .gets eggs, 1 sausage, oatmeal or dry cereal, biscuit .if its bacon they should receive 2 pieces of bacon .a couple of times didn't have enough bacon to give them 2 pieces . The Housekeeping and Laundry Supervisor confirmed sometimes residents didn't get sausage and just got 1 piece of bacon. During an interview on 12/23/2024 at 8:38 AM, Housekeeper I stated, .sometimes a person is supposed to receive double portion but we don't have enough for them to have double portion . Housekeeper I confirmed residents are supposed to receive 2 pieces of bacon and stated, If they have enough that day .if not receive 1 piece .they aren't ordering enough food .it's all disorganized . Housekeeper I was asked if residents are receiving the appropriate meal. Housekeeper I stated, Not really .would only get a meat and one vegetable and .like yesterday they had breakfast, it was bacon, eggs and muffin .grits . the resident got the meal, wanted pancakes .they didn't have pancakes and just sent out what they had . During an interview on 12/23/2024 at 9:08 AM, The Director of Nursing (DON) was asked about complaints from residents or families of the food portions being small, that the food is cold and inedible. The DON stated, I have heard all three .I think that goes back to not having leadership in the kitchen and not doing the planning .I don't know who is doing the ordering . The DON confirmed if a resident was supposed to receive double portion the orders should be followed, and they should receive double portions. The DON was asked if 1 piece of ham and 1 vegetable was a double portion. The DON stated, .it should have been double meat and double portion of the 2 vegetables .double portion of everything . The DON was asked what her concerns are in the kitchen. The DON stated, .the kitchen needs guidance, leadership and thorough training . During an interview on 12/23/2024 at 11:30 AM, the Administrator confirmed physician orders should be followed, residents should receive a full nutritional meal, residents should had received 2 pieces of bacon. The Administrator was asked had she had complaints from residents or families, that there is not enough food in the kitchen. The Administrator stated, Yes ma'am .when our truck didn't deliver due to the transition .I went to the store and bought groceries to make it through for the truck to be delivered the next day . During a random interview on 12/23/2024 at 1:00 PM, Resident #10 stated, Can you get us some more food .get one scoop of egg .one sausage and one biscuit .won't give us anymore until everyone is served . 3. Observation in the kitchen on 12/9/2024 at 9:00 AM, revealed the November 2024, and December 2024, dish machine temperature log had not been fully completed. Review of the DISH MACHINE TEMPERATURES-SANITATION sanitation logs dated 11/2024 and 12/2024, revealed dish machine temperature checks and sanitizer testing with a chemical strip were to be tested at breakfast, lunch, and dinner and initialed as being completed. Review of the sanitation logs failed to show the completion of all the breakfast, lunch and dinner dish machine temperature checks, sanitizer checks, with initials on 11/1/2024, 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024,11/10/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/3/2024,12/4/2024, 12/5/2024, 12/6/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/17/2024, 12/19/2024, and 12/21/2024. During an interview on 12/23/2024 at 11:30 AM, the Administrator confirmed she was unable to find the kitchen sanitation log for the month of September and October 2024. 4. Review of the November CLEANING SCHEDULE dated 11/11/2024 - 12/1/2024 revealed the cleaning schedule had multiple blank areas without initials that the AM aide was to perform. The following dates staff failed to empty and rinse out the mop bucket, wash and clean the mops with soapy water and rinse and hang up, shake off the crumbs and wipe off the toaster, walk in the cooler sweep and mop, check the dates, in the beverage station, clean the nozzles, empty the drip pan and wipe outside, clean the inside and wipe outside the microwave, spray and wipe down the outside carts, wash the inside of the coffee machine with soapy water and wipe clean outside, condiment, silverware bins and carts, sweep the kitchen floors, sanitize the garbage disposal, run the ice machine scoop through the dishwasher. Review of the cleaning schedule from 11/11/2024 - 12/1/2024 revealed the AM aide failed to perform the kitchen cleaning duties 18 days on 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/28/2024, 11/29/2024, 11/30/2024, and 12/1/2024. Review of the November CLEANING SCHEDULE dated 11/17/2024 - 12/1/2024 revealed the cleaning schedule had multiple blank areas without initials that the cook was to perform. The following dates the cook failed to clean the blender/food processor, can opener, ovens, counters, grill, mixer, slicer, steam table to replace the foil in the range, sweep and check dates in the freezer. The cook failed to perform the kitchen cleaning duties 15 days on 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, 11/30/2024, and 12/1/2024. Review of the November CLEANING SCHEDULE dated 11/24/2024 - 12/1/2024 revealed the cleaning schedule had multiple blank areas without initials for the PM aide. The following dates staff failed to clean the hand sink, soap and paper towels, empty and clean the mop bucket, wash and clean the mops with soapy water and rinse and hang up, sweep and mop the walker in cooler and check dates, sweep the kitchen floors, sweep and mop the dish room floor, clean the reach in cooler, clean any spills and check dates, sweep and mop the store room wipe and sanitize the tray carts inside and out, wash the garbage can and lids inside and out. The PM aide failed to perform the kitchen duties on 11/29/2024, 11/30/2024, and 12/1/2024. 5. Staff failed to ensure appropriate kitchen sanitation as follows: a. Observation in the kitchen on 12/9/2024 at 8:40 AM, revealed the following: The CDM J, from another facility, and Dietary [NAME] 2 were not wearing facial covering to cover their facial hair. The Kitchen floor had small pieces of paper on the floor and the floor was dirty. 1 large cooking pan with dark black sticky build up. 2 large skillets with peeling Teflon on the inside and a black sticky build up on the inside and outside of the skillet. During an interview on 12/9/2024 at 8:50 AM, CDM J from another facility confirmed that the pan and the skillets had carbon build up on them and facial hair should be covered in the kitchen. b. Observation in the kitchen on 12/10/2024 at 7:10 AM, revealed the following: Dietary [NAME] 2 was not wearing a facial covering to cover his facial hair while serving breakfast meals. The kitchen floor had small pieces of paper scattered on the floor and the floor was dirty. The Metal storage racks had dust buildup, peeling mental and the racks were dirty. The Convection Oven had dried food particles and brown buildup inside. c. Observation in the kitchen on 12/10/2024 at 12:13 AM, revealed the following: Dietary [NAME] 2 was not wearing a facial covering to cover his facial hair while serving lunch meals. The kitchen floor was dirty with 2 cup lids, plastic paper and small pieces of paper lying on the floor. The Metal storage racks had dust buildup, peeling mental and the racks were dirty. The Convection Oven had dried food particles and brown buildup inside. d. Observation in the kitchen on 12/10/2024 at 3:45 PM, revealed the following: The kitchen floor was dirty with 2 cup lids, plastic paper and small pieces of paper lying on the floor. The Metal storage racks had dust buildup, peeling mental and the racks were dirty. The Convection Oven had dried food particles and brown buildup inside. e. Observation in the kitchen on 12/11/2024 at 12:10 PM, revealed the following: The kitchen floor was dirty, with 2 cups lids, plastic paper, salt and pepper packets, a plastic fork and small pieces of paper scattered on the floor. The Metal storage racks had dust buildup, peeling mental and the racks were dirty. The Convection Oven had dried food particles and brown buildup inside. f. Observation in the kitchen on 12/14/2024 at 10:35 AM, revealed the following: Dietary [NAME] #3 was not wearing a facial covering to cover his facial hair. The kitchen floor was dirty, with 2 cups lids and small pieces of paper scattered on the floor. The Metal storage racks had dust buildup, peeling mental and the racks were dirty. The Convection Oven had dried food particles and brown buildup inside. 