**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 privacy for 1 (Resident #5) of 17 residents reviewed for privacy. The facility failed to ensure the WCN provided privacy for Resident #5 while performing his wound care. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy. The findings include:Record review of Resident # 5's face sheet dated 07/21/25 reflected an [AGE] year-old-male with an original admission date of 09/09/24. Diagnoses included congestive heart failure, high blood pressure, type two diabetes (insufficient production of insulin in the body), and pressure ulcer (a localized injury to the skin and underlying tissue caused by prolonged pressure) at an unspecified site and location. Record review of Resident #5's physician orders dated 07/20/25 reflected: Cleanse Sacrum (triangular bone at the base of the spine. Upper cack part of the pelvic cavity) with normal saline, pat dry, pack with hydrofera blue (bacteriostatic foam dressing infused with a combination that provides powerful antibacterial effect while maintaining a moist wound environment), cover with dry gauze and secure every other day one time a day. During an observation of wound care on 07/21/2025 at 9:48 AM, the WCN began to provide wound care for Resident #5. The WCN left the door open, closed the left side of the privacy curtain but not the front side of the privacy curtain, leaving Resident #5 exposed to people who passed by in the hallway. In an interview on 07/21/2025 at 10:13 AM, the WCN stated it was important to provide privacy to all residents because it was part of their patient rights, their dignity and respect. The WCN stated she should have closed the door or the rest of the curtain but did not because she was unsure of how I would be able to observe the wound care process. The WCN stated she should have at least closed the door but just forgot. In an interview on 07/22/2025 at 9:56 AM, the DON stated Resident #5's door or curtain should have been closed to maintain the resident's privacy and dignity. The DON stated by not providing privacy, anyone walking past the door would be able to see Resident #5 exposed. Record review of the facility's policy of Promoting/Maintaining Resident Dignity dated 01/13/23 reflected: Policy: It is the practice of this facility to protect and promote resident rights and teat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 12. Maintain resident privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one resident (Resident #7) of 17 residents whose care plans were reviewed. The facility failed to ensure Resident #7's comprehensive care plan was updated was developed and implemented after starting anticoagulant (blood thinner) medication on 04/26/25. The deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. Findings include:Record review of Resident #7's face sheet dating 07/20/25 reflected a [AGE] year-old-male with an original admission date of 1/07/20. Diagnoses included pulmonary fibrosis (lung disease characterized by the scarring and damage of lung tissue), congestive heart failure, high blood pressure, chronic kidney disease, and type two diabetes (insufficient production of insulin in the body). Record review of Resident #7's Physician orders dated 04/26/25 reflected: Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to chronic atrial fibrillation (type pf heart arrhythmia characterized by irregular and often rapid beating of the atria, upper chambers of the heart). Record review of Resident #7's care plan initiated on 01/07/2020 and revised on 06/02/2025 reflected no care plan for anticoagulants. In an interview on 07/22/2025 at 9:41 AM, the MDS Coordinator stated she was unable to find Resident #7's anticoagulant medication in the care plan. The MDS Coordinator stated it should be care planned to ensure the staff are aware of the signs and symptoms such as the risk of bleeding and bruising. The MDS stated it was an oversight, and there was no reason why Resident #7's care plan was not updated. In an interview on 07/22/2025 at 9:48 AM, the DON stated Resident #7's anticoagulants should have been care planned. The DON stated it was important to have any anticoagulants care planned so staff could be aware of what signs and symptoms to look for such as bleeding or bruising. The DON stated that whenever there is a change in condition or new medications for any resident, it would be discussed during morning meetings and the team would go over any revisions of care plans. The DON stated Resident #7's care plan was just overlooked. In an interview on 07/22/25 at 1:28 PM, the ADM stated Medical Records would do a lot of auditing and needed to get with her to see if she was responsible for conducting care plan audits. The ADM stated the facility had ensured Medical Records personnel were nurses so they would be able to assist with this kind of documentation. In an interview on 07/22/2025 at 1:47 PM, Medical Records stated she did not audit resident care plans and was not sure who did. Record review of the facility's Care Plan Revisions Upon Status Change dated 10/24/25 