**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 7 of 12 residents reviewed for environment. 1. The facility failed to ensure the secure unit was a comfortable temperature on 11/26/24, and Residents #1, 2, 3, 4, 5, and 6 felt uncomfortably cold. 2. The facility failed to ensure Resident #7's room was free of holes, paint scuffs, and had a well-fitting screen for the window. These failures placed residents at risk of discomfort and diminished quality of life. Findings included: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hypertension, anemia, underweight, osteoarthritis of hip, pain in right lower leg, and dementia. Review of the quarterly MDS assessment for Resident #1 dated 08/23/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision/touching assistance in the activity of dressing. Review of the undated face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hypertension, muscle wasting and atrophy, lack of coordination, dementia, and major depressive disorder. Review of the admission MDS assessment for Resident #2 dated 11/17/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision and touching assistance in the activity of dressing. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, vascular dementia, urinary incontinence, facial pain, difficulty in walking, weakness, adjustment disorder with depressed mood, unspecified head injury, muscle wasting and atrophy, chronic obstructive pulmonary disease, and depressive episodes. Review of the quarterly MDS assessment for Resident #3 dated 11/07/24 reflected a BIMS score of 06, indicating severe cognitive impairment. It also reflected he required supervision or touching assistance in the activity of dressing. Review of the undated face sheet for Resident #4 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included mild malnutrition, vascular dementia, peripheral vascular disease, muscle wasting and atrophy, hypothyroidism, and vitamin D deficiency. Review of the quarterly MDS assessment for Resident #4 dated 11/06/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he was independent in the activity of dressing. Review of the undated face sheet for Resident #5 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included muscle wasting and atrophy, abnormal weight loss, atherosclerotic heart disease, malnutrition, anxiety disorder, and Alzheimer's disease. Review of the quarterly MDS assessment for Resident #5 dated 10/22/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he required substantial/maximal in the activity of dressing. Review of the undated face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, muscle wasting and atrophy, difficulty in walking, vitamin D deficiency, and unspecified pain. Review of the annual MDS assessment for Resident #6 dated 11/05/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he required substantial/maximal in the activity of dressing. Review on 11/29/24 of a web page found at the address www.timeanddate.com/weather/@4700235/historic reflected the outside temperature in the facility town was 46 degrees Fahrenheit at 09:30 AM on 11/26/24. Observation and interview on 11/26/24 at 09:39 AM revealed the thermostat in the secure unit of the facility was reading 67 degrees Fahrenheit. Residents #1 and #2 were sitting in a television room on chairs, both in their pajamas with shoes and socks on. The room was dark, due to a large entertainment center blocking the window. It felt cold in the room. Resident #1 stated it was very cold in there, and she would love some hot coffee. Resident #2 did not use words, but when asked if she was cold, nodded her head vigorously. The ADM adjusted the desired heat from 76 to 79 degrees Fahrenheit. Within five minutes, the thermostat read 70 degrees Fahrenheit. Observation and interview on 11/26/24 at 11:26 AM revealed the thermostat in the hall for the secure unit read 68 degrees Fahrenheit. Residents #1 and #2 were walking around the common areas talking about how cold it was. Resident #1 was wearing a robe over her pajamas, and Resident #2 had on a sweater. Resident #1 said to Resident #2 Even the chairs feel too cold to sit in. Resident #1 held out her hands, and they were very cold to touch. Resident #6 was walking up and down the halls in a t-shirt, pajama pants, and non-skid socks, and his hands were also cold to touch. He did not respond verbally when asked if he was cold. A call light came on in Resident #598's room, and he stated he needed another blanket. When asked if he was cold, he stated, Hell yeah! Resident #3 was lying in his bed and stated he was trying to take a nap but was cold. Resident #4 was lying in his bed with a coat on and several blankets over him. He did not respond verbally to any questions. The MAINT used a laser thermometer to take the temperatures in the resident rooms. Resident #3 and #4's room was 66 degrees Fahrenheit by the door and 63 degrees Fahrenheit by the window. Resident #5's room was 66 degrees by the door and 64 degrees by the window. The MAINT stated he was going to take apart the heater and figure out what was going on. The ADM was passing out warm hats, and a medication aide brought warm coffee in to serve the residents. Observation and interview on 11/26/24 at 01:13 PM revealed the temperature in the secure unit was no longer cold. The thermostat read 74 degrees. Resident #1 stated she was comfortable now, and she was warm enough. 2. Review of the undated face sheet for Resident #7 reflected a [AGE] year-old female admitted to the facility on [DATE]. Review of the quarterly MDS assessment for Resident #7 dated 08/13/24 reflected a BIMS score of 12, indicating intact cognition. Observation and interview on 11/26/24 at 10:41 AM revealed two holes in the drywall in Resident #7's room, scratches in the wall paint behind her bed, and many scratches in the paint on her dresser. Observation also revealed the window screen was bent and no longer fit in the window. Resident #7 stated the holes in the drywall scared her, because she was worried rats and bugs would come into her room. She stated she did not know if any bugs or rats had come inside. She stated the scratches in the paint were ugly, but the facility had said they were going to fix it. She stated she would really like to open her window sometimes and get fresh air. She stated she could not open her window, because the screen was broken. During an interview on 11/26/24 at 03:00 PM, the MAINT stated the company had just been in the building to fix the heater a couple of weeks prior. He stated the problem was the sensor that went from the thermostat to trigger the fan to start blowing out warm air became disconnected. He stated that was what had happened that morning, and he was able to go into the machine and adjust it, and it was now working. He stated the HVAC company would still be coming out, because they thought they had fixed it permanently but obviously had not. The MAINT stated the holes in drywall and paint scratches in the rooms were on the back burner, as there were so many other things that needed fixing in the building. He stated it was an old building, and he had worked there a little over a year, but problems came up every day. He stated he wanted to take all the doors and handrails off, sand them, and repaint them, but the facility owner had told him to wait until they do a complete renovation. He stated he did not know exactly when that would happen, but it was supposed