6. Review of the facility MEAL TIMES document revealed meals are to be served as follows: The Main dining room breakfast was scheduled at 7:15 AM, Lunch at 11:30 AM and supper at 5:15 PM. The 300 hall Restorative dining room meal cart breakfast was at 7:15 AM, Lunch at 11:30 AM and supper at 5:15 PM. The 300 hall meal cart breakfast was at 7:30 AM, lunch at 11:45 AM, supper at 5:30 PM. The 300 hall overflow meal cart breakfast was at 7:40 AM, lunch at 11:55 AM, supper at 5:40 PM. The 200 hall dining room breakfast was at 7:50 AM, Lunch at 12:05 PM, and supper at 5:50 PM. The 100 hall breakfast was at 8:00 AM, lunch at 12:15 PM, and supper at 6:00 PM. During an interview on 12/9/2024 at 8:00 AM, the Administrator confirmed that she had fired the previous Certified Dietary Manager (CDM) in September 2024, that she (the Administrator) had been having to work in the kitchen and had worked 600 hours . The Administrator stated, .has a CDM [from another facility that comes on the weekends to help] . when I fired the Dietary Manager .had to get rid of some of them .not had a lot of staff which caused meal times to be late .Friday before the transition, our truck didn't come .I went to Walmart and spent 400 dollars .I had to call today [the company that delivers food] .and place order. The Administrator stated, .I order, schedule, cook .last Sunday I cooked all three meals . During an observation and interview in Resident #16's room on 12/9/2024 at 2:39 PM, revealed the resident to be dressed, and sitting up in the bed. Resident #16 was asked if her meals have ever been late. Resident stated, .one time it was 2 o'clock for lunch . During an observation and interview in Resident #10's room on 12/10/2024 at 11:28 AM, revealed resident neatly dressed sitting in his wheelchair. Resident #10 was asked if his meals have ever been late. Resident #10 stated, .it has been 1:30 [PM] or 2:00 [PM] o'clock before we get something . Observation in the kitchen on 12/14/2024 at 10:35 AM, revealed there was a new Dietary cook for the facility that started this day, and two employees from 2 other facilities (a cook and a CDM). The meal trays were served late according to the scheduled times. The meal cart for the main dining room left the kitchen at 12:11 PM, and was 41 minutes late. The 300 hall meal cart left the kitchen at 12:19 PM, and was 49 minutes late. The 300 hall over flow meal cart went out at 12:26 PM, and was 31 minutes late. The 200 hall meal cart went out at 12:33 PM, and was 28 minutes late. The 100 hall meal cart went out at 12:39 PM, and was 24 minutes late. During a telephone interview on 12/19/2024 at 10:06 PM, Certified Nursing Assistant (CNA) L was asked if meals were ever served late. CNA L stated, .there have been days that they [referring to the CNA's] have had to pass the supper trays and pick them up . the staff had walked out [referring to some of the kitchen staff] .some of the CNA's have been asked to help in dietary .most of the time we have had the Administrator or Laundry to help us in the morning .sometimes Administrator or Laundry supervisor would have to come in at 5:00 AM to cook breakfast .it's almost pretty common .in the last few months .I have had the lady in Laundry to go ahead and tell [residents] breakfast was going to be late because they didn't have anybody come in . During a telephone interview on 12/19/2024 at 10:31 PM, CNA M was asked are if the meals were ever late. CNA M stated Yes .as soon as I walked in the door at 7:00 PM .I know the entire meals for that day was late .didn't get breakfast till 9:30 [AM] .lunch .about 2 [2:00 PM] .a couple a weeks ago . I believe it was the time we had a lot of the kitchen staff to quit . CNA M was asked if the staff on the floor and the Administrator were having to work in the kitchen due to not having enough staff in the kitchen. CNA M stated, Yes . 7. During an interview on 12/11/2024 at 1:00 PM, the Administrator confirmed the facility had a Registered Dietician (RD) until the facility's transition to another company on 12/1 and that they had a CDM (Certified Dietary Manager) that was supposed to have started last Friday and she had text the Friday she was supposed to have started work and said she wasn't coming. During a telephone interview on 12/19/2024 at 4:07 PM, the previous Registered Dietician (RD) was asked about the kitchen staff. The previous RD stated, Their short staff has been issue .a few of my homes have been able to go help .because of short staffing . The previous RD confirmed residents' meals are sometimes late and stated, I have done inservice related to meal times .we have been trying to implement more staff to help with that issue . The previous RD confirmed staff in the kitchen should be trained, the kitchen should be clean and meal temperatures should be taken with every meal. During a telephone interview on 12/19/2024 at 4:08 PM, the previous RD confirmed she was no longer the RD at the facility and stated, My last time at the facility was last month .their short staff has been issue. The Previous RD confirmed due to the kitchen being short staff sometimes meals are served late, kitchen should be kept clean, meal temperatures should be taken with all 3 meals, and the dish machine temperatures and sanitizer should be checked twice a day and documented. During a telephone interview on 12/19/2024 at 4:27 PM, Dietary Aide A was asked if the meals were ever late. Dietary Aide A stated .lunch was served as late at 2 PM a couple weeks ago .due to the cook being new and me being by myself .that day it was just him [cook] and I . Dietary Aide A confirmed for the last 2 or 3 months it's just been her (Dietary Aide A) and the cook in the kitchen. Dietary Aide A confirmed due to being short staffed in the kitchen, the dish temperature machine checks and keeping the kitchen clean doesn't always get done and stated, .it's a lot . Dietary Aide A was asked what her concerns were in the kitchen. Dietary Aide stated, .being under staff [under staffed], and with a full staff we could operate a lot smoother . During an interview on 12/23/2024 at 7:40 AM, Housekeeping and Laundry Supervisor confirmed having to work in the kitchen and hadn't checked dish washing machine temperature or the sanitizer and stated, .I didn't know . I'm not officially trained to work back there .I've just volunteer to work back there and learning a little bit here and there .as I go . During an interview on 12/23/2024 at 8:14 AM, Housekeeper H confirmed she had been helping in the kitchen the last 3 months and stated, The kitchen is a mess .no one wants to listen to . Housekeeper H confirmed that the CDM from another facility had showed her the dish washing machine and what the temperatures were supposed to be and stated, I didn't know about dipping the little thing in there [referring to the sanitizer strip] .he [the CDM from another facility] asked me to show the others and they weren't taking me serious .I just worked the dish machine and put stock away . Housekeeper H confirmed she was not trained to work in the kitchen. Housekeeper H confirmed breakfast has been as late as 9:00 AM, lunch as late as 2:00 PM and supper as late as 6:30 PM. Housekeeper H was asked if the floor staff and the Administrator were having to work in the kitchen due to not having enough staff in the kitchen. Housekeeper H stated, They can't keep anyone back there . During an interview on 12/23/2024 at 8:38 AM, Housekeeping I confirmed meal trays are sometimes late, breakfast as late as 9:00 AM, and lunch as late as 2:00 PM. Housekeeper I was asked is the staff on the floor and the Administrator were having to work in the kitchen due to not having enough staff in the kitchen. Housekeeper I stated, Yes. Housekeeper I confirmed she had worked in the kitchen and stated, .usually for breakfast .because they don't have enough staff and my boss [Named Housekeeper/Laundry Supervisor] will go back there and cook breakfast because there is not enough staff and she will ask me to go with her .I'm running around trying to do everything . Housekeeper