reflected: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observations, interviews and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure the medication room was locked at 11:21 AM on 07/20/25 This failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm. The findings included:During an observation at 11:21 AM on 07/20/25, the medication room door was left slightly ajar, allowing this state surveyor to open the door and gain entrance without any key. No employees were in the medication room at that time. This state surveyor stayed by the entrance to the medication room until the ADM walked by at 11:50 AM and was informed the door was slightly ajar. In an interview with the ADM at 11:50 AM on 07/20/25, the ADM stated the medication room door was supposed to be closed and locked when no one was inside the room. The ADM stated the medication room should be closed and locked to prevent any unauthorized personnel from gaining access to residents' medications. The ADM stated LVN A, CMA C, and RN B all had keys to the medication room and had been working today from 6:00 AM to 2:00 PM. The ADM stated if the door was left open, residents or unauthorized staff could gain access to medications and ingest them or steal them. In an interview with RN B on 07/20/25 at 1:05 PM, RN B stated she had a key to the medication room, and the last time she was in the room today was around 9:30 AM. RN B stated she closed and locked the door behind her when she left. RN B stated it was important to keep the door to the medication room closed and locked, so unauthorized people did not gain access to medications. In an interview with CMA C on 07/20/25 at 1:20 PM, CMA C stated she had a key to the medication room, and the last time she was in the room was around 10:00 AM. CMA C stated she closed and locked the door behind her when she left. CMA C stated it was important to keep the door locked so residents or staff could not go in and out of the room and possible eat or steal medications. In an interview with LVN A on 07/20/25 at 1:35 PM, LVN A stated she had a key to the medication room, and the last time she was in the room was around 10:30 AM. LVN A stated she closed and locked the door behind her after she left. LVN A stated it was important to keep the door closed and locked to keep any unauthorized people from going into the medication room and taking things that did not belong to them. In an interview with the DON on 07/22/25 at 1:11 PM, the DON stated the medication room door should be closed and locked whenever no authorized staff were present in the room. The DON stated the room should be locked to prevent any unauthorized people from getting int the room and ingesting or stealing medications. The DON stated he liked to pull on the door handle whenever he walked by the room just to be sure it was closed. Record review of the facility policy titled Medication Carts and Supplies for Administering Meds revealed the following: .The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications: 1. Lockable medication carts, cabinets, drawers, and/or rooms with well-lit medication preparation areas.

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 2 glucometers (device used to measure the amount of glucose in a resident's blood) reviewed for pharmacy services. The facility failed to ensure the glucometer in the nurse cart for halls 100, 200 and 400 were tested for accuracy and recorded in the glucometer logbook on 07/01/25, 07/02/25, 07/07/25, 07/08/25, and 07/21/25 in the month of July. These failures could place residents at risk of receiving either too much insulin or not enough. The findings included:Record review of the glucometer logbook on 07/22/25 at 10:37 AM revealed the test results for the glucometer in the nurse cart for halls 100, 200 and 400 were not recorded on 07/01/25, 07/02/25, 07/07/25, 07/08/25, and 07/21/25. In an interview with the DON on 07/22/25 at 1:11 PM, the DON stated the glucometers were supposed to be tested every day on the night shift by the nurses and the results recorded in the logbook. The DON stated night shift nurses were trained to test the glucometers every shift. The DON stated it was the DON and ADON's responsibility to check the logbooks and ensure the night shift nurses were recording the results of the tests. The DON stated he did not think there was an official policy on testing the glucometers every day, but that it was best practices for nursing. The DON stated it was important to test the glucometers to ensure they gave accurate readings. The DON stated if a glucometer gave inaccurate readings a resident may end up receiving insulin when they did not need it, or not receive insulin when they did need it. The DON stated this could impact any resident that received insulin. In an interview with LVN D on 07/22/25 at 2:06 PM, LVN D stated he did not work the night shift. LVN D stated it was the night shift nurse's responsibility to test the glucometers and record the results in the logbook every night. LVN D stated it was important to ensure the glucometers were working so there would not be any mistakes in administering insulin. LVN D stated an inaccurate glucose measurement may result in administering insulin to a resident that did not need it or vice versa. A phone interview was attempted with three different night shift nurses on 07/22/25 between 1:50 PM and 1:57 PM, but none answered the phone or called back. This stated surveyor requested a facility policy from the DON on 07/22/25 at 1:11 PM dictating how often to test the glucometers but none was provided prior to exit.