to be coming up soon. He stated Resident #7 had not complained to him about the holes and scratched paint in her room or the window screen. He stated he did not know what the potential negative impact on a resident might be if they had no working window screen or damaged areas of their rooms. During an interview on 11/26/24 at 03:43 PM, the ADM stated the MAINT was the responsible person for ensuring the temperatures in the facility were compliant. She stated she looked at the thermostats each day. She stated she had already turned up the thermostat early that morning, but then when she walked back through, it was still cold, so she had turned it up again. The ADM stated she always did a morning round of the whole facility when she arrived for the day, and she made rounds throughout the day but could not say at what interval she did so. She stated she perceived it was cold in the secure unit that morning, turned the thermostat up to 76 degrees F, and then when she walked through with the surveyor, and it was still cold, so she turned the thermostat up to 79 degrees F. She stated she had put a call out to their HVAC company to come look at it, but the HVAC company had only just been there to ensure everything was working well, and they fixed the exact thing that was not working well that morning. She stated she was not sure of the exact date but would produce the invoice. The ADM stated they generally made all repairs as they came up. She stated the Owner recently visited the building, and they made a list of things that needed to be done. She stated a potential negative outcome of the secure unit being colder than required was it could make the residents sick. She stated a potential negative impact of the holes and scratched paint in resident rooms was it might mess with their minds a little bit. Review of an invoice provided by the ADM on 11/26/24 reflected the service performed by the HVAC company on 11/19/24 was the following: Checked unit operation: flame sensor was unplugged, removed and cleaned the flame sensor, and checked heating operations. No other mechanical issues at this time. Review of the maintenance log from September 2024-November 2024 reflected no mention of any issues with the heater in the facility and no issues related to damage to Resident #7's room. Review of facility policy dated February 2021 and titled, Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home setting. These characteristics include: A. clean, sanitary, and orderly environment; H. Comfortable and safe temperatures (71°F to 81°F).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain the resident's privacy during wound treatments for 2 of 2 resident (Residents #8 and #13) reviewed for privacy. The facility failed to ensure Dr-B and the ADON protected the resident's privacy by closing the curtain and/or the resident's door when performing wound care on Resident #8 and Resident #13. This failure could place residents at risk for embarrassment, shame, and loss of dignity. Findings include: Record review of Resident #8's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Pressure ulcer Stage 3 (skin damage extending into muscle) depression, Hyponatremia (low sodium), Dementia, and Fracture of the lower leg. Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #8's Care Plan dated 8/6/24 reflected a Focus area was initiated for Dementia on 5/24/2018 with a goal to maintain current level of cognitive function. Resident #8's interventions included to promote dignity, converse with resident, and maintain privacy while providing care. Record review of Resident #13's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (lung disease), Muscle Wasting, and Abnormality of Gait and Mobility. Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 01, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #13's Care Plan dated 6/25/2024 reflected a Focus area was initiated for Dementia on 1/7/2020 with a goal to maintain current level of cognitive function. Resident #13's interventions included to promote dignity, converse with resident, and ensure privacy while providing care. Record review of Resident #18's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Diabetes Mellitus Type II, Anxiety disorder, depression, and Pressure Ulcer Stage 1 (skin damage is superficial). Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated the resident's cognitive ability was not impaired. Observation on 10/09/2024 at 8:54 a.m. revealed Dr-B and the making wound care rounds and performing wound care on Resident 8. Wound care was in process with the privacy curtain pulled to the right which left a large gap between the wall and the curtain. Roommate Resident 18 was sitting a few feet from the curtain gap and had a view of care and Resident #8's uncovered body. Surveyor observation from the hallway included a full view of Resident #8's uncovered buttock area when she was turned. Staff corrected the curtain several minutes later. Observation on 10/09/2024 at 9:05 a.m. revealed Dr-B and the ADON making wound care rounds and performing wound care on Resident 13. Wound care was performed with the door open completely and people walking up and down the hallway. Resident was visible from the hall as the wound dressing on her foot was done. Progress of the wound was discussed during the treatment. In an interview on 10/10/24 at 12:47 PM CNA-A stated privacy should be protected during all resident's treatments by pulling resident's curtain, closing shades/blinds, covering resident, and closing the door. She stated that would include all wound care treatments. CNA-A stated it was not acceptable at all for roommates to be able to see the other resident's private body areas during treatments. She stated that could cause the resident to feel exposed, embarrassed, and not to feel good. In an interview on 10/10/24 at 1:42 PM LVN -A stated privacy should be protected during all resident treatments by closing the resident's door and curtain, pulling blinds closed, and limiting exposed body areas to only the part that had to be exposed at that time. She stated that would include wound treatments and that it was not acceptable for a roommate to be able to see the other resident's private body areas. LVN-A stated the negative outcome to the resident if privacy was not maintained would be loss of self-esteem and embarrassment. In an interview on 10/10/24 at 1:45 PM the ADMIN stated privacy should be protected during all resident treatments by closing blinds, closing resident's door and curtain. She stated that would include all wound treatments and that it is not acceptable for a roommate to be able to see the other resident's private body areas. The ADMIN stated the negative outcome to the resident if privacy was not maintained would be shame at personal exposure. In an interview on 10/10/24 at 2:13 pm the DON stated that privacy should absolutely be protected during all resident treatments by pulling the curtain, closing the door, and only allowing the nursing personnel needed in the room. She stated that would include wound care treatments and that it was not acceptable for the roommate to be able to see the other resident's private body areas. The DON stated the negative outcome to the resident if privacy was not maintained would be embarrassment and loss of dignity. A record review of the facility policy titled, Dignity dated 2001 Med-Pass, Inc. with a last revision date of February 2021, reflected the following: Residents are treated with dignity and respect at all times. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents (Residents #36) reviewed for resident assessments. The facility failed to ensure Resident #36's Quarterly MDS reflected that Resident #36 primary diagnosis of orthostatic hypotension. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #36's face sheet dated 10/09/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36's diagnoses included orthostatic hypotension (a type of low blood pressure that occurs when you stand up after sitting or lying down), age related nuclear cataract bilateral (a common cause of blindness in older adults and the elderly), and ocular pain left eye (sharp and throbbing pain in the eye), muscle weakness (loss of muscle strength of the inability to move a muscle normally), and vascular dementia (occurs when the blood vessels in the brain are damaged, causing problems with thinking, memory, and behavior). A record review of Resident #36's Quarterly MDS assessment, dated 08/07/24, reflected the resident had a BIMS score of 06, which indicated severe cognitive impairment. Resident #36's Quarterly MDS did not reflect Resident 36's current primary diagnosis of orthostatic hypotension. A record review of Resident #36's care plan, dated 08/06/2024, did not reflect or address Resident #36's primary diagnosis of orthostatic hypotension. A record review of Resident #36's physician's orders, dated 10/09/2024, reflected Resident #36 had an order dated 06/19/24 for midodrine tablet with special instructions: give at 0700 and at noon. Keep patient sitting or standing for several hours after giving it each time. During an interview with the MDS Coordinator on 10/10/24 at 12:30pm, the MDS Coordinator stated that she was responsible for completing MDS and care plan assessments. The MDS Coordinator stated a Resident #36's MDS assessment should reflected her primary diagnoses of orthostatic hypotension. The MDS Coordinator stated it was mistake she forgot to list Resident #36 primary diagnoses of orthostatic hypotension. The MDS Coordinator stated that if a resident's MDS assessment was inaccurate then the resident may not receive the appropriate care. During an interview with the DON on 10/10/24 at 1:20pm, the DON stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the MDS assessment dated [DATE]. The DON stated there would be no negative outcome if Resident #36's MDS assessment did not reflect the resident's primary diagnosis because the resident's physician's orders had special instruction when giving her medication for her diagnosis of orthostatic hypotension. During an interview with the ADM on 10/10/24 at 1:45pm, the ADM stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the MDS assessment. The ADM stated that diagnosis of orthostatic hypotension would cause a person to be dizzy or lightheaded due to blood pressure dropping when standing after lying down. The ADM stated that Resident #36's primary diagnose of orthostatic hypotension should be reflected on her most MDS due to the MDS triggering care plan care areas. The ADM stated if Resident #36's MDS was inaccurate that could cause the care plan to be inaccurate as well. The ADM stated it was the MDS nurses' responsibility for completing the MDS assessments and care plans. The ADM stated she expected staff to thoroughly review residents' records to ensure MDS assessments and care plans are completed accurately. A record review of the facility's Resident Assessment policy, dated 2001 revised October 2023, reflected A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MDS) is submitted to the internet Quality Improvement Evaluation Systems (iQIES) as required. Policy Interpretation and Implementation 1. OBRA Required Assessment are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessment include: a. admission Assessment. b. Quarterly Assessment. c. Annual Assessment. d. Significant Change in Status Assessment (SCSA). e. Significant Correction to Prior Comprehensive Assessment (SCPA). f. Significant Correction to Prior Quarterly Assessment (SCQA); and g. Discharge Assessment (return anticipated and return not anticipated). 10. Assessment are completed by staff members who have the skills and qualifications to assess relevant care area and who are knowledgeable about the resident's strengths and areas of decline. 11. All persons who have completed any portions of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessment will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Residents #36) reviewed for comprehensive care plans. Resident #36's comprehensive care plan did not reflect Resident #36's primary diagnosis of orthostatic hypotension. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #36's face sheet dated 10/09/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36's diagnoses included orthostatic hypotension (a type of low blood pressure that occurs when you stand up after sitting or lying down), age related nuclear cataract bilateral (a common cause of blindness in older adults and the elderly), and ocular pain left eye (sharp and throbbing pain in the eye), muscle weakness (loss of muscle strength of the inability to move a muscle normally), and vascular dementia (occurs when the blood vessels in the brain are damaged, causing problems with thinking, memory, and behavior). A record review of Resident #36's Quarterly MDS assessment, dated 08/07/24, reflected the resident had a BIMS score of 06, which indicated severe cognitive impairment. Resident #36's Quarterly MDS did not reflect Resident 36's current primary diagnosis of orthostatic hypotension. A record review of Resident #36's care plan, dated 08/06/2024, did not reflect or address Resident #36's primary diagnosis of orthostatic hypotension. A record review of Resident #36's physician's orders, dated 10/09/2024, reflected Resident #36 had an order dated 06/19/24 for midodrine tablet with special instructions: give at 0700 and at noon. Keep patient sitting or standing for several hours after giving it each time. During an interview with the MDS Coordinator on 10/10/24 at 12:30pm, the MDS Coordinator stated that she was responsible for completing MDS and care plan assessments. The MDS Coordinator stated a Resident #36's care plan should have reflected the residents' primary diagnosis of orthostatic hypotension. The MDS Coordinator stated that if a resident's care plan was inaccurate then the resident may not receive the appropriate care. During an interview with the DON on 10/10/24 at 1:20pm, the DON stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the resident care plan. The DON stated there would be no negative outcome if Resident #36's care plan did not reflect the resident primary diagnosis because the resident's physician's orders had special instruction when giving her medication for her diagnosis of orthostatic hypotension. During an interview with the ADM on 10/10/24 at 1:45pm, the ADM stated that Resident #36's primary diagnosis of orthostatic hypotension should have been reflected on the resident care plan. The ADM stated it was the MDS nurses' responsibility for completing the MDS assessments and care plans. The ADM stated she expected staff to thoroughly review residents' records to ensure MDS assessments and care plans are completed accurately. The ADM stated if a resident care plan was inaccurate that could cause the resident not to receive the proper care. A record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2001, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The Comprehensive, person-centered care plan will: a. Include measurable objective and time frames. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including: . c. includes the resident's stated goals upon admission and desire outcomes. d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 residents' (Resident #34) refrigerators reviewed. Resident #34's personal in-room refrigerator was not monitored for safe temperatures. This deficient practice could place residents who had personal in-room refrigerators at risk of food borne illnesses. The findings were: A record review of Resident #34's face sheet dated 10/10/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34's diagnoses included essential hypertension (a type of blood pressure that develops gradually over time and has to clear cause), major depression disorder (a mental health condition that involves a persistent feeling of sadness, loss of interest, or low mood that last for a long time), Gastro-esophageal reflux disease with esophagitis without bleeding (occurs when stomach contents leak back into the esophagus, causing inflammation and damage), paranoid schizophrenia (type of schizophrenia that involves paranoia and delusions) A record review of Resident #34's Quarterly MDS assessment, dated 08/0824, reflected the resident had a BIMS score of 12, which indicated moderate cognitive impairment. During an observation on 10/08/24 at 9:35am, revealed Resident #34 had a personal room refrigerator with no refrigerator temperature log attached. During an observation on 10/08/24 at 11:50am, revealed Resident #34 had a personal room refrigerator with no refrigerator temperature log attached. During an interview with Resident #34 on 10/08/24 at 9:45am, Resident #34 stated that she had not seen a refrigerator temperature log on her refrigerator in months. During an interview with the NA on 10/10/24 at 2:20pm, the NA stated it was the housekeeper's responsibility to document on the resident's personal refrigerator temperature log daily. The NA stated that if a resident's temperature log was not completed daily the resident's refrigerator may not be cooling correctly. The NA stated if the resident's refrigerator was not working properly then the items in the resident's refrigerator would spoil. During an interview with the HK on 10/10/24 at 2:30pm, the HK said that it was the HKs responsibility to document the resident's personal refrigerator temperature daily. The HK stated he was responsible for completing Resident #34's personal refrigerator's temperatures log. The HK stated that he didn't remember if he completed the temperature log or not. The HK stated each resident that had a personal refrigerator should have a temperature log on it for the housekeeping staff to document the temperature daily. The HK stated if temperatures weren't documented daily the refrigerator may not be working properly. During an interview with the DON on 10/10/24 at 2:50pm, the DON stated that it was the housekeeper's responsibility to document the resident's personal refrigerator's temperature. The DON stated that if a resident's temperature log was not completed daily the refrigerator might not be working properly. During an interview with the ADM on 10/10/24 at 2:55pm, the ADM stated that it was the housekeeper's responsibility to document the resident's personal refrigerator's temperature. The ADM stated that if a resident's temperature log was not completed daily the refrigerator might not be working properly. The ADM stated if a resident's refrigerator was not working properly then that could cause the resident refrigerated items to be spoil or be thrown out. The ADM stated she expect for the housekeepers to document temperatures on the resident's refrigerators daily. A record review of the facility's Refrigerators and Freezers policy, dated 2001 revised November 2022, reflected This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation 1. Refrigerators and/pr freezers are maintained in good working condition. Refrigerators keep foods at or below 41 [degrees] F and freezers keep frozen foods frozen solid. 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Resident representative when the Resident experienced a significant change in condition for 1 (Resident #1) of 7 Residents reviewed for Resident rights. The facility failed to notify Resident #1's Family Member or Hospice Agency of his x-ray results that showed he had a left hip fracture on 05/15/24 due to Resident #1 falling on 05/14/24. The facility failed to notify Resident #1's Family Member or Hospice Agency that he was transferred to the hospital on [DATE] due to the left hip fracture which was revealed from an x-ray taken on 05/15/24 due to Resident #1 falling on 05/14/24. This failure could result in the Resident representative not being aware of conditions that may require them to make medical decisions. Findings included: Record review of Resident #'1s face sheet dated 07/18/24 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included: dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), left femur fracture (a serious injury that requires immediate medical attention), and repeated falls (frequent falling). Resident #1's face sheet revealed FM was 1st in line to be called. Record review of Resident #1's initial MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 06 indicating Resident #1 had severe cognitive impairment. Section GG-Functional Abilities and Goals revealed Resident #1 required partial/moderate assistance with bathing and personal hygiene and required set-up or touching assistance with toileting hygiene. Record review of Resident #1's progress notes dated 05/16/24 at 11:16 AM and signed by LVN A reflected [Recorded as Late Entry on 05/17/2024 11:22] Daughter called and said that they did not know that her father was sent to the hospital. She said, I wouldn't have sent him to the hospital. He wouldn't be able to go thru surgery anyway. I apologized for not calling her myself thinking the nurse on duty was going to call. Record review of Resident #1's SBAR/Change in Condition form dated 05/17/2024 at 1:53 PM reflected when asked for Name of Responsible Party/Health Care Agent Notified the answer was none. Form was created due to Resident #1 previously falling and x-ray reports revealed resident had a fractured left hip. In an interview on 07/18/2024 at 12:58 PM, LVN A stated Resident #1 had the x-ray done due to the change in condition after the fall he had on 05/14/24. She stated she had gotten the results from the x-ray and called and informed the doctor that resident had a left hip fracture. She stated the doctor gave orders to transfer Resident #1 to the emergency room for evaluation and treatment. She stated she sent Resident #1 to the hospital and was going to call the RP the next morning because it was late in the evening when Resident #1 went out to the hospital. She stated she did not notify the family or hospice when resident was transferred to the hospital. She stated she sent the Resident #1's face sheet to the hospital when he transferred there via care flight. She stated residents family and hospice was in the facility when the x-ray was ordered but not when the results came back in. She stated she would normally call and inform the family