I confirmed at times it would just be her and the Housekeeper /Laundry Supervisor in the kitchen cooking breakfast, due to no dietary staff. Housekeeper/Laundry Supervisor I confirmed she had not been trained to work in the kitchen, that she had not checked the dish washier machine temperature or the sanitizer, and that no one had trained her about the checking the temperature or the sanitizer. During an interview on 12/23/2024 at 9:08 AM, the Director of Nursing (DON) confirmed that she has had to work in the kitchen due to low staffing in the kitchen, and had not been trained to work in the kitchen. The DON confirmed the dish washer machine temperature and sanitizer should be checked and documented. The DON was asked if the meals were sometimes late coming out of the kitchen. The DON stated, .Yes .to be honest .I have seen all three meals to be late .breakfast 9:00 o'clock .1:30 PM for lunch .supper the last tray called at 6:30 . The DON was asked what the reasons were for the meal trays to be late. The DON stated .I know we don't have fully trained staff in the kitchen, we lost our CDM in September .there were problems before that .trays wasn't late then .now they just don't have leadership .things fall apart quick . During an interview on 12/23/2024 at 10:15 AM, CNA G was asked, have you worked in the kitchen. CNA G stated, .I went back there to help them a few times . CNA G was asked if the meals were ever late. CNA G stated, It's easier to say are they never on time .they are always late . CNA G confirmed she had worked in the dish room and had not been told to check the dish machine temperature or the sanitizer and stated, None of the people back there have been trained .just get hired and thrown back there . CNA G was asked if the kitchen is dirty. CNA G stated, .it's disgusting . we have been complaining about dietary for months . During an interview on 12/23/2024 at 11:30 AM, the Administrator confirmed she was unable to find the kitchen sanitation log for the month of September 2024 and October 2024, and the temperatures of the dish machine and sanitizer should be checked before breakfast, lunch and supper and documented. The Administrator was asked if the floor staff had worked in the kitchen due to low staffing. The Administrator stated, On occasion . The Administrator confirmed having worked in the kitchen and stated, .logged 600 hours since last September including last week .no one to cover .sister facility had schedule to come in and they decided not to come .the Sunday before you came in .fixed all 3 meals .had to do breakfast .and lunch one day last week . The Administrator was asked is the kitchen dirty. The Administrator stated, Yes, it can be . The Administrator confirmed the kitchen, the floors, skillets, pans, metal racks and kitchen equipment should be kept clean and facial hair should be covered. The Administrator was asked to provide dietary competencies on all employees working in the Kitchen. Record review revealed there were no dietary competencies on Dietary Aides A, B, C, D, E, and F, CNA G, Housekeeper H and I, the Housekeeper/Laundry Supervisor, the DON and the Administrator. The Administrator confirmed not everyone has been trained and stated, We train as we go . The Administrator was asked what her concerns were in the kitchen. The Administrator stated, .proper training and compliance .as well as we have the right individual in there that actually cares .

Based on facility policy review, document review, observation, and interview, the facility failed to provide sufficient staff with competencies and skill sets to carry out the functions of the food and nutrition services for 12 of 17 staff members (Dietary Aide A, B, C, D, E, F, Certified Nursing Assistant (CNA) G, Housekeeper H and I, Housekeeper/Laundry Supervisor, Director of Nursing (DON) and Administrator) working in the kitchen. The facility had a census of 78, with 76 of those residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility's policy titled, Dietary: Food Safety Requirements, dated 9/20/2024, revealed .Food will be stored, prepared and served in accordance with professional standards of food service safety . Review of the facility policy titled, Dietary-Mechanical Dish Washing, dated 10/9/2023, revealed .to ensure dishes and utensils are cleaned under sanitary conditions. Dishes shall be cleaned and sanitized after each use .The temperature of the dish machine shall be recorded three (3) times a day .Wash and rinse temperatures shall be observed and recorded at each meal service .Low temperature machines should be between 120-140 F [Fahrenheit] .Dish machine sanitizer must be tested and recorded before each meal when using a low temp machine .Employees should initial after completion . Review of the policy titled, Dietary-Dining Services, dated 3/28/2024, revealed .CART DELIEVERY TIMES .Meals shall be delivered to the residents in a timely fashion . Review of the facility's policy titled, Dietary: Food Safety Requirements, dated 9/20/2024, revealed .Food will be stored, prepared and served in accordance with professional standards of food service safety . Review of the facility's form titled, ORIENTATION AND COMPETENCY ASSESSMENT DIETARY revealed .DIETS .Therapeutic Diets .Tray Cards .FOOD PREPARATION .Menu Substitution .Meal Alternates .MEAL SERVICE .Meal Times .WARE WASHING .Dish Machine Temps [temperatures] .Test Strips for dish machine .Logs for Dish Machine .SANITATION .Equipment Cleaning .Mopping .Staff Member Has Completed All Items, Demonstrated Competence . 2. Observation in the kitchen on 12/9/2024 at 9:00 AM, revealed the November 2024, and the December 2024, dish machine temperature log had not been fully completed. Review of the DISH MACHINE TEMPERATURES-SANITATION sanitation logs dated 11/2024 and 12/2024, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper and initialed as being completed. Review of the sanitation logs failed to reflect the completion of all the breakfast, lunch and supper dish machine temperature checks, sanitizer checks, with initials as required on 11/1/2024, 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024, 11/10/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/17/2024, 12/19/2024, and 12/21/2024. 3. Review of the facility MEAL TIMES document revealed meals are to be served as follows: The Main dining room breakfast was scheduled at 7:15 AM, Lunch at 11:30 AM and supper at 5:15 PM. The 300 hall Restorative dining room meal cart breakfast was at 7:15 AM, Lunch at 11:30 AM and supper at 5:15 PM. The 300 hall meal cart breakfast was at 7:30 AM, lunch at 11:45 AM, supper at 5:30 PM. The 300 hall overflow meal cart breakfast was at 7:40 AM, lunch at 11:55 AM, supper at 5:40 PM. The 200 hall dining room breakfast was at 7:50 AM, Lunch at 12:05 PM, and supper at 5:50 PM. The 100 hall breakfast was at 8:00 AM, lunch at 12:15 PM, and supper at 6:00 PM. During an interview on 12/9/2024 at 8:00 AM, the Administrator confirmed that she had fired the previous Certified Dietary Manager (CDM) in September 2024, that she (the Administrator) had been having to work in the kitchen and had worked 600 hours . The Administrator stated, .has a CDM [from another facility that comes on the weekends to help] . when I fired the Dietary Manager .had to get rid of some of them .not had a lot of staff which caused meal times to be late .Friday before the transition, our truck didn't come .I went to Walmart and spent 400 dollars .I had to call today [the company that delivers food] .and place order. The Administrator stated, .I order, schedule, cook .last Sunday I cooked all three meals . During an observation and interview in Resident #16's room on 12/9/2024 at 2:39 PM, revealed the resident to be dressed, and sitting up in the bed. Resident #16 was asked if her meals have ever been late. Resident stated, .one time it was 2 o'clock for lunch . During an observation and interview in Resident #10's room on 12/10/2024 at 11:28 AM, revealed resident neatly dressed sitting in his wheelchair. Resident #10 was asked if his meals have ever been late. Resident #10 stated, .it has been 1:30 [PM] or 2:00 [PM] o'clock before we get something . Observation in the kitchen on 12/14/2024 at 10:35 AM, revealed there was a new Dietary cook for the facility that started this day, and two