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food per professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.The facility failed to ensure dishes were cleaned after washing and not used for service.The facility failed to ensure the utensils were in good condition.The facility failed to ensure personal items were not in the prep areas.The facility failed to ensure a cabinet door was safe to open.The facility failed to ensure table scraps were disposed of properly.The facility failed to ensure personal items were separated from leftovers in refrigerator #D2.The facility failed to ensure food items in refrigerators #A1, and #D2, and freezers #B3, #C3, and #D2 were labeled, dated, and stored properly.The facility failed to ensure the dry storage area was free from fruit and dented cans.The facility failed to ensure food items in the dry storage area were properly sealed, labeled, and dated. The facility failed to properly maintain temperature logs in refrigerators #A1, and #D2, and freezers #B3, #C3, and #D2.The facility failed to maintain dishwasher temperature and sanitation logs. The facility failed to ensure all staff were properly trained in removing dishes from meal trays and serving residents seated at the same table at the same time. The facility failed to ensure all kitchen staff were using the designated handwashing sink and not the prep sink for handwashing.These failures could place residents who received meals and/or snacks from the kitchen and satellite kitchens at risk for food contamination and foodborne illness.Findings included:Observation and initial tour of the kitchen on 07/20/25 at 10:45 am revealed 13 of 26 coffee cups on the coffee cart were scratched and stained inside, and some had food stuck to the inside. The coffee maker on the coffee cart was leaking coffee. There were 20 of 78 juice glasses on the clean rack with a partially removable white substance in the bottoms and up the sides. There was a serving ladle stacked in another ladle in a clean drawer that had a sticky, red substance in it. When moved, the ladle beneath it had a sticky, red substance on its bottom, and inside the drawer. There was a large rubber spatula hanging from the pot rack with chips missing from the sides. There was a Styrofoam cup with foil over it and a personal cup next to the mixer on a prep table, both unlabeled and undated. There was a cabinet door above a prep area with an unscrewed hinge at the bottom that fell sharply when it opened. The DW was using an open trash bag on the floor to scrape food scraps into it. Refrigerator #D2 had a sign on the outside of the door that read, Kitchen Staff Only Refrigerator. One of the drawers inside refrigerator #D2 had a sign on it that read, This area is exclusive for employees and was full of what appeared to be jalapeno peppers. The peppers were loose in the drawer. Inside refrigerator #D2, there was an open Styrofoam cup without a lid that was 1/2 full of red liquid, unlabeled and undated. There were food items (later identified by the CK as leftovers for residents) stored in 5, 2-quart containers. Three of the containers were dated 07/16/25. There was a 1-gallon bag of what appeared to be 6 egg rolls unlabeled and undated; a partially empty 1-pint bottle of red liquid unlabeled and undated; 7 small sausages in a wrinkled, open piece of foil; a 1-gallon bag labeled turkey, but had no dates on it; a 1-gallon bag of a brown/red substance (later identified by the CK as left over beans) unlabeled and dated 07/16/25 inside refrigerator #D2. Refrigerator #A1 and freezer #s B3 and C3 had several unlabeled and undated trays of desserts inside. There was a 1/2-pint carton of milk open to air, unlabeled and undated in refrigerator #B3. There was a small juice glass filled with a white substance next to the open carton that was also not labeled or dated. There was a large bag of frozen ravioli in freezer #C3 dated 01/12/25. The ravioli was covered in frost and discolored. There were 3 resident pitchers open to air, 1/2 full of ice, undated and unlabeled in freezer #B3. There were 5, 6-pound dented cans on the use shelf in the dry storage room. The bin labeled Do Not Use Damaged Food Cans was empty. There was an uncut melon on the shelf in the dry storage room. There was a 1-gallon bag of bread and 8 slices of bread in a partially closed bag and a large, loosely closed bag of tortillas unlabeled and undated in the dry storage room. Refrigerator #A1 had an outer digital thermometer that read 36F even when the doors were opened for several minutes. The internal thermometers read 42F-45F with the doors open. The