and hospice, if a resident had been receiving hospice services, if a resident was transferred to the hospital, but because the family member and HRN already knew Resident #1 had a possible fracture and the family member worked in a hospital, family member knew they would possibly have to send resident out. She stated she had been trained on notifying RP's, families, and hospice agencies for any change with the residents, including x-ray results and sending resident to the hospital. She stated if she did not notify the family or hospice agency of a resident transferring out of the facility, the family or hospice agency would not have known where the resident was and a wreck with the ambulance or anything could have happened. In an interview on 07/18/2024 at 1:10 PM, the ADM stated it was her expectation that staff would notify family, responsible parties, or hospice when there was any change in condition, new orders received, or transfer to hospital. She stated staff had been trained on notifying families of residents and hospice, if a resident was receiving hospice services, of any emergency transfers. She stated there could have been a delay in treatment if a residents family member or hospice was not notified of a resident transferring to the hospital. She stated she had not been aware that Resident #1's family or hospice agency had not been notified of his transfer to the hospital. In an interview on 07/18/2024 at 2:09 PM with FM, she stated she had initially been informed by the facility that Resident #1 had fallen and had been assessed with no injuries found. She stated the following day she went to the facility and when she tried to get Resident #1 up out of bed, she could tell something was wrong with him. She stated she had brought something to eat for Resident #1, and after they ate, she asked the nurse on duty to help her get Resident #1 back into bed. She stated the HRN came to the facility about 30 minutes later and ordered an x-ray due to Resident #1's foot being turned outward. She stated the facility nurse told HRN she would notify her and the family of the x-ray results when they came in. She stated she or the HRN was not notified of the x-ray results or Resident #1's transfer to hospital. In an interview on 07/18/2024 at 3:49 PM, the HRN stated she was informed by the facility that Resident #1 had a fall, and she went out to the facility to assess Resident #1. She stated upon her assessment she found that Resident #1's left ankle was turned outward which was a sign of a possible fracture, so she ordered an x-ray. She stated Resident #1 only complained of pain when he was moved but when asked if he was in pain, he said no. She stated Resident #1 had a diagnoses of dementia. She stated the staff at the facility had medicated resident with his PRN pain medication as ordered and the medication appeared to be effective. She stated the x-ray was done but she was not notified of the results. She stated when Resident#1's FM called her the following morning to ask for results, she could not reach the facility. She stated she went back to the facility and found that Resident #1 had a fractured left hip and had been transferred to the hospital. She stated she informed the Resident #1's FM and they called the hospital where Resident #1 had been sent. She stated Resident #1 had not received any treatment besides his regularly ordered medication and the hospital had been waiting on the doctor to see Resident #1 for any possible treatment. She stated it was usually up to the family if they want to send a resident out to the hospital for treatment or not, but because this family had not been made aware, they could not make that decision. Record review of facility's policy dated 2001 and revised September 2012 titled Transfer or Discharge, Emergency reflected Policy Statement: Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident. Policy Interpretation and Implementation: 1. Should it become necessary to make and emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: e. Notify the representative (sponsor) or other family member.

Based on observation, interview, and record review, the facility failed to maintain an effective ongoing pest control program to ensure the facility was free of pests and rodents for 4 of 8 resident rooms (rooms 1, 3, 5, and 7) reviewed for issues with pest control. The facility failed to follow their pest control company's recommendations to prevent pests' and rodents' entry into the building. This failure could place residents at risk for exposure to diseases carried by rodents. Findings included: Interview on 8-22-2023 at 10:03 AM with the RN on the SU revealed that the SU had recent rodent activity on the SU about 1 month ago. She explained that there was a rodent problem, which stemmed from the closet in one of the resident's rooms. She stated that the previous resident, who had since expired, kept food in their closet. The RN stated that the room number was 3A. Record review on 8-22-2023 of the facility's pest control company, August 2023 inspection, dated 8-21-2023, revealed two pages of their recommendations for the facility to prevent pests from entering the building. On 8-21-2023, the inspector annotated a comment which reflected that a screen was broken on a vent; recommended to repair it to prevent pest entry. Observation on 8-23-2023 at 11:00 AM of the facility's perimeter brick walls revealed a rectangular hole, a vent, which was uncovered. The screen was partially removed, which could allow rodents and pests to enter the building. The vent was on the outer portion of the building which housed the secure unit. Observations and interview on 8-23-2023 at 11:30 AM with the MW resulted in a brief tour outside of the facility. The tour revealed the uncovered vent on the outer perimeter of the building. The MW stated that he was working on a plumbing issue in April 2023 near where the vent was located. He stated he had to remove the screen from the vent but did not secure the screen when he was finished. He stated that the screen was off the vent since April 2023. The MW stated that the wall on the other side of the vent was the SU's dining room and rooms 1-8. The MW stated that he did not get instructions from the ED for pest management or building modifications. Observations on 8-23-2023 at 11:49 AM in Res # 29 and Res # 11's room, 1A and 1B, of the SU revealed multiple small black cylinder-shaped (size of a grain of rice) mouse droppings on the windowsill. Observations on 8-23-2023 at 11:50 AM in Res # 29's room, 3A, revealed dozens of small black cylinder-shaped (size of a grain of rice) mouse droppings in the closet. Interview on 8-23-2023 at 1:15 PM with Res # 29 revealed that he had seen mice in his room recently. He was unable to recall specific dates or times. Observations on 8-23-2023 at 11:53 AM in Res # 41 and Res # 20's room, 5A and 5B, revealed several small black cylinder-shaped (size of a grain of rice) mouse droppings in the closet. Observations on 8-23-2023 at 11:55 AM in Res # 197's room, 7B, revealed dozens of small black cylinder-shaped (size of a grain of rice) mouse droppings on the windowsill. Interview on 8-24-2023 at 10:42 AM with the ADM revealed she did not review the pest control reports. She did not think that there was anything to do in conjunction with the pest control company's reports. The ADM stated that the facility was in a rural area and that critters