employees from 2 other facilities (a cook and a CDM). The meal trays were served late according to the scheduled times. The meal cart for the main dining room left the kitchen at 12:11 PM, and was 41 minutes late. The 300 hall meal cart left the kitchen at 12:19 PM, and was 49 minutes late. The 300 hall over flow meal cart went out at 12:26 PM, and was 31 minutes late. The 200 hall meal cart went out at 12:33 PM, and was 28 minutes late. The 100 hall meal cart went out at 12:39 PM, and was 24 minutes late. During a telephone interview on 12/19/2024 at 10:06 PM, Certified Nursing Assistant (CNA) L was asked if meals were ever served late. CNA L stated, .there have been days that they [referring to the CNA's] have had to pass the supper trays and pick them up . the staff had walked out [referring to some of the kitchen staff] .some of the CNA's have been asked to help in dietary .most of the time we have had the Administrator or Laundry to help us in the morning .sometimes Administrator or Laundry supervisor would have to come in at 5:00 AM to cook breakfast .it's almost pretty common .in the last few months .I have had the lady in Laundry to go ahead and tell [residents] breakfast was going to be late because they didn't have anybody come in . During a telephone interview on 12/19/2024 at 10:31 PM, CNA M was asked are if the meals were ever late. CNA M stated Yes .as soon as I walked in the door at 7:00 PM .I know the entire meals for that day was late .didn't get breakfast till 9:30 [AM] .lunch .about 2 [2:00 PM] .a couple a weeks ago . I believe it was the time we had a lot of the kitchen staff to quit . CNA M was asked if the staff on the floor and the Administrator were having to work in the kitchen due to not having enough staff in the kitchen. CNA M stated, Yes . During a telephone interview on 12/19/2024 at 4:07 PM, the previous Registered Dietician (RD) was asked about the kitchen staff. The previous RD stated, Their short staff has been issue .a few of my homes have been able to go help .because of short staffing . The previous RD confirmed residents' meals are sometimes late and stated, I have done inservice related to meal times .we have been trying to implement more staff to help with that issue . The previous RD confirmed staff in the kitchen should be trained, the kitchen should be clean and meal temperatures should be taken with every meal. During a telephone interview on 12/19/2024 at 4:27 PM, Dietary Aide A was asked if the meals were ever late. Dietary Aide A stated .lunch was served as late at 2 PM a couple weeks ago .due to the cook being new and me being by myself .that day it was just him [cook] and I . Dietary Aide A confirmed for the last 2 or 3 months it's just been her (Dietary Aide A) and the cook in the kitchen. Dietary Aide A confirmed due to being short staffed in the kitchen, the dish temperature machine checks and keeping the kitchen clean doesn't always get done and stated, .it's a lot . Dietary Aide A was asked what her concerns were in the kitchen. Dietary Aide stated, .being under staff [under staffed], and with a full staff we could operate a lot smoother . During an interview on 12/23/2024 at 7:40 AM, Housekeeping and Laundry Supervisor confirmed having to work in the kitchen and hadn't checked dish washing machine temperature or the sanitizer and stated, .I didn't know . I'm not officially trained to work back there .I've just volunteer to work back there and learning a little bit here and there .as I go . During an interview on 12/23/2024 at 8:14 AM, Housekeeper H confirmed she had been helping in the kitchen the last 3 months and stated, The kitchen is a mess .no one wants to listen to . Housekeeper H confirmed that the CDM from another facility had showed her the dish washing machine and what the temperatures were supposed to be and stated, I didn't know about dipping the little thing in there [referring to the sanitizer strip] .he [the CDM from another facility] asked me to show the others and they weren't taking me serious .I just worked the dish machine and put stock away . Housekeeper H confirmed she was not trained to work in the kitchen. Housekeeper H confirmed breakfast has been as late as 9:00 AM, lunch as late as 2:00 PM and supper as late as 6:30 PM. Housekeeper H was asked if the floor staff and the Administrator were having to work in the kitchen due to not having enough staff in the kitchen. Housekeeper H stated, They can't keep anyone back there . During an interview on 12/23/2024 at 8:38 AM, Housekeeping I confirmed meal trays are sometimes late, breakfast as late as 9:00 AM, and lunch as late as 2:00 PM. Housekeeper I was asked is the staff on the floor and the Administrator were having to work in the kitchen due to not having enough staff in the kitchen. Housekeeper I stated, Yes. Housekeeper I confirmed she had worked in the kitchen and stated, .usually for breakfast .because they don't have enough staff and my boss [Named Housekeeper/Laundry Supervisor] will go back there and cook breakfast because there is not enough staff and she will ask me to go with her .I'm running around trying to do everything . Housekeeper I confirmed at times it would just be her and the Housekeeper /Laundry Supervisor in the kitchen cooking breakfast, due to no dietary staff. Housekeeper/Laundry Supervisor I confirmed she had not been trained to work in the kitchen, that she had not checked the dish washier machine temperature or the sanitizer, and that no one had trained her about the checking the temperature or the sanitizer. During an interview on 12/23/2024 at 9:08 AM, the Director of Nursing (DON) confirmed that she has had to work in the kitchen due to low staffing in the kitchen, and had not been trained to work in the kitchen. The DON confirmed the dish washer machine temperature and sanitizer should be checked and documented. The DON was asked if the meals were sometimes late coming out of the kitchen. The DON stated, .Yes .to be honest .I have seen all three meals to be late .breakfast 9:00 o'clock .1:30 PM for lunch .supper the last tray called at 6:30 . The DON was asked what the reasons were for the meal trays to be late. The DON stated .I know we don't have fully trained staff in the kitchen, we lost our CDM in September .there were problems before that .trays wasn't late then .now they just don't have leadership .things fall apart quick . During an interview on 12/23/2024 at 10:15 AM, CNA G was asked, have you worked in the kitchen. CNA G stated, .I went back there to help them a few times . CNA G was asked if the meals were ever late. CNA G stated, It's easier to say are they never on time .they are always late . CNA G confirmed she had worked in the dish room and had not been told to check the dish machine temperature or the sanitizer and stated, None of the people back there have been trained .just get hired and thrown back there . CNA G was asked if the kitchen is dirty. CNA G stated, .it's disgusting . we have been complaining about dietary for months . During an interview on 12/23/2024 at 11:30 AM, the Administrator confirmed she was unable to find the kitchen sanitation log for the month of September 2024 and October 2024, and the temperatures of the dish machine and sanitizer should be checked before breakfast, lunch and supper and documented. The Administrator was asked if the floor staff had worked in the kitchen due to low staffing. The Administrator stated, On occasion . The Administrator confirmed having worked in the kitchen and stated, .logged 600 hours since last September including last week .no one to cover .sister facility had schedule to come in and they decided not to come .the Sunday before you came in .fixed all 3 meals .had to do breakfast .and lunch one day last week . The Administrator was asked to provide dietary competencies on all employees working in the Kitchen. Record review revealed there were no dietary competencies on Dietary Aides A, B, C, D, E, and F, CNA G, Housekeeper H and I, the Housekeeper/Laundry Supervisor, the DON and the Administrator. The Administrator confirmed not everyone has been trained and stated, We train as we go . The Administrator was asked what her concerns were in the kitchen. The Administrator stated, .proper training and compliance .as well as we have the right individual in there that actually cares .

