**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to have a call light in reach for 1 of 93 sampled residents (Resident #27) observed. The findings include: Review of the facility policy titled, Resident Rights, revised 8/16/2018, revealed, .The facility provides equal access to quality of care regardless of diagnostic and severity of condition . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Quadriplegia and Guillian-Barre Syndrome. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed Resident #27 required total assistance with two staff members for Bed Mobility and Transfers. Continued review revealed Resident #50 had upper and lower impairments of the extremities bilaterally. Observations in Resident #27's room on 2/27/2022 at 11:44 AM and 2:32 PM, revealed Resident #50's flat call light was not in reach for her to touch and call for help. Observation in Resident #27's room on 2/28/2022 at 10:42 AM revealed Resident #50's flat call light was not in reach for her to touch and call for help. Observation and interview in Resident #27's room on 2/28/2022 at 10:44 AM, Certified Nurse Aide (CNA) #7 confirmed Resident #27 was not able to reach her call light. During an interview on 3/2/2022 at 10:33 AM, the Unit Manager also known as LPN #5 confirmed the call light should be placed near Resident #27's face so she can reach it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to implement a person-centered care plan for 3 of 93 sampled residents (Resident #14, #43, and #50) for respiratory care for Resident #14, anticoagulant for Resident #43, and elopement for Resident #50. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 7/19/2018, revealed, .A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .10. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS [Minimum Data Set]/ CAA [Care Area Assessment]). Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses which included Encounter for other Orthopedic Aftercare, Hypertension, Epilepsy, Chronic Respiratory Failure, Dependence on Supplemental Oxygen, and Osteoporosis. Review of the Scheduled 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 received oxygen therapy. Review of the Physician's Orders for Resident #14, revealed, .Oxygen Therapy: Oxygen via NC [nasal cannula] to keep sats [saturation] above 88% .Oxygen therapy: Change tubing every week .change on Thur [Thursday] .albuterol sulfate aerosol inhaler; 90 mcg [micrograms]/actuation; amt [amount]: 2 puffs; inhalation Every 6 Hours - PRN [as needed] .Trelegy Ellipta (fluticasone-umeclidin-vilanter) blister with device; 100-62.5-25 mcg; amt: 1 inhalation; inhalation Once A Day .Inhaler use: following inhaler medication administration, have resident rinse mouth with water .Oxygen Weaning- wean as tolerated .Oxygen therapy: Check humidification bottle every shift, change when empty . Review of the Care Plan for Resident #14 dated 1/3/2022, revealed Resident #14 had no Care Plan for Respiratory Care. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which indicated Atrial Fibrillation. Review of the Quarterly MDS dated [DATE] revealed Resident #43 received anticoagulant medication 7 out of 7 days of the lookback period. Review of the Physician's Orders for Resident #43 dated 2/17/2022, revealed, .Eliquis (apixaban) 5 mg twice a day .diagnosis: Chronic atrial fibrillation . Review of the Care Plan for Resident #43 dated 2/18/2022, revealed the resident had no care plan for anticoagulants. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Dementia without Behavioral Disturbance. Review of the Care Plan for Resident #50 revised 2/7/2022, revealed the resident had no care plan for elopement risk. Review of the Physician's Orders for Resident #50 dated 12/17/2021, revealed .Check placement of Wander Guard every shift . Review of the Elopement Risk Assessments for Resident #50 dated 4/20/2021 and 2/11/2022 revealed the resident was considered a high elopement risk. During an interview on 3/1/2022 at 9:34 AM, MDS Coordinator #1 confirmed risk for elopement was not on Resident #50's care plan. During an interview on 3/1/2022 at 1:39 PM, Director of Nursing (DON) confirmed elopement was not on Resident #50's care plan. During an interview on 3/1/2022 at 1:40 PM, MDS Coordinator #2 confirmed Resident #14 had no Care Plan for Respiratory Care. During an interview on 3/2/2022 at 8:34 AM, MDS Coordinator #1 confirmed Resident #43 was taking anticoagulant medication and did not have a care plan for anticoagulants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to revise a care plan for 1 of 93 sampled residents (Resident #8) reviewed. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 4/6/15 and revised 7/19/18, revealed, .A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .The nurse/Interdisciplinary Team (IDT) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Each resident's Comprehensive Care plan is designed to: a. incorporate identified problem areas; .j. Reflect currently recognized standards of practice . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Palsy, Generalized Anxiety Disorder, Unspecified Behavioral Syndromes Associated with Physiological Disturbances and Need for Assistance with Personal Care. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 is rarely/never understood and his cognitive skills for daily decision making is severely impaired. Continued review revealed he rejected care 1 to 3 days in the 7 day evaluation period and he required extensive assistance of 2 or more caregivers for dressing. Review of the Care Plan for Resident #8 did not address the resident preferred to only wear a brief and would remove the gown, sheet, or blanket while in bed. Observations on 2/27/2022 at 12:10 PM, 2:12 PM, and 3:00 PM in Resident #8's room, revealed him laying in bed, uncovered, and wearing only a brief. Observations on 2/28/2022 at 7:46 AM, 10:00 AM, 10:25 AM, and 12:45 PM in Resident #8's room, revealed him laying in bed, uncovered, and wearing only a brief. During an interview on 2/28/2022 at 10:25 AM, Certified Medication Assistant (CMA) #2 stated, He [Resident #8] doesn't like to be clothed or covered up with a blanket or sheet. He will take his gown off and throw it. He doesn't like a pillow under his head either. During an interview on 3/1/2022 at 8:46 AM, Licensed Practical Nurse (LPN) #4 stated, He [Resident #8] appears more comfortable wearing only a brief. During an interview on 3/1/2022 at 8:55 AM, MDS Coordinator #1 confirmed the Care Plan for Resident #8 should include the fact he prefers to wear only a brief, and it was not. During an interview on 3/1/2022 at 9:25 AM, the Director of Nursing confirmed Resident #8 should be care planned for preferring to wear only a brief, and was not.

Based on facility policy review, observations, and interviews, the facility failed to ensure 1 of 93 sampled residents (Resident #63) had clean and groomed fingernails. The findings include: Review of the facility's policy titled, Nail Grooming, dated 5/18/2018, revealed, .Regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as necessary . Observation on 2/27/2022 at 9:51 AM, revealed Resident #63 sitting in his wheelchair in his room. Continued observation revealed the resident had long fingernails with dried brown debris noted under his nails on both hands. Observation and interview on 2/27/2022 at 11:39 AM, Resident #63 was sitting in his wheelchair in his room. The resident had different clothes on but his nails on both hands continued to be long with dried brown debris noted under his fingernails. Resident #63 confirmed he had received a bath. Observation and interview in Resident #63's room on 2/27/2022 at 12:15 PM, Certified Nurse Aide (CNA) #1 confirmed Resident #63's nails on both hands were dirty and long. He stated, We use an orange stick to clean them when we give them a bath and when they need it done, but I didn't clean them today. Observation and interview in Resident #63's room on 2/27/2022 at 12:30 PM, Licensed Practical Nurse (LPN) #1 looked at Resident #63's hands and confirmed Resident #63's nails were dirty and long. She stated residents' nails were supposed to be cleaned with showers and baths and whenever they are dirty and clipped when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for 3 of 93 sampled residents (Resident #38, #43, and #59) reviewed regarding wound dressing changes for Resident #38, Midline dressing changes for Resident #43, and medication administration for Resident #59. The findings include: Review of the facility's policy titled, Skin Tears-Abrasions and Minor Breaks, Care of, revised 9/2013, revealed, .The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin .Steps in the Procedures: 18. Apply the ordered dressing and secure with tape or bordered dressing per order .Label with date and initials to top of dressing . Review of the facility policy titled, Guidelines for Preventing Intravenous Catheter-Related Infections, revised August 2014, revealed, .Change TSM [transparent, semi permeable membrane] dressings on CVADs [Central Venous Access Device] every 5-7 days or PRN [as needed] if damp, loosened, or visible soiled . Review of the facility's policy titled, General Medication Order, revised 6/26/2018, revealed, .The purpose of this procedure is to establish uniform guidelines in the receiving and recording of the medication orders .Recording Orders: 6. Treatment Orders- When recording treatment orders, specify the treatment, location, frequency and duration of the treatment . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses which included Unspecified Dementia without Behavioral Disturbance and Chronic Kidney Disease. Review of the Care Plan for Resident #38 dated 2/16/2022, revealed, .Elder has skin tear to left shin area . Appropriate goals and interventions in place. Review of the Physician's Orders for Resident #38, dated 2/16/2022, revealed, .skin tear left shin, clean with normal saline, apply petroleum gauze and border gauze dressing, change every 3 days . During an interview on 2/27/2022, at 3:56 PM, Licensed Practical Nurse (LPN) #1 confirmed the dressing on Resident #38's left lower leg was dated 2/22/2022. LPN #1 also confirmed the physician's order was that wound care with dressing change to be performed every 3 days. She stated, It should have been changed on the 25th [2/25/2022]. During an interview on 2/28/2022 at 7:41 AM, LPN #2 confirmed she did not change the dressing to Resident #38's left lower leg on the due date of 2/25/2022. She stated she thought LPN #5 had performed the wound care and changed the dressing on 2/25/2022, because LPN #5 was assisting with wound care on the floor that day. During an interview on 3/1/2022 at 9:18 AM, LPN #5 stated she did work on the floor and assist with wound care on 2/25/2022. LPN #5 confirmed she did not change the wound dressing to Resident #38's left lower leg on 2/25/2022. She stated, I did not see that it was due to be changed. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses which included Bacteremia, Chronic Kidney Disease, Neuromuscular Dysfunction of Bladder, and Personal History of Urinary (tract) Infections. Review of the Physician's Orders for Resident #43 dated 2/18/2022, revealed, .Midline extension, connector and dressing change weekly . Review of the Care Plan for Resident #43 dated 2/18/2022, revealed, .Elder has midline in place for IV [intravenous] infusion .midline dressing change as ordered . Observation in Resident #43's room on 2/27/2022 at 10:25 AM and 2:23 PM, revealed a midline to the resident's right upper arm. The midline dressing was dated 2/17/2022. Observation and interview in Resident #43's room on 2/27/2022 at 2:30 PM, Registered Nurse (RN) #1 confirmed the resident's midline dressing was dated 2/17/22. She stated, It's out of date; it should have been changed on the 24th [2/24/2022]. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus and Hypoglycemia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Continued review revealed Resident #59 received 7 days of insulin injections. Review of Resident #59's Care Plan dated 2/18/2020, revealed, .Elder has diagnosis of diabetes and is at risk for hyper [hyperglycemia]/hypoglycemia . Review of Resident #59's Physician's Orders dated 2/19/2022, revealed, .Lantus Solostar U [units]-100 Insulin (insulin glargine) insulin pen; 100 unit/mL [milliliter] (3 mL); amt [amount]: 37 units; subcutaneous Special Instructions: 37 units SQ [subcutaneous] every morning . Review of Resident #59's Physician's Orders dated 08/02/2021, revealed, .Blood sugar checks AC + HS Before Meals and At Bedtime 06:00 [6:00 AM], 12:00 [12:00 PM], 17:00 [5:00 PM], 21:00 [9:00 PM] . Review of Resident #59's Physician's Orders dated 6/29/2021, revealed, .Glucagon (HCl [Hydrochloride]) Emergency Kit (glucagon hcl) recon soln [reconstitute solution]; 1 mg [milligram]; amt: 1 MG; injection Special Instructions: Reconstitute & GIVE 1 mg IM [intramuscular] As Needed For Blood Glucose Less Than 60 . Review of Resident #59's vitals dated 3/1/2022 recorded at 6:37 AM, revealed Resident #59 had a blood glucose of 34mg/dl (milligram per deciliter). During an interview on 3/1/2022 at 8:00 AM, Resident #59 stated her blood glucose was 31 this morning and she was given chocolate pudding and crackers. During an interview on 3/1/2022 at 8:00 AM, LPN #3 confirmed she did not administer the ordered glucagon. During an interview on 3/1/2022 at 1:39 PM, the Director of Nursing (DON) confirmed he expected the nurse to follow the physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the medical record for Resident #60 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes Mellitus Without Complications. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Continued review revealed the use of oxygen. Review of the Physician's Orders for Resident #60 revealed an order dated 1/13/2022 for Ipratropium-Albuterol solution for nebulization three times a day as needed, and an order dated 8/13/2021 for Oxygen therapy at 2 liters per minute for shortness of breath as needed. Review of the current Care Plan for Resident #60 revealed assessments for risk for respiratory distress related to COPD and Chronic Respiratory Failure with appropriate goals and interventions including administering medications as ordered and using oxygen as ordered. Observation on 2/27/2022 at 9:45 AM in Resident #60's room, revealed the oxygen tubing was touching the floor on the right side of her bed and a nebulizer mask and nebulizer machine in the bed with her. Observation on 2/27/2022 at 11:09 AM in Resident #60's room, revealed the oxygen tubing was touching the floor on the right side of her bed and a nebulizer mask and nebulizer machine was in the bed with her. During an observation and interview on 2/27/2022 at 11:28 AM with the Director of Nursing in Resident #60's room, he confirmed the nebulizer mask and nebulizer machine should not be in the bed with the resident, the nebulizer mask should be in a bag, and the oxygen tubing should not be touching the floor. Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent the spread of infection for 2 of 93 sampled residents (Resident #54 and #60) reviewed, regarding indwelling urinary catheter drainage bag and tubing was laying in the floor for Resident #54, oxygen tubing was touching the floor for Resident #60. The facility also failed to ensure staff donned appropriate Personal Protective Equipment (PPE) prior to entering a Transmission Based Precaution (TBP) room. The findings include: Review of the facility policy titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, dated September 2017, revealed, .The purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs) .Do not place the drainage bag on the floor . Review of the facility policy titled, Policies and Practices-Infection Control, dated October 2018, revealed, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Review of the facility policy titled, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed, .Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Droplet Precautions .Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions . Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Urinary Tract Infection, Obstructive and Reflux Uropathy, Retention of Urine, and Chronic Kidney Disease. Review of the Reentry Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had an indwelling urinary catheter. Review of Resident #54's Physician's Order dated 2/26/2022, revealed an order for an indwelling urinary catheter. Observations in Resident #54's room on 2/27/2022 at 10:36 AM and 2:15 PM, revealed the urinary drainage bag and tubing was laying on the floor. Observation and interview in Resident #54's room on 2/27/2022 at 3:00 PM, Registered Nurse (RN) #1 confirmed Resident #54's urinary drainage bag and tubing was laying on the floor. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes Mellitus Without Complications. Review of the Annual MDS assessment dated [DATE] revealed Resident #60 required oxygen. Review of Resident #60's Physician's Order dated 1/13/2022 for Ipratropium-Albuterol solution for nebulization three times a day as needed and an order dated 8/13/2021 for Oxygen therapy at 2 liters per minute for shortness of breath as needed. Observation in Resident #60's room on 2/27/2022 at 9:45 AM and 11:09 AM, revealed the oxygen tubing was touching the floor on the right side of her bed and a nebulizer mask and nebulizer machine was in the bed with her. Observation and interview in Resident #60's room on 2/27/2022 at 11:28 AM, the Director of Nursing (DON) confirmed the nebulizer mask and nebulizer machine should not be in the bed and the oxygen tubing should not be touching the floor. Observation on 2/27/2022 at 11:42 AM, revealed Certified Nurse Aide (CNA) #5 took a meal tray into a resident's room who was on TBP without donning gloves or a gown. During an interview on 2/27/2022 at 11:43 AM, CNA #5 confirmed he took a meal tray into a TBP room and didn't wear appropriate PPE. He stated, I should have put a gown and gloves on, but I didn't. During and interview on 3/2/2022 at 8:24 AM, Licensed Practical Nurse (LPN) #6 stated when staff were delivering and picking up meals from a resident that's on TBP they must wear a mask, goggles, gown, and gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to keep 1 of 93 sampled residents (Resident #8) who was wearing only a brief, covered, and the facility failed to ensure 3 of 7 sampled residents (Resident #33, #43 and #54) indwelling urinary catheter drainage bags were covered with a privacy cover. The findings include: Review of the facility's policy titled, Resident Rights, dated 8/16/18, revealed, .All residents have the right to be treated with respect and dignity .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life .The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Palsy, Generalized Anxiety Disorder, Unspecified Behavioral Syndromes Associated with Physiological Disturbances and Need for Assistance with Personal Care. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 is rarely/never understood and his cognitive skills for daily decision making is severely impaired. Continued review revealed he rejected care 1 to 3 days in the 7 day evaluation period and he required extensive assistance of 2 or more caregivers for dressing. Observations in Resident #8's room on 2/27/2022 at 12:10 PM, 2:12 PM, and 3:00 PM, revealed the resident laying in bed, uncovered, and only wearing a brief. Observations in Resident #8's room on 2/28/2022 at 7:46 AM, 10:00 AM, 10:25 AM, and 12:45 PM, revealed the resident laying in bed, uncovered, and only wearing a brief. During an interview on 3/1/2022 at 12:15 PM, the Director of Nursing (DON) stated that he (Resident #8) should have been clothed/covered. The DON stated, I told them [nursing staff] to put a gown on him this morning. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Neuromuscular Dysfunction of Bladder, Chronic Kidney Disease, and Severe Sepsis. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #33 had an indwelling urinary catheter. Review of the Physician Order Report dated 1/27/2022-2/27/2022 for Resident #33 revealed the resident had an order for an indwelling urinary catheter. Observations in Resident #33's room on 2/27/2022 at 9:45 AM, 11:31 AM, and 2:55 PM, revealed the urinary drainage bag was not in a privacy bag. Observation and interview in Resident #33's room on 2/27/2022 at 2:55 PM Registered Nurse (RN) #1 confirmed Resident #33's urinary drainage bag was not in a privacy bag. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Bacteremia, Chronic Kidney Disease, Neuromuscular dysfunction of bladder, Obstructive uropathy, and Personal history of urinary (tract) infections. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #43 had an indwelling urinary catheter. Review of the Physician Order Report for Resident #43 dated 1/27/2022-2/27/2022, revealed the resident had an order for an indwelling urinary catheter. Observation in Resident #43's room on 2/27/2022 at 10:25 AM and 2:23 PM revealed the resident's indwelling urinary catheter drainage bag was hanging on the left side of the bed facing the door and was not in a privacy bag. Observation and interview in Resident #43's room on 2/27/2022 at 2:30 PM, RN #1 confirmed the resident's indwelling urinary catheter drainage bag was not in a privacy bag. She stated, It's not in a privacy bag and it should be. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection, Obstructive and Reflux Uropathy, Retention of Urine, and Chronic Kidney Disease. Review of the Re-entry MDS assessment dated [DATE], revealed Resident #54 had an indwelling urinary catheter. Review of the Physician Order Report for Resident #54 dated 1/28/2022-2/28/2022, revealed the resident had an order for an indwelling urinary catheter. Observations in Resident #54's room on 2/27/2022 at 10:36 AM and 2:15 PM, revealed the urinary drainage bag was laying on the floor and not in a privacy bag. Observation and interview on 2/27/2022 at 3:00 PM, RN #1 confirmed Resident #54's urinary drainage bag was laying on the floor and not in a privacy bag.

Based on facility policy review, facility documentation review, observations, and interview, the facility failed to store food at the proper temperature, prevent contamination of food, and ensure the Dietary Department was maintained in a sanitary manner, affecting 89 of 93 residents in the facility. The findings include: Review of the facility's policy titled, Food Storage: Cold Foods, revised 4/2018, revealed, .All perishable foods will be maintained at a temperature of 41' [degrees] F [Fahrenheit] or below, except during necessary periods of preparation and service . Review of the facility's undated policy titled, Food: Preparation, revealed, .All staff will practice proper hand washing techniques and glove use .Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination .All staff will use serving utensils appropriately to prevent cross contamination . Review of the facility's undated policy titled, Handwashing/Hand Hygiene, revealed, .This facility considers hand hygiene the primary means to prevent the spread of infection .Use an alcohol-based hand rub .m. after removing gloves . Review of the manufacturer's recommendations for testing the efficacy of Oasis 146 Multi-Quat Sanitizer, (the sanitizing solution used in the kitchen for sanitzing surfaces) revealed, .Withdraw and tear off 2 inches of paper (pHydrion Papers QT-40) from dispenser .Testing solution should be at room temperature .Dip paper for 10 seconds .Compare colors immediately with colors on the test strip package to determine ppm (parts per million) .Testing solution should be between 150-400 ppm . Observation in the kitchen on 2/27/2022 at 9:30 AM, revealed the temperature in the walk-in cooler was 43 degrees F. Observation in the kitchen on 2/27/2022 at 11:40 AM, revealed a silver bowl with 2 bread rolls wrapped in a plastic bag on the floor between the steamer and the tilt skillet. Observation in the kitchen on 2/27/2022 at 11:43 AM, revealed the [NAME] touched a baked potato with her gloved hand, and continued preparing meals on the tray line. Observation in the kitchen on 2/27/2022 at 11:49 AM, revealed the [NAME] was plating food on the tray line with gloved hands. She left the tray line, retrieved a pan of spinach out of the steamer, placed the pan of spinach on the steam table, removed her gloves and donned new gloves without sanitizing/washing her hands. Observation in the kitchen