daily freezer and refrigerator temperature logs were missing data. The low-temp dishwasher temp and sanitation logs had the same numbers logged every day. There was one tray cart that had no covering on the sides or top. There were four regular push carts near the open tray cart.Observations and interview with the DW on 07/20/25 at 10:55 am, he said the low temp dishwasher temperature should be 120F, but it read 115F. He said he did not know how long the dishwasher water temperature had been low. He said he did not know what the sanitation level should be. [Chem strip container numbers and colors were scaled 0-light yellow, 100-light green, etc.] The DW demonstrated using a chem strip during the rinse cycle and he said the activated chem strip should be on the 100 of the chem strip container. The chem strip read 0. The DW said the chem strip was closer to zero than to 100. The DW said he was not sure what the level of sanitation was. He said the dishwasher temperature and sanitation log might not be accurate, as all the numbers were the exact same and did not reflect the temperatures or the sanitation level that had been documented. The DW said if the dishes were not getting sanitized in the dishwasher, it could cause cross-contamination and make residents sick. The DW said he did not know why he was not using a trash bin with a removable lid and the garbage bag inside to remove food from the dishes. Regarding the unhinged cabinet door, the DW said he had verbally told the maintenance man multiple times and wrote it in the log at the nurse's station but did not use the facility's electronic maintenance system. There was no log at the nurse's station. The DW said the kitchen staff never used the designated handwashing sink. He said kitchen staff used the prep sink for handwashing. He said he did not know why it mattered which sink they used for handwashing.Observation of dinner service in the dining room on 07/21/25 at 5:05 pm revealed CNA E was observed grabbing multiple resident cups and bowls by the top rim during meal service. Several tables with seated residents were not served at the same time. In an interview with the CK on 07/20/25 at 11:00 am, she said the coffee maker had been leaking badly for about 3 months and she told the FPM about it. She said they were not supposed to be using the leaking coffee maker. She said they liked it better than the thermoses they were supposed to be using. The CK said the food in refrigerator #D2 was leftovers for the residents. She said staff items should not be in there. She said all food should be labeled and dated. She said food should be thrown out after 3 days. She said she did not know who was responsible for making sure expired food in the refrigerators was removed. She said all kitchen staff were responsible for making sure food in the refrigerators and freezers was labeled and dated so everyone knew what it was and when to get rid of it. She said the kitchen staff were supposed to be using the designated handwashing sink for handwashing, and she never used the prep sink for handwashing. She said the dietary aides were responsible for logging the refrigerator and freezer temperatures. The FPM was unavailable for interview at this time.In an interview with the FPM (food protection manager) and the RD on 07/21/25 at 2:58 pm, the FPM said the DW did not know how to take the temperature of the dishwashing machine because he was nervous about it and the chem strips. She said he had been trained and should have known. She said the DW was responsible for making sure dishes were clean before placing them on the clean rack. She said the CNAs were responsible for the stains and stuck-on food in the coffee cups because it was easy for them to put oatmeal in the cups for the residents to eat from. The FPM and RD both said the residents used metal spoons to eat from the cups and to stir their coffee. She said the chemicals in the dishwasher were not strong enough to wash everything. She said the chem strip should be at 100ppm and thought they were using the correct test strips for the low temperature dishwasher. She said the water may not have been hot enough to clean the dishes. She said the dishwasher company did not come to check the (low temperature) dishwasher, even though the ADM called them. The RD said cross contamination from dirty dishes could make residents sick and affect their health. The RD said they could start using plastic spoons or wooden stirrers to prevent the plastic cups from becoming scratched and harboring bacteria. The FPM said leftover food was good for 3 days only and all food should be labeled and dated in the refrigerators, freezer, and dry storage area to prevent contamination. She said she had been trying to replace the coffee maker for 3 months and had let the ADM know. She said the ADM told her he was trying to see if another facility had a replacement. She said personal items were never allowed in the prep areas, but sometimes kitchen staff ate or drank inside the kitchen anyway. She said staff had been trained and should not have personal items in