Based on policy review, observation, kitchen sanitation logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions and when for 3 of 6 (Certified Dietary Manager (CDM) J from another facility, Dietary [NAME] O, and Dietary [NAME] V) dietary staff were observed. The dietary staff failed to cover facial hair, the kitchen floor was dirty with pieces of paper scattered on the floor, and cook ware had sticky black carbon build-up. The facility failed to take dish washer temperatures and test the sanitizing solution level of the low temperature dishwasher three times a day. The convection oven had dried food particles inside with thick brown sticky substance buildup, the metal storage racks were rusty with peeled metal and dust buildup. The facility had a census of 78 with 76 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled, Dietary-Cleaning, dated 7/25/2024, revealed .Adequate cleaning and sanitizing shall minimize the risk of food borne illnesses .Cleaning surfaces, equipment or utensils involves the use of hot water and detergent which removes soil, grease, food and odors .Sanitizing can occur by applying heat and/or chemicals for enough time to reduce bacterial count on counters, dishware .pots and pans .The CDM [Certified Dietary Manager]/Kitchen Supervisor shall audit the cleaning schedule for completeness .shall conduct sanitation / safety inspection / kitchen observations . Review of the facility policy titled, Dietary-Mechanical Dish Washing, revised on 10/9/2023, revealed .to ensure dishes and utensils are cleaned under sanitary conditions. Dishes shall be cleaned and sanitized after each use .The temperature of the dish machine shall be recorded three (3) times a day .Wash and rinse temperatures shall be observed and recorded at each meal service .Low temperature machines should be between 120-140 F [Fahrenheit] .Dish machine sanitizer must be tested and recorded before each meal when using a low temp machine .Employees should initial after completion . Review of the facility policy titled, Dietary: Cleaning revised on 7/25/2024, revealed .Adequate cleaning and sanitizing shall minimize the risk of food borne illnesses .The CDM/Kitchen Supervisor is responsible for maintaining a cleaning schedule to indicate which equipment and areas are to be cleaned and at what frequency .The CDM/Kitchen Supervisor shall post a weekly cleaning schedule that identifies .The equipment or area to be cleaned .frequency of cleaning .position/staff responsible for cleaning .The weekly cleaning schedule shall be used to document when a cleaning assignment is completed . Review of the policy titled, Dietary-Dining Services, dated 3/28/2024, revealed .CART DELIEVERY TIMES .Meals shall be delivered to the residents in a timely fashion . 2. Observation in the kitchen on 12/9/2024 at 8:40 AM, revealed the following. The CDM J, from another facility, and Dietary [NAME] 2 were not wearing facial covering to cover their facial hair. 2 large skillets with a black sticky build up on the inside and outside of the skillet and peeling Teflon on the inside of the skillet. 1 large cooking pan with dark black sticky build up on the inside and outside of the pan. The Kitchen floor was dirty with small pieces of paper throughout the kitchen floor. During an interview on 12/9/2024 at 8:50 AM, CDM J from another facility was shown the skillets and pan and asked what the black sticky were on them. CDM J stated, .that's bad buildup .carbon and grease. CDM J was asked should facial hair be covered in the kitchen. CDM J stated, .can't find any here .going to have them bring some from my facility today . 3.Observation in the kitchen on 12/9/2024 at 9:00 AM, revealed the November 2024, and December 2024, dish machine temperature log had not been fully completed. Observation in the kitchen on 12/9/2024 at 9:00 AM, revealed the November 2024, and the December 2024, dish machine temperature log had not been fully completed. Review of the DISH MACHINE TEMPERATURES-SANITATION sanitation logs dated 11/2024 and 12/2024, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper and initialed as being completed. Review of the sanitation logs failed to reflect the completion of all the breakfast, lunch and supper dish machine temperature checks, sanitizer checks, with initials on the following dates: 11/1/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/2/2024, no temperatures or sanitizer were checked for supper. 11/3/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/4/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/5/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/6/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/7/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/8/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/9/2024, no temperatures or sanitizer were checked for breakfast or supper. 11/10/2024, no temperatures or sanitizer were checked for breakfast or supper. 11/11/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/12/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/13/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/14/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/15/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/16/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/17/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/18/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/19/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/20/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/21/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/22/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/23/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/24/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/25/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/26/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/27/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/29/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 11/30/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/1/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/2/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/3/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/4/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/5/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/6/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/7/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/8/2024, no temperatures or sanitizer were checked for breakfast, lunch, or supper. 12/9/2024, no temperatures or sanitizer were checked for breakfast or supper. 12/10/2024, no temperatures or sanitizer were checked for lunch or supper. 12/11/2024, no temperatures or sanitizer were checked for breakfast or lunch. 12/17/2024, no temperatures or sanitizer were checked for breakfast. 12/19/2024, no temperatures or sanitizer were checked for supper. 12/21/2024, no temperatures or sanitizer were checked for breakfast or lunch. During an interview on 12/23/2024 at 11:30 AM, the Administrator confirmed she was unable to find the kitchen sanitation log for the month of September and October 2024. 4. Review of the November CLEANING SCHEDULE dated 11/11/2024 - 12/1/2024 revealed the cleaning schedule had multiple blank areas without initials that the AM aide was to perform. The following dates staff failed to empty and rinse out the mop bucket, wash and clean the mops with soapy water and rinse and hang up, shake off the crumbs and wipe off the toaster, walk in the cooler sweep and mop, check the dates, in the beverage station, clean the nozzles, empty the drip pan and wipe outside, clean the inside and wipe outside the microwave, spray and wipe down the outside carts, wash the inside of the coffee machine with soapy water and wipe clean outside, condiment, silverware bins and carts, sweep the kitchen floors, sanitize the garbage disposal, run the ice machine scoop through the dishwasher. Review of the cleaning schedule from 11/11/2024 - 12/1/2024 revealed the AM aide failed to perform the kitchen cleaning duties 18 days on 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/28/2024, 11/29/2024, 11/30/2024, and 12/1/2024. Review of the November CLEANING SCHEDULE dated 11/17/2024 - 12/1/2024 revealed the cleaning schedule had multiple blank areas without initials that the cook was to perform. The following dates the cook failed to clean the blender/food processor, can opener, ovens, counters, grill, mixer, slicer, steam table to replace the foil in the range, sweep and check dates in the freezer. The cook failed to perform the kitchen cleaning duties 15 days on 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, 11/30/2024, and 12/1/2024. Review of the November CLEANING SCHEDULE dated 11/24/2024 - 12/1/2024 revealed the cleaning schedule had multiple blank areas without initials for the PM aide. The following dates staff failed to clean the hand sink, soap and paper towels, empty and clean the mop bucket, wash and clean the mops with soapy water and rinse and hang up, sweep and mop the walker in cooler and check dates, sweep the kitchen floors, sweep and mop the dish room floor, clean the reach in cooler, clean any spills and check dates, sweep and mop the store room wipe and sanitize the tray carts inside and out, wash the garbage can and lids inside and out. The PM aide failed to perform the kitchen duties on 11/29/2024, 11/30/2024, and 12/1/2024. 