are always trying to get in the building. The ADM stated that she would start to review the recommendations from the pest control company and assign them to the MW. Record review of the facility's undated pest control policy revealed the facility was to maintain an on-going pest control program to ensure that the building is kept free of insects and rodents; windows are screened at all times; maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety. The facility failed to label and date food products io the refrigerator and thaw foods appropriately. There failures could place residents at risk for food-born illness. Findings included: Observations on 8-22-2023 at 8:30 AM of the facility's refrigerator revealed parmesan cheese and sliced American cheese loosely wrapped, exposed to the air, without labels to signify the date in which the product was opened and when it was supposed to expire. Observations on 8-22-2023 at 8:30 AM of the facility's freezer revealed two large containers of ice cream that were not labeled or dated. The outside of the ice cream tubs were covered in a 1/2 inch layer of frost. Interview on 8-22-2023 at 8:35 AM with the KM revealed she knew that food was supposed to be labeled and dated but was unsure how long the facility policy allowed food to be stored in the refrigerator. She stated that she would check the items that were undated for freshness and either throw them out or affix a label and date. KM stated that they were responsible for ensuring that food subject to spoilage were properly packaged, labeled, and dated. Observations and on 8-22-2023 at 11:15 AM in the facility's kitchen revealed one medium sized package of frozen turkey thawing in a large metal sink basin in 120-degree Fahrenheit water. The turkey in the 120 Degree Fahrenheit was not thawed out; a second medium sized frozen turkey, still frozen solid, was left out at room temperature to thaw on a cart just outside of the freezer door. Interview on 8-22-2023 at 11:15 AM with the KM revealed that soaking the frozen turkey in120-degree Fahrenheit water was not the correct way to thaw food. The KM stated that the correct way to thaw out a frozen turkey was to place it refrigerator in a sheet pan and thawed over the course of 2-3 days. The KM removed the turkey from the 120 degree Fahrenheit water, opened it, and began to cut it with a large serrated knife. The turkey was still visably frozen. The KM put the other frozen turkey, the one that was left out at room temperature to thaw on a cart, back in the freezer Record review of the KM food handlers card revealed a valid date from 7-21-2021 to 7-7-2024 and a Hospitality Manager Diploma dated July 2021. Interview on 8-24-2023 at 8:39 AM with the ADM revealed that she wanted more training about the kitchen requirements so they could provide better supervision. She stated that she did not want anyone to get sick. She stated that food borne pathogens could cause residents to get sick, which could lead to dehydration unintended weight loss, and result in the resident having to be isolated. Record review of the facility's Food and Preparation Service policy, which was dated July 2014, reflected the proper procedure for thawing foods. The policy reflected that food could not be thawed at room temperature. The policy reflected to thaw in the refrigerator in a drip proof container; submerge the item in cold running water (70 degrees Fahrenheit or below); thaw in a microwave oven and then cook and serve immediately; or thaw as a continued cooking process. Record review of the facility's Food Receiving and Storage policy, which was dated July 2014, reflected that all stored in the refrigerator and freezer were to be covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 2 medication aides (MA E) observed for skills competency. The facility failed to ensure MA E had the appropriate competencies and skills to administer medications unsupervised. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing exposure accidents, hazards, and communicable diseases and infections. Findings include: During an observation on 06/07/22 at 10:20 AM revealed LVN F and MA E conducted a medication pass. LVN F prepared the medications and handed them to MA E to give to the resident. MA E walked in with the medication in the medication cup and was attempting to give them to the resident, however, she could not get the resident to sit up. LVN F then proceeded to walk in the room to assist MA E. When the med aide was asked by this Surveyor if she was going to give the medications, even though she did not prepare them, she stated, I trust her (meaning LVN F). When asked if that was a common practice to not verify the medications before giving them, she said she was new and was not sure of the facility's policy. LVN F said they had done this same process earlier in the day. When asked if this was a common practice to have someone else prepare the medications and then give them to residents without verifying what medications were in the cup, both LVN F and MA E said they were not sure. During an interview on 06/07/22 at 10:54 AM the DON said her expectations regarding one nurse preparing the medications and another MA attempting to give them were that the meds should be given by the person that prepared them. During an observation of a med pass on 06/07/22 at 12:13 PM revealed MA E was passing meds to a resident. MA E said this was her second day working at the facility and she was employed by an agency. MA E completed the med pass on her own with no supervision. During an interview on 06/07/22 at 2:19 PM the DON said MA's should be observed for a minimum of three days by a nurse before passing medications on their own. When asked if the MA E should be passing meds on her own, the DON stated, No. During an interview on 06/08/22 at 9:44 AM the DON said for three consecutive days, the MA in training should be watched with every single medication pass by another nurse or another MA that had been trained. The DON said something could happen to the resident if given medications by a MA that was not fully trained. She said checking off and assessing competency was important. Record review of the facility's Administering Medications policy and procedure revised December 2012 revealed the following: Policy Interpretation and Implementation 1. Only person licensed or permitted by this state to prepare, administer and document the administration of mediations may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 26. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 27. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored in locked compartments for 1 of 2 med carts observed. LVN D left insulin pens unattended on top of a med cart. This failure could place residents at risk for drug diversion, drug overdose, and accidental or intentional administration of medications to the wrong resident. Findings include: During an observation and interview of a medication administration on 06/07/22 at 11:51 AM revealed LVN D had a basket with insulin pens inside the basket. LVN D then proceeded into the room to administer the medication to a resident and left the basket with insulin pens on top of the cart unattended. When asked if it was policy to leave medications unattended, she stated, No. It's not like it had a needle so it wouldn't matter. During an interview on 06/07/22 at 11:56 AM, the DON stated no medications should be left unattended. The DON was asked what could happen if a resident was walking by when meds were left on top of the med cart and she said the resident could have taken the medication. Record review of the facility's Administering Medications policy and procedure revised December 2012 revealed the following: Policy Interpretation and Implementation 16. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to resident or others passing by.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment; housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; and comfortable and safe temperature levels withing a range of 71° to 81° F for 4 of 40 rooms on 3 of 3 Zones (Zone 3, 5, & 6) and 3 of 3 shower rooms (Shower Room A, B and C) reviewed for environment. A. In Resident #20's shower/bathroom on Zone 3, the temperature was 68.0° F. B. In Residents #8 & # 43's room on Zone 6, the temperature was 64.5° F. C. In Resident #48 & # 24's room on Zone 6, the temperature was 65.0° F. D. In Resident #30's room on Zone 5, the temperature was 70.7° F. E. In Shower Room A on Zone 5, there was scratched paint on the door and door trim, multiple missing tiles on the floor, lightbulbs were out, and a brown splattered substance on the wall behind the toilet. F. In Shower Room B on Zone5, the air vent was covered in dust, the door to the vanity cupboard was missing exposing a soiled urine measuring container, the faucet on the sink had a small stream coming from it, there was grime on the floor behind the toilet and the door and door frame was also scratched up. G. In Shower Room B on Zone 6, there were flies, multiple missing tiles on the floor, trash on the floor behind the toilet and the temperature was 68.8° F. H. On Zone 5, there were multiple scratches on the handrails exposing the bare wood under the paint, all air vents were covered with dust, paint scratched off the walls, approximately 3-5 flies in the dining room, dead bugs inside the light fixtures in the dining room over the tables, cobwebs on the ceiling from the water sprinklers to the light fixtures, missing coverings on the light fixtures exposing the bulbs, dirty air return vents, and debris on the floor These failures could place residents at risk for a diminished quality of life and a diminished clean, safe, and homelike environment. Findings included: During an observation on 06/09/22 at 9:37 AM of room [ROOM NUMBER] on Zone 6 revealed there two residents in the room sleeping, Resident #8 and Resident #43. Both were covered from head to toe with a thick blanket and a heavy comforter. The room temperature was 64.5° F. The air vent in the ceiling was fully open. During the observation Resident #43 sat up and started sneezing. He sat on the side of the bed and was wearing a long-sleeved sweatshirt and sweatpants. An interview was attempted but he didn't answer any questions. During an observation and interview on 06/09/22 at 9:41 AM of room [ROOM NUMBER] on Zone 6 revealed there were two residents in the room. Resident #48 was sitting in his wheelchair wearing a heavy red cardigan sweater. He said he was uncomfortably cold. The temperature in his room was 65.0 degrees. Resident #24 said the housekeepers didn't clean very well, especially in the bathroom/shower room. Resident #24 said sometimes there was water standing in the shower room an inch deep. During an observation on 06/09/22 at 9:47 AM in the secured unit on Zone 5 revealed Resident #30 was in her room lying in her bed asleep. She had a heavy sweater on with a blanket and a comforter covering her body up to her shoulders. The temperature in the room was 70.7° F. During an observation on 06/09/22 at 9:50 AM of Shower Room A on the secured unit on Zone 5 revealed the door was scratched up and showing the wood surface all along the inside edge of the door. Inside of the room, the floor between the shower and the rest of the room had two different types of tile. The edge of the boundary had large grout patches that had no tiles, causing an uneven surface of the floor. The tile wall behind the toilet had a dark brown splattered substance that had dried to the tiles. The black plastic trim along the bottom of the wall had pealed back and onto the floor behind the toilet revealing dirt and grime. The light fixture above the sink did not illuminate and the light in the shower stall also did not illuminate. The overhead light of the room had 2 lights burnt out and the fixture had no cover, exposing the bulbs. The tile floor between the toilet and the vanity had a dark brown stain leading from the toilet to the vanity. The air vent above the toilet was covered in a thick layer of dust. The mirror above the sink had spots on it. There was a square cut out of the wall behind the shower that exposed the pipes. The outlet beside the mirror had no cover on it. The countertop sink on the vanity was not connected on one of the corners, exposing the wood frame. The front of the vanity had scratches in the paint and unknown yellow substances dried onto the cupboard doors. During an observation on 06/09/22 at 9:54 AM of room [ROOM NUMBER] on Zone 3 revealed the temperature in the room was 71° F. The air vent on the ceiling had dust on it and the ceiling surrounding the vent also had dust all around the vent spreading out approximately 12 inches. The temperature of the adjoining shower/bathroom was 68.8° F. During a previous interview on 06/07/22 at 2:04 PM, Resident #20 said she resided in room [ROOM NUMBER]. She said her room was cold and her adjoining shower room was even colder. She said she was always cold, and the air ducts were full of dust. During an observation on 06/09/22 at 10:01 AM of Shower Room C on Zone 6 revealed the door was scratched up along the bottom edge of the door The door trim leading into the room was also scratched along the lower portion of the trim. Inside of the room there were several flies flying around, multiple missing tiles on the floor, and trash on the floor near the toilet. There was an unknown brown substance on the wall behind the toilet. The air vent above the toilet had a thick layer of dust on it. The temperature inside the shower/bathroom was 68.8° F. During an observation on 06/09/22 at 10:07 AM of the secured unit on Zone 5 revealed there were multiple scratches on the hand rails exposing the bare wood under the paint, all air vents were covered with dust, paint scratched off the walls, approximately 3-5 flies in the dining room, dead bugs inside the light fixtures in the dining room over the tables, cobwebs on the ceiling from the water sprinklers to the light fixtures, missing coverings on the light fixtures exposing the bulbs, dirty air return vents, and debris on the floor. In Shower Room B the air vent was covered in dust, the door to the vanity cupboard was missing exposing a soiled urine measuring container, the faucet on the sink had a small stream coming from it, there was grime on the floor behind the toilet and the door and door frame was also scratched up. During an observation on 06/09/22 at 10:18 AM of the hallway in Zone 6 revealed there was a hole in the middle of the ceiling where an air vent would go but the air vent was missing. On the wall near the conference room, above the baseboard, there was a rectangle cut out of the sheetrock that had been patched but not painted over. The doorway separating the hallway of Zone 6 was scratched exposing bare wood. During a follow-up observation on 06/09/22 