the kitchen. She said she was unaware of the broken cabinet door. She said she did not know why the DW was not using the trash bin for table scraps. She said refrigerator #1 was for residents only. She said she was unaware the staff was using refrigerator #1 for personal items. The FPM said the dry storage area had a bin for dented cans and did not know why the dented cans were on the shelf with the good cans. She said the dented cans were not to be used because the inside would go bad and could make residents very sick. She said a shipment came in last Thursday (07/17/25) and she was out that day for medical reasons. She said nothing when asked why the other kitchen staff did not place the dented cans in the dented can bin. She said temperatures for refrigerators should be 41F or less, or the food would go bad and must be thrown away. She said the temperatures of refrigerators and freezer were checked twice a day. She said no one was monitoring the logs for accuracy. The FPM said she did not know if kitchen staff were using the prep sink to wash their hands because the handwashing sink was easier to get to. She said the open tray cart and the four open push carts were how trays were delivered to residents who received their meals in their rooms.Refrigerator and Freezer Daily Temperature logs, Dishwasher Temperature and Sanitation Logs, Trainings/In-Services from May 2025 to present, and policies for Dishwasher Temperature and Sanitation, Food Storage, Refrigerator and Freezer Temperatures and Logs, and Personal Items in the kitchen were requested at this time. In an interview with CNA A on 07/21/25 at 5:29 pm, she said there was no reason why she was grabbing the resident cups from the lids. CNA A stated she just forgot to grab from the side. She said she had been trained on proper service but could not say when. CNA A stated it was important not to grab resident cups from the top due to cross contamination. She said she could be spreading germs and could make the residents sick. In an interview with the RD on 07/21/25 at 5:32 pm, she said she passes by the dining room when she was at the facility for her monthly visits. She said she had to help the FPM because she was new at her job and was coming in 2-3 times a month for the past month, then she said she had been coming in 2-3 times a month since May 2025. (The FPM hire date was 06/30/23). She said she was involved with training the kitchen staff monthly on various topics including serving from trays, but not nursing staff. She said cups and bowls should be handled by staff by the sides, not the top. She said tables should be served at the same time. The RD said she observed dining on the days she came to the facility and did not train nursing staff on how to pass out meal trays. The RD stated if she saw something wrong with the CNAs, she would let the DON know so further education could be provided. The RD said she did not know if residents who received meals in their rooms complained of the food being cold. She said she did tastings but could not elaborate timing or frequency. She said she was aware of the tray delivery system (open tray cart and open push carts). A test tray was requested at this time.Test tray received on 07/21/25 at 5:43 pm-temperatures were within range. The ADM and RD were present with the survey team. Ham, sweet potatoes, and green beans, along with a roll, matched the menu. The green beans were tasty and had a good texture. Everyone agreed the ham and sweet potatoes were not tasty. The ADM looked up the recipe and discovered it called for lemon juice and orange juice for both the ham and sweet potatoes. Everyone agreed with the ADM who said the texture was ok for the ham, but the sweet potato texture was not identifiable as potato and the flavor of the ham and sweet potatoes was not right and did not taste good. The ADM told the RD she should oversee the recipes.In an interview with the ADM on 07/22/25 at 1:00 pm, he said, the kitchen staff had a thermos to put coffee in. He said the coffee maker worked, but it leaked. He said he got a new coffee maker, but the temperature of the coffee was too hot, so they stopped using it and purchased the thermoses. He said the leaking coffee maker was supposed to have been thrown out. He said the leaking coffee maker was used on Sunday (07/20/25) out of convenience. He said he did not know why kitchen staff preferred wiping up the mess the leaking coffee maker made over the thermoses. He said he called the dishwasher maintenance guy on Sunday (07/20/25) but he did not come to the facility. He said the dishwasher maintenance guy did some trouble shooting over the phone with him instead. He said he checked the hot water heater, and the temperature of the water was 140F. He said he checked the sanitizer lines for blockages and kinks, and they were in good shape. He said the chem strips were correct for the machine. He said there was no excuse why the temperatures of the refrigerators and freezer were being documented by the external digital temp reading. He said the FPM did training on it. He said he did not