5. Observation in the kitchen on 12/10/2024 at 7:10 AM, revealed the following: Dietary [NAME] 2 was serving breakfast meals and not wearing a facial covering to cover his facial hair. The kitchen floor was dirty, with small pieces of paper throughout the kitchen floor. The metal storage racks rusty, peeling mental and dust buildup. The Convection Oven had a brown buildup and dry food particles inside. 6. Observation in the kitchen on 12/10/2024 at 12:13 AM, revealed the following: Dietary [NAME] 2 was serving lunch meals without a facial covering to cover his facial hair The kitchen floor was dirty with small pieces of paper scattered throughout the kitchen, and 2 cups lids and plastic paper lying on the floor. The Metal storage racks were rusty, the meal was peeling and had a buildup of dust. The Convection Oven had a brown buildup and dry food particles inside. 7. Observation in the kitchen on 12/10/2024 at 3:45 PM, revealed the following: The kitchen floor had small pieces of paper scattered throughout the kitchen, and 2 cups lids and plastic paper lying on the floor. The metal storage racks were rusty, was peeling, and had a dust buildup. The Convection Oven had a brown buildup and dry food particles inside 8. Observation in the kitchen on 12/11/2024 at 12:10 PM, revealed the following: The kitchen floor was dirty with small pieces of paper scattered, salt and pepper packets, a plastic fork, 2 cups lids and plastic paper lying throughout on the floor. The metal storage racks were rusty, peeling metal and a dust buildup. The Convection Oven had a brown buildup and dry food particles inside 9. Observation in the kitchen on 12/14/2024 at 10:35 AM, revealed the following: Dietary [NAME] #3 was not wearing a facial covering to cover his facial hair. The metal storage racks were rusty, had peeling metal and had a buildup of dust. The Convection Oven had a brown buildup and dry food particles inside. The kitchen floor was dirty with small pieces of paper scattered throughout and 2 cup lids. 10. The facility was unable to provide October 2024 daily food temperatures for breakfast, lunch, and dinner, and could only show 11/28/2024 dinner meal temperatures for the month of November 2024. During an interview on 12/11/2024 at 12:23 PM, CDM J, from another facility, stated .just my second time here .they are so shorthanded .don't want them to lose what they already got . CDM J was asked if the kitchen was clean. CDM J stated, .the lack there of .it's some bad habits for sure .tray carts had not been cleaned from the night before .4 of my people came Monday and cleaned for about 3 hours .I think it's an afterthought . CDM J confirmed the kitchen should be clean. During an interview on 12/23/2024 at 7:40 AM, the Housekeeping and Laundry Supervisor confirmed she worked in the kitchen and the kitchen should be clean and stated, .me and one of my housekeepers came in and strip the floor it was bad . The Housekeeper/Laundry Supervisor confirmed that she hadn't checked dish washer machine temperature or the sanitizer and stated, .I didn't know .we need somebody in there that can manage the kitchen and get them on the right track . During an interview on 12/23/2024 at 9:08 AM, the Director of Nursing (DON) was asked has she had to work in the kitchen. The DON stated, I've gone back there .a couple of weeks ago . The DON was asked if the kitchen was dirty. The DON stated, .parts of it are .their main focus to get the food out and no one in the leadership to make them adhere to the cleaning scheduled . The DON confirmed all hair should be covered in the kitchen and the dish wash machine temperature and sanitizer should be checked and documented and stated, It just goes back to accountability and some people need constant supervisor at least till they get in the habit of things. During an interview on 12/23/2024 at 10:15 AM, Certified Nursing Assistant (CNA) G was asked if they have worked in the kitchen. CNA G stated, .I went back there to help them a few times . CNA G confirmed she worked in the dish room, and she had not been told to check the dish washer machine temperature or the sanitizer. CNA G was asked if the kitchen was dirty. CNA G stated, .yes it's filthy . During an interview on 12/23/2024 at 11:30 AM, the Administrator was asked is the kitchen dirty. The Administrator stated, Yes, it can be . The Administrator confirmed the kitchen, the floors, skillets, pans, metal racks and kitchen equipment should be kept clean and facial hair should be covered. The Administrator was asked how often the dish machine temperature, and the sanitizer should be taken. The Administrator stated, .before they clean the breakfast .dinner and supper dishes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and interview, the facility failed to provide information regarding a resident's right to formulate an advanced directive for 5 of 24 sampled residents (Resident #7, #37, #44, #53, and #58) reviewed for advance directives. The findings include: 1. Review of the facility's policy titled Advanced Directives dated 10/18/2022, revealed .Residents will be informed, and written information provided, during the admission process, regarding the right to accept or refuse medical or surgical treatment. The facility will honor the Advance Directive as the resident's wishes for future care and treatment .An Advance Directive is a written instruction given by the patient that either appoints another person to make health decisions for the resident or states the resident's health care preferences, or both .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Rheumatoid Arthritis, Chronic Obstructive Pulmonary Disease, Seizures, and Anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. Review of Resident #7's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 3. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, Pressure Ulcer Stage 3, Pressure Deep Tissue Damage Right Heel and Dementia. Review of the quarterly MDS dated [DATE] BIMS 0, which indicated the resident had severe cognitive impairment. Review of Resident #37's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 4. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, diabetes, Atrial Fibrillation, Aortic Valve Stenosis, Chronic Obstructive Pulmonary Disease, and Anxiety. Review of the annual MDS dated [DATE], revealed Resident #44 had a BIMS score of 14, which indicated Resident #44 was cognitively intact. Review of Resident #44's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 5. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of Heart Disease, Chronic Obstructive Pulmonary Disease, Anxiety, Dementia, Violent Behavior and Depression. Review of the annual MDS dated [DATE], revealed Resident #53 had a BIMS score of 13 which indicated Resident #53 was cognitively intact. Review of Resident #53's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 6. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease, Hypokalemia, Dysphagia, and Heart Failure. Review of the annual MDS dated [DATE], revealed Resident #58 had a BIMS score of 4, which indicated Resident #58 had severe cognitive impairment. Review of Resident #58's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 7. During an interview on 9/29/2023 at 10:38 AM, the Director of Nursing (DON) was asked should residents have an advance directive in their record. The DON stated, Absolutely .