at 10:50 AM of Shower Room A on the secured unit on Zone 5, there was now a sign sitting on the floor that reflected, Caution Wet Floor. The floor was wet. The room appeared to be in the same condition as it had when observed at 9:50 AM on 06/09/22. During an interview on 06/09/22 at 10:53 AM with Housekeeper B and Housekeeper C, they said Housekeeper B had just cleaned Shower Room A. Housekeeper C said she had worked at the facility for 8 years and no renovations had been done in that time. When asked about the spots still on the mirror, Housekeeper C said those spots wouldn't come off. When asked about the plastic trim along the bottom of the wall that had pealed back and onto the floor behind the toilet revealing dirt and grime, she said the Maintenance Supervisor was supposed to fix that. Housekeeper C said Housekeeping was responsible for maintaining a clean environment. During an interview and observation on 06/09/22 at 10:56 AM with the Housekeeping Supervisor, when shown the shower room/restroom on the secured unit on Zone 5, he said the air vent and the tile behind the toilet should have been cleaned by the housekeepers. He said the Maintenance Supervisor needed to replace the plastic trim behind the toilet and replace the lightbulbs that were burnt out. During an interview, record review and observation on 06/09/22 at 11:01 AM with the Maintenance Supervisor, he said he tried to keep the temperature in the building between 72° F and 75° F. He said the residents tampered with the thermostats and turn the setting cooler sometimes. He said even though the thermostats have a plastic covering on them that are locked with a key, they stick something inside the box to push the buttons to adjust the air temperature. He said everyday he randomly checked the air temperature in the rooms of the facility but did not have a log of these temperatures. He said he did have a daily checklist of duties he did each day. While reviewing the checklist titled, Morning Walk-Through Log it was noted that checking the air temperature throughout the building was not listed. When shown the hole in the ceiling that didn't have an air vent in it and asked what that was, he said, I don't have a clue. I think it should have a cover on it. When shown the large grout patches that had no tiles on the floor in Shower Room A on Zone 5, he said he was replacing tiles throughout the facility and was working his way to this room. The Maintenance Supervisor said he had no assistants to help him and that he was responsible for maintaining the environment. During an interview on 06/09/22 at 11:19 AM with the ADM, she said the room temperatures should be not higher than 77° F and no lower than 70° F. She said they had been working on replacing the missing tiles on the floors. She said they have tried to paint the patches on the walls but couldn't find any matching paint color. Record review of the facility's Maintenance Service policy & procedure revised December 2009 reflected the following: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Record review of the facility's Quality of Life - Homelike Environment policy & procedure revised April 2014 reflected the following: Policy Interpretation and Implementation 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order. g. Comfortable temperatures.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. B. Ensure stored food was properly labeled and dated. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: An observation of the kitchen freezer on 6/7/22 at 9:05 a.m. revealed the following: 1. 4 bags of French fries, no label or date, and not in the original box. 2. 1 package of meat, no label or date, and not in the original box. 3. 1 package of fish, no label or date, and not in the original box. 4. 4 packages of diced chicken, no label or date, and not in the original box. In an observation on 06/07/2022 at 11:40 AM revealed [NAME] A was observed touching various surfaces in the kitchen with gloved hands. [NAME] A got the lunch serving utensils out of a drawer, placed the utensils in the food items on the steam table, adjusted the rolling rack for the lunch trays and then picked up a clean plate. [NAME] A then began plating food. [NAME] A then picked up a piece of chicken with her gloved hand and placed the chicken on the plate. [NAME] A put a cover on the plate and placed the plate of food in the rolling rack. [NAME] A picked up another plate and began plating food. [NAME] A then picked up a piece of chicken with her gloved hand and placed it on the plate without washing her hands or changing her gloves. [NAME] A was asked about touching food with gloved hands and [NAME] A stated she should be using tongs to plate the chicken and she should have washed her hands and changed her gloves before plating the food. She stated she just forgot. [NAME] A stated she could cause residents to get sick from cross contamination by using her dirty gloves to pick up the meat. [NAME] A stated the DM was in charge of education and she had told dietary staff to wash their hands, change gloves and use tongs. In an observation of the kitchen freezer on 6/8/22 at 9:00 a.m. revealed the following: 1. 1 bag of French fries, no label or date, and not in the original box 2. 2 packages of diced chicken, no label or date, and not in original box In an interview on 06/08/2022 at 10:00 AM, the DM stated she expected the food employees to use tongs when serving food and to wash their hands and change gloves between tasks. The DM stated she will in-service [NAME] A and all the kitchen staff on proper handwashing. The DM further stated she thought she had labeled and dated all food items. The DM stated she would make sure the foods are labeled and dated from now on. The DM stated the consequences of improper glove changes and not labeling and dating foods would be food borne illness for the residents. Record Review of the facility's undated policy titled Glove Use Policy reflected hand hygiene should be performed before and after the use of gloves Record Review of the facility's undated policy titled Safe Food Handling in the Changing Long Term Care Environment reflected foods should be stored, prepared and distributed under sanitary conditions .Facility must follow proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses. Change gloves if moving to another food activity .Use tongs while handling food Record Review of the facility's policy titled Food Receiving and Storage from the Dietary Services Policy and Procedure Manual 2008 reflected all foods stored in the freezer would be covered, labeled and dated. Record Review of the facility's policy titled Food Service Distribution from the Dietary Services Policy and Procedure Manual 2010 reflected food service staff would wash their hands before serving food to residents and prior to handling food trays .gloves were single use items and must be discarded after each use. Record review of the FDA Food Code, dated 2017, revealed in part: 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD .3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . Record review of the USDA Food Code dated 2017, revealed in part: Preventing Contamination by Employees 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under § 2-301.12. (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. P (C) FOOD EMPLOYEES shall minimize bare hand and arm contact with exposed FOOD that is not in a READY-TO-EAT form.