know why the DW was scraping trash into a bag on the floor-that was not their process. He said their process was for trash to go into a bag inside the trash can with a lid. He said he told the entire team they had a process for getting repairs done through their electronic maintenance system. He said the cabinet door had been fixed several weeks ago, or so he thought. He said the cabinet was fixed yesterday and he uploaded a photo of the cabinet on 07/21/25. (Verified) He said the spatula looked melted and it should not be in use. He said there was more training to be done with kitchen staff to resolve these issues. He said more oversight was necessary, and the RD was coming out every other week, as well as her back-up. He said the RD performed dietary sanitation reviews monthly. He said the RD had her own system for food tasting but he did not know what it was nor if she watched service delivery. He said the RD could train staff on serving and seating arrangements, so the residents at the same table received their trays at the same time and not have to watch the others at the same table eat while they were waiting.Record review of the facility's Dish Machine Temperature and Sanitizing Logs revealed the following out-of-range findings for morning (a.m.), noon, and evening (p.m.) wash temps, final rinse temps, and sanitizer ppm: May 2025- a.m. wash temps 100F on five days, 110F on 3 days. Final Rinse temps were within range. Sanitizer ppm logged at 100ppm on 24 days and 50ppm seven days. Noon wash temps 100F on 12 days, 110F on 11 days. Final Rinse temps 110F on 2 days and 115F on 2 days. Sanitizer ppm logged at 200ppm on 4 days and 50ppm 1 day. p.m. wash at 100F on 8 days. Final Rinse 100F on 3 days, 110F on 4 days. Sanitizer logged at 100ppm each day.June 2025 (31 days logged)- had no outstanding numbers but had 4 days marked out for an unknown reason.July 1-22 2025 (the 19th was missing all data) a.m. Final rinse 110F for 6 days, 115F for 1 day. Sanitizer 110ppm. Noon wash temp 100F for 5 days. Final Rinse 100F for 12 days and 110F for 3 days. Sanitizer had no outstanding numbers. p.m. wash temps 100F for 4 days, Final rinse 100F for 13 days and 110F for 2 days. Sanitizer logged at 100ppm each day.Record review of the facility's Refrigerators and freezer temperature logs for May, June, and July 2025 revealed Refrigerator #A1 was 40F, and freezer #B3 was 0 degrees F for all a.m. and p.m. dates in May. Refrigerator #D2 was 40F for all days in June. Refrigerator #A1 was missing data for the mornings of July 15 and 22, and evenings of July 1 and 21. All July temperatures recorded were 36F. Freezer #B3 was missing data for the mornings of July 15 and 22, and evenings of July 1 and 21. Temperatures were out of range (above 0 degrees F) for 5 p.m. days. There was no documentation of reporting the out-of-range temperatures. Freezer #C3 was missing data for mornings of July 4, 15, and 22, and evenings of July 1, 12, 13, and 21. Temperatures were out of range (above 0 degrees F) for 7 a.m. days and 15 p.m. days. There was no documentation of reporting the out-of-range temperatures.Refrigerator #D2 was missing data for the mornings of July 12, 13, 14, 15, and 22, and evenings of July 1, 2, 5, and 21. All recorded temperatures were 40F. Freezer #D2 was missing data for the mornings of July 12, 13, 14, 15, and 22, and evenings of July 1, 22, and 21. All recorded temperatures were 0 degrees F except 4 a.m. days which were 36F, 38F, 40F, and 5F. One of the p.m. temperatures was recorded as 10F. There was no documentation of reporting the out-of-range temperatures.Record review of the facility's kitchen in-services: 04/17/25 For future dietary manager on how to access tray cards and diet orders. 07/21/25 Labeling and Dating, Food storage Guidelines, Temperature Logging, Cleaning, Sanitation, and Food Service Equipment Conditions. 07/22/25 Personal Items and Employee Sanitation.Record review of the facility policy titled, Employee Sanitation approved 10/01/18 reflected, Policy: The nutrition and foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infections and food borne illness. Procedure: 3e. Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped utensils, or where utensils are cleaned or stored. 4b. Cups, glasses, and bowls must be handled so that fingers or thumbs do not contact inside surfaces or lip-contact outer surfaces.Record review of the facility policy titled, Mechanical Cleaning and Sanitizing of Utensil and Portable Equipment approved 10/01/18 reflected, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Procedure: 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120F. e. The chemical sanitizing rinse water temperature must be at least or no less than the temperature specified by the machine's manufacturer. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used. Record review of the facility policy titled, Food Storage approved 10/01/18 reflected, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines. Procedure: Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators a. Keep fresh meat, poultry, seafood, dairy products, and most fresh fruit and vegetables in the refrigerator at an internal temperature of 41F or less. c.Do not overstock the refrigerators and leave space between items to further improve air circulation. d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. h. Place a thermometer inside refrigerators near the door where the temperature is warmest. Check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the refrigerator. 3. Freezers h. Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer. Record review of the manufacturer specification for the dishwashing machine indicated for low-temperature models: Wash and rinse at temperatures between 120F and 140F, relying on chemical sanitizing agents with the wash water. Use test strip to ensure sanitizer levels is at least 50ppm and no more than 200ppm. Test strips are most accurate at 120F. Higher temperatures may distort reading. If this occurs, use a clean glass to dip water from inside the machine and let cool to 120F before testing. Contact your service representative if you still have trouble verifying sanitizer levels. References: https://www.autochlor.net

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the right to be free from abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse on 01/13/25 when Resident #2 grabbed Resident #1 ' s head with both of his hands and hit Resident #1 ' s head against the wall several times then punched Resident #1 on the left side of his face with a closed fist. This failure could place residents at risk for physical, mental and psychosocial harm. Findings included: Record review of Resident #1's admission record on 05/14/25 reflected an [AGE] year-old male originally admitted to the facility on [DATE], with most recent admission on [DATE]. Resident #1's diagnoses included hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke or brain injury) affecting left side, vascular dementia (problems with thought processes and memory caused by brain damage from impaired blood flow), cognitive communication deficit (difficulty with communication), generalized muscle weakness, Alzheimer ' s disease (progressive brain disorder that slowly destroys memory and thinking skills), reduced mobility, and need for assistance with personal care. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 7, which indicated severe cognitive impairment, and Resident #1 used a wheelchair and required substantial assistance with transfers. Record review of Resident #1's care plan dated 03/30/16 reflected on 12/12/24, Resident #1 had the potential to be physically and verbally aggressive, picked fights and struck at others due to dementia related poor impulse control. Resident #1's goal was to verbalize understanding of need to control physical and verbal aggressive behavior through the review date with interventions which included monitor and document observed behavior and attempted interventions in behavior log, monitor/ document/ report any s/sx (signs/symptoms) of resident posing danger to self or others, and when Resident #1 became agitated, intervene before agitation escalated, guide away from source of distress, engage calmly in conversation and if he responded aggressively, staff would walk calmly away and approach later. This care plan also reflected on 01/13/25, Resident #1 had an altercation with another resident (Resident #2). Resident #1's goal was to remain free of any altercations with other residents with interventions which included resident would be redirected to the living, dining, or his room if he engaged in discussion with other residents and he would be encouraged to participate in activities. Record review of Resident #1's progress notes reflected the following entry: Type: NURSING - Nurse Note Effective Date: 01/13/2025 at 9:24 am by GVN Resident (#1) physically assaulted by another resident (Resident #2); resident (#1) was at living room sitting on his wheelchair when another resident (Resident #2) approached him and started to smack him against the wall. When staff intervened to stop him, resident (#2) stuck him on the left eye. SN asked to resident (#1) what happened, and resident responded: I was here on the wheelchair when the other resident came to me and attack me.SN performed head to toe assessment and noted redness discoloration to his outer side of left eye and left cheek. No other observations noted at this time. Resident #1 denies pain or discomfort. Vital signs as follows: BP-157/87, P-76, O2-97@RA, RR-20, T-97.7. RP made aware of incident and stated to call on any updates of Resident #1. [Physician] made aware and gave order as follows: Xray of skull and facial bones. Record review of Resident #1's order summary report dated 05/14/25 reflected the following physician orders: 1. [Psychiatric services provider] may provide psychological services (ordered 01/13/25), 2. SN to monitor skin q shift for- Resident has mild swelling and bruising to left side of face (ordered 01/13/25), and 3. Facial 2V/ Skull 2V (2 view x-rays of the face and skull) one time only (ordered 01/13/25). Record review of Resident #1's radiology