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to include the resident and/or family member in the Interdisciplinary Team (IDT) Care Plan meeting for 4 of 24 sampled residents (Resident #7, #44, #58 and #69) reviewed for Care Plan Meetings. The finding include: 1. Review of the facility's policy titled .Care Planning-Resident Participation, dated 10/21/2022, revealed .This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care) .The facility will inform the resident .of his or her rights regarding planning and implementing care .The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care . The facility will honor requests for care plan meetings and acknowledge requests for revisions to the person-centered plan of care .The facility will discuss the plan of care with the resident and/or representative, and allow them to see the care plan, initially, as routine intervals, and after significant changes. The facility will obtain a signature from the resident and/or representative chooses to participate via a conference call, documentation of participation will be noted in place of a signature . Review of the facility's policy titled .Comprehensive Care Plan, dated 10/24/2022, revealed .The comprehensive care plan shall be prepared by an interdisciplinary team, that includes, but is not limited to .The attending physician .A registered nurse with responsibility for the resident .A nurse aide with responsibility for the resident .a member of food and nutrition services staff .The resident and the resident's representative .Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to .Activities Director/Staff . Social Services Director/Social Worker .Licensed therapists .Family members . Administration . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Rheumatoid Arthritis, Chronic Obstructive Pulmonary Disease, Seizures, and Anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. During an interview on 9/25/2023 at 4:05 PM, Resident #7 was asked if she had been invited to a care plan meeting. Resident #7 stated, No, I haven't. 3. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Congestive Heart Failure, Diabetes, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Anxiety. Review of the annual MDS dated [DATE], revealed Resident #44 had a BIMS score of 14, which indicated cognitively intact. During an interview on 9/25/2023 at 3:43 PM, Resident #44 was asked if she had been invited to a care plan meeting. Resident #44 stated, No . 4. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease, Hypokalemia, Dysphagia, and Heart Failure. Review of the annual MDS dated [DATE], revealed Resident #58 had a BIMS score of 3, which indicated she was severe cognitive impairment. During an interview on 9/25/2023 at 10:46 AM, Resident #58's Responsible Party, was asked if he had been invited to a care plan meeting. He stated, No ma'am . 5. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE], with diagnoses of Congestive Heart Failure, Infection of Amputation of Stump, Diabetes, Chronic Viral Hepatitis, and Severe Sepsis. Review of the quarterly MDS dated [DATE], revealed Resident #69 had a BIMS of 15, which indicated resident is cognitively intact. During an interview on 9/27/2023 at 5:21 PM, Resident #69 was asked if he attended the care plan meeting on 8/11/2023. Resident #69 stated, .no, I don't remember attending a meeting . 6. During an interview on 9/28/2023 at 3:06 PM, Minimum Data Set (MDS) Coordinator #1, was asked about the care plan meetings. She stated, .the MDS Coordinator meets with [resident] .it's not a formal meeting .we don't have a formal care plan meeting we just document any concerns on our meetings .physician is not always in meeting but can delegate to Nurse Practitioner .We do it in huddle most times.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when a medication was left in a resident's room for 1 of 24 (Resident #54) sampled residents. The findings include: 1. Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy dated of 9/20/2021, revealed .all drugs and biologicals will be stored in locked compartments .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . 2. Random observation in Resident #54's room on 9/25/2023 at 9:45 AM, revealed a large white pill in a clear medication cup on the resident's bed on top of the sheet and blanket. During an interview on 9/25/2023 at 9:50 AM, LPN #1 confirmed that she left the pill in the resident's room during medication pass. LPN #1 was asked should medications be left at bedside in a resident's room. LPN#1 stated, No. During an interview on 9/29/2023 at 10:45 AM, the Director of Nursing (DON) was asked should medications be left in a resident's room unsecured and unattended. The DON stated No.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 13 staff members (Certified Nursing Assistant (CNA) #1, #2, #4, #5, and #6) failed to use courtesy titles to address Resident #15, #17, #20, #26, #31, #36, #39, #63, #64, #68, and #232, and 2 of 13 (CNAs #1, and #2) stood over Resident #58 and Resident #20 while assisting them to eat lunch. The findings include: 1. Review of the facility's policy titled, .Promoting/Maintaining Resident Dignity Policy, dated 10/24/2022, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity .Staff attempt to be at eye level during assist feeding . 2. Dining observation in the resident's room on 9/25/2023 at 11:58 AM, revealed CNA #4 spoke to Resident #17 and said, .there you go baby . 3. Dining observation in the resident's room on 9/25/2023 at 12:17 PM, revealed CNA #1 entered Resident #232's room and stated, Here is your tray, Honey . A visitor was in the room. 4. Dining observation in the resident's room on 9/25/2023 at 12:19 PM, revealed CNA #5 spoke to Resident #26 and said, .was checking on you baby . while serving the meal tray. 5. Dining observation in the resident's room on 9/25/2023 at 12:20 PM, revealed CNA #1 entered Resident #15's room and stated, Here is your tray, Sweetheart. 6. Dining observation in the resident's room on 9/25/2023 at 12:22 PM, revealed CNA #4 spoke to Resident #36 and said, .hi honey . while serving the meal tray. 7. Dining observation in the resident's room on 9/25/2023 at 12:27 PM, revealed CNA #4 spoke to Resident #64 and said, .let me get some gloves baby . while serving the meal tray. 8. Dining observation on the 300 Hall on 9/25/2023 at 12:29 PM, revealed CNA #1 told CNA #2 We only have feeders left. 9. Dining observation in resident's room on 9/25/2023 at 12:29 PM, revealed CNA #1 stood over Resident #20, who was in a gerichair, to assist her with eating lunch. 10. Dining observation in resident's room on 9/25/2023 at 12:29 PM, revealed CNA #2 stood over Resident #58, to assist her with eating lunch. 11. Dining observation in the resident's room on 9/25/2023 at 12:32 PM, revealed CNA #4 spoke to Resident #31 and said, .thank you darling . while serving the meal tray. 12. Dining observation in the resident's room on 9/26/2023 at 8:12 AM, revealed CNA #6 spoke to Resident #26 and said, .baby . while serving the meal tray. 13. Dining observation in the resident's room on 9/26/2023 at 8:16 AM, revealed CNA #6 spoke to Resident #63 and said, .baby . while serving the meal tray. 14. Dining observation in the resident's room on 9/26/2023 at 8:20 AM, revealed CNA #6 spoke to Resident #31 and said, .baby . while serving the meal tray. 15. Dining observation in the resident's room on 9/26/2023 at 8:24 AM, revealed CNA #6 spoke to Resident #39 and said, .baby . while serving the meal tray. 16. Dining observation in the resident's room on 9/26/2023 at 8:28 AM, revealed CNA #6 spoke to Resident #68 and said, .baby . while serving the meal tray. 17. During an interview on 9/29/2023 at 10:38 AM, the Director of Nursing (DON) was asked how should staff address a resident. The DON stated, As Mr. or Mrs. and last names unless they prefer to go by their first name . The DON was asked should staff stand over residents to serve them their meals. The DON stated, No supposed to be sitting.