on 2/28/2022 at 9:00 AM, revealed the temperature in the walk-in cooler was 43 degrees F. Observation in the kitchen on 2/28/22 at 9:05 AM, revealed the Certified Dietary Manager (CDM) tested the sanitizing water for the proper concentration of sanitizing solution, and the test strip read less than 100 ppm. Observation in the Nourishment Room on 2/28/2022 at 9:10 AM, revealed the temperature in the nourishment refrigerator was 44 degrees F. During an interview on 2/27/2022 at 11:40 AM, the CDM confirmed the silver bowl with 2 bread rolls wrapped in a plastic bag on the floor between the steamer and tilt skillet should not be there. During an interview on 2/27/2022 at 11:45 AM, the [NAME] confirmed she should not have touched the baked potato with her gloved hand. During an interview on 2/27/2022 at 11:50 AM, the CDM confirmed the [NAME] should not have touched the baked potato with her gloved hand and confirmed the [NAME] should have sanitized/washed her hands before donning clean gloves. During an interview on 2/28/2022 at 9:05 AM, the CDM confirmed the sanitizing solution should measure between 200-400 ppm and it was registering less than 100 ppm. During an interview on 2/28/2022 at 9:00 AM, the CDM confirmed the temperature in the walk in cooler in the kitchen was 43 degrees F, and should be 41 degrees F or below. During an interview on 2/28/2022 at 9:10 AM, the CDM confirmed the temperature in the Nourishment room refrigerator was 44 degrees F, and it should be 41 degrees F or below.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and interview, the facility failed to follow Physician's Orders for 1 of 24 sampled residents (Resident #73) related to application of heel floats. Findings include: Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Diarrhea, Adult Failure to Thrive, Seizures, Anemia, Chronic Pain Syndrome, Muscle Weakness, and Paroxysmal Atrial Fibrillation. Medical record review of the admission Minimum Data Set (MDS) for Resident #73 dated 4/17/18 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 indicating moderate cognitive impairment. Medical record review of Physician Telephone Orders for Resident #73 dated 4/18/18 revealed .Heel floats to bilateral heels while in bed . Medical record review of the Physicians orders for Resident #73 dated May 2018 revealed .Heel floats to bilateral heels while in bed . Medical review of the Treatment Administration Record (TAR) for Resident #73 dated 5-1-18 through 5-31-18 revealed .Heel floats to bilateral heels while in bed . Observation of Resident #73 on 5/9/18 at 7:27 AM and again at 8:17 AM in the resident's room revealed the resident lying in bed with his feet exposed from under the cover and no heel floats were in place. Interview with Licensed Practical Nurse (LPN) #1 on 5/8/18 at 3:25 PM in the common area room revealed Resident #73 had a Suspected Deep Tissue Injury (SDTI) to his right heel and she stated .he has heel floats when he's in bed . Interview with Registered Nurse (RN) #1 on 5/9/18 at 1:49 PM in the [NAME] nurses station confirmed he expected heel floats to be placed on residents when in bed, he stated .It wouldn't do them any good if they didn't have them on in bed, that's supposed to help protect them .

Based on observation and interview, the facility dietary department failed to maintain dietary equipment in a sanitary manner in 2 of 5 observations. Findings include: Observation on 5/8/18 between 11:53 AM to 12:00 PM, at 1:53 PM, and 2:25 PM, with the Certified Dietary Manager (CDM) present, revealed the floor mixer had multiple splatters of various colored dried debris on the underside of the beater arm and the mixer bowl holder arms had dried accumulation of brown colored debris around the 3 connection sites to the bowl. Further observation revealed the stacked convection oven interior had a heavy accumulation of blackened debris. Further observation in the walk-in freezer revealed the condenser fan grate and blade had an accumulation of blackened debris. Interview with the CDM on 5/8/18 at 12:00 PM and 1:55 PM in the dietary department confirmed the floor mixer, stacked convection oven, and the walk-in freezer condenser grate and blades were not maintained in a sanitary manner. Observation on 5/8/18 at 2:25 PM in the dietary department dish room, with the CDM present, revealed the dish machine was in operation. Further observation revealed silverware and multiple racks with dishes and mugs had been washed, air dried, and stored. Further observation revealed a wall mounted fan in operation positioned on the dirty side of the dish machine. Further observation revealed the fan was in operation and directed at the dirty side of the dish machine, therefore contaminating the cleaned dishes. Interview with the CDM on 5/8/18 at 2:25 PM in the dietary department dish room confirmed the fan blades and grate were dirty and not maintained in a sanitary manner.