results dated 01/13/25 reflected, Multiple views of the skull/face demonstrate no overt fracture or dislocation. The nasal septum is midline. The soft tissues are unremarkable. Record review of Resident #1's skin and wound evaluation dated 01/14/25 at 3:25 pm reflected intact skin with a bruise to his left eye area that measured 1.5cm long by 1.9cm wide. Resident #1 denied any pain or discomfort. Record review of Resident #2's admission record on 05/13/25 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged to another facility on 01/24/25. Resident #2's diagnoses included frontal lobe and executive function deficit following cerebral infarction (difficulties with higher level cognitive processes such as planning, organization, and impulse control after a stroke or brain injury), conversion disorder (a condition in which emotional or psychological stress causes physical symptoms) with seizures (abnormal brain activity which affects muscle control, behavior, and awareness), schizoaffective disorder, depressive type (mental health problem characterized by thinking and behavior problems and sadness), dementia, mild, with psychotic disturbance (dementia with delusions or hallucinations), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), and cognitive communication deficit. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated moderate cognitive impairment and Resident #2 did not exhibit physical or verbal behavioral symptoms directed toward others nor other behavioral symptoms not directed toward others. Resident #2 required minimal to no assistance with walking and transfers. Record review of Resident #2's care plan dated 08/21/24 reflected on 01/13/25, Resident #2 had an episode of aggression toward another resident (Resident #1). Resident #2's goal was to be free of confrontations with other residents with interventions which included keeping him occupied or interested in activities he enjoyed such as watching football, providing him snacks and treats of choice twice a day. Resident #2 was also placed on one-to-one observation until he was discharged to another facility on 01/24/25. This care plan also reflected on 01/13/25, Resident #2 had potential to be physically aggressive r/t (related to) poor impulse control. Resident #2's goal was to not harm self or others through the review date and interventions included analyze times of day, places, circumstances, triggers, and what deescalated behavior and document, assess and address contributing sensory deficits, assess Resident #2's needs: food, thirst, toileting, comfort level, pain, etc., monitor/document/report any s/sx of resident posing danger to self or others, psychiatric/ psychogeriatric consult as indicated, one to one monitor for behavior, and when Resident #2 became agitated, intervene before agitation escalated, guide away from source of distress, engage calmly in conversation and if he responded aggressively, staff would walk calmly away and approach later. Record review of Resident #2's progress notes reflected the following entries: Type: NURSING - Nurse Note Effective: 01/13/25 at 8:17 am by LVN A Resident #1 was sitting on his wheelchair in the lobby and Resident #2 approached other resident and banged his head against the wall then punched him on the face with closed fist. Resident #2 was instructed to go to his room. Notified RP and physician made aware. Type: SOCIAL SERVICES - Social Service Note Effective: 01/13/2025 at 1:03 pm by SW This morning [Resident #2] was involved in a physical altercation with another resident (Resident #1), he was the aggressor, he lashed out at another male resident (Resident #1) that male resident is in a wheelchair, [Resident #2] grabbed the other male resident (Resident #1) and was banging the head of that male resident against the wall. Staff intervened and managed to get Resident #2 away from the male resident, but as per staff when [Resident #2] released his hold on the other male resident, [Resident #2] punched the male resident on his eye.The D.O.N. stated that the psychiatrist from [Psychiatric Services Provider] was contacted, she is recommending inpatient psychiatric care. Record review of Resident #2's order summary report dated 01/24/25 reflected the following physician orders: 1, Resident placed on one-to-one monitoring pending transfer to another facility (ordered 01/13/25), 2. Resident to be placed in an inpatient psychiatric hospital (ordered 01/13/25), 3. Hydroxyzine Pamoate Oral Capsule 50mg. Give 1 capsule by mouth every 4 hours as needed for restlessness related to anxiety disorder due to known physiological condition until 01/27/25 at 11:59 pm (ordered 01/13/25). 4. Lorazepam Oral Tablet 0.5mg. Give 1 tablet by mouth every 6 hours as needed for anxiety until 01/27/25 at 11:59 pm (ordered 01/13/25), 5. Quetiapine Fumarate Tablet 50mg. Give 1 tablet by mouth at bedtime related to schizoaffective disorder (ordered 01/13/25), 6. Lab work: CBC (complete blood count) with auto diff (automatic differential), Comp. (Complete) Metabolic Panel, and Urinalysis with reflex (urine test with urine culture