Based on policy review, observation, and interview, the facility failed to ensure proper infection control practices when 5 of 13 (Certified Nursing Assistants (CNA #1, #3, #4, #5, and the Staffing Coordinator) staff members failed to perform hand hygiene during meal pass, placed dirty trays on the cart with clean trays, transported a tray with uncovered food items down the hall, when an enteral pump [machine used to deliver nutrition through a gastrostomy tube] and pole was observed dirty, and when toilet plungers, urinals, and wash basin were stored uncovered. The findings include: 1. Review of the facility's policy titled .Infection Prevention and Control Program, dated 10/24/2022, revealed .policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .All staff shall preform hand hygiene .between resident contacts, after handling contaminated objects .Staff shall perform hand hygiene before and after performing resident care procedures .All reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment .Reusable items potentially contaminated with infectious materials shall be placed in impervious plastic bags . 2. Observation in the Restorative Dining Room on 9/25/2023 at 11:46 AM, revealed CNA #3 assisted Resident #46 to eat his/her lunch meal. CNA #3 began to assist Resident #2 and Resident #18 with their meals and failed to perform hand hygiene. 3. Observation on 9/25/2023 at 12:13 PM, in the resident's room, revealed CNA #1 repositioned Resident #61 up in the bed, used the remote to lower the bed, moved the over bed table to the other side of the bed, the CNA failed to perform hand hygiene before she opened the milk carton and the straw and placed the straw into the milk. 4. Observation on 9/25/2023 at 12:05 PM, in the 300 Hall, revealed the Staffing Coordinator carried a tray from the meal cart halfway down the hall to Resident #57's room, with the cake on the tray uncovered. 5. Observation on 9/25/2023 at 12:17 PM, in the resident's room, revealed CNA #4 delivered a meal tray and placed it on Resident #67's overbed table, and returned the dirty meal tray and placed it into the meal cart with clean meal trays. 6. Observation on 9/26/2023 at 8:09 AM, in resident's room revealed CNA #5 delivered a meal tray and placed it on the Resident #74's overbed table, and returned the dirty meal tray and placed it into the meal cart with 3 clean meal trays inside. CNA #5 stated, .the clean ones aren't off yet . 7. Observation in Resident #15's bathroom on 9/25/23 at 9:15 AM, revealed a graduated dispenser uncovered on the back of the toilet, and an uncovered gray wash basin was on top of the paper towel dispenser. Observation in Resident #15's bathroom on 9/25/23 at 10:29 AM, revealed the graduated dispenser remained on the back of the toilet and the wash basin remained on the towel dispenser, both not covered. 8. Observation in the Resident #281's bathroom on 9/25/23 at 9:15 AM, revealed a blue toilet plunger in a gray wash basin and a urinal uncovered on back of toilet. Observation in Resident #281's bathroom on 9/25/23 at 10:28 AM, revealed the toilet plunger was in the gray wash basin on the bathroom floor, the plunger and basin were not covered. 9. Observation in Resident #40's bathroom on 9/25/23 at 9:15 AM, revealed a blue toilet plunger was uncovered. Observation in Resident #40's bathroom on 9/25/2023 at 10:31 AM, revealed the blue toilet plunger was uncovered. 10. Observation in Resident #73's bathroom on 9/25/2023 at 9:22 AM, revealed a pair of dirty gloves on the floor and a dirty wash basin with white substance that was sitting beside the toilet. 11. Observation in Resident #59's room on 9/25/2023 at 9:30 AM and 2:55 PM, revealed a brown substance on the enteral feeding pump and on the bottom/ base of the pole. Observation in Resident #59's room on 9/26/2023 at 8:11 AM, revealed a dried brown substance to the top of the enteral pump and on the bottom/base of the pump pole. 12. Observation in Resident #47's bathroom on 9/25/2023 at 10:09 AM and 2:43 PM, revealed a dirty wash basin with a brown substance in the corner, on the floor behind the toilet. Observation in Resident #47's bathroom on 9/26/2023 at 9:11 AM, revealed a dirty a wash basin with a brown substance, in the corner, on the floor behind the toilet. 13. During an interview on 9/27/2023 at 10:03 AM, the Director of Nursing (DON) was asked how should wash basins be stored when not in use. The DON stated, Covered and placed in the bathroom or in the wardrobe. The DON was asked how a toilet plunger should be stored. The DON stated, In a plastic bag next to the toilet . During an interview on 9/29/2023 at 10:38 AM, the DON was asked when should staff wash their hands when serving meal trays to residents. The DON stated, Supposed to sanitize before and after each tray and if they touch anything in the room .before they set up their tray. The DON was asked should staff put dirty meal trays on a meal cart that has clean trays waited to be served. The DON stated, Absolutely not. During an interview on 9/29/2023 at 10:47 AM, the DON was asked how often enteral pumps and poles should be cleaned. The DON stated, .should be monitored daily and cleaned as needed . The DON was asked should the enteral pump and enteral pole be dirty with dried brown substance. The DON stated, No. During an interview on 10/03/23 at 11:12 AM, the Assistant Director of Nursing (ADON) was asked should the food on the trays be covered when walking the tray halfway down the hall to the resident's room. The ADON stated, No, nothing should come down the hall uncovered.

Based on policy review, observation, and interview, the facility failed to ensure milk was maintained at a proper holding temperature on 6 meal trays, there were 106 residents receiving a meal tray from the kitchen, and that thickened water was not stored past the expiration date in 1 of 2 (Station 2) nourishment refrigerators. The findings include: The facility's Food Storage policy dated 10/18 documented, .foods will be stored at proper temperatures .Refrigerated food items at or below 41 [degree symbol] F [Fahrenheit] . Observations in the kitchen on 8/6/19 at 11:22 AM, revealed a glass of milk with a holding temperature of 43 degrees. There were 6 trays with glasses of milk that had been served to residents. Interview with the Certified Dietary Manager (CDM) on 8/7/19 at 3:15 PM, in the Main Dining Room, the CDM was asked should milk be served at 43 degrees. The CDM stated, No, it should be 40, 41, it was suppose to held in the ice hole. Observations in the Station 2 Nourishment Room on 8/7/19 at 2:40 PM, revealed 9 Nectar Thick Consistency Lemon Flavored Waters with an expiration date of 8/3/19, stored in the nourishment refrigerator. Interview with Licensed Practical Nurse (LPN) #1 on 8/7/19 at 2:40 PM, in the Station 2 Nourishment Room, LPN #1 was asked if the expired thickened waters should be in the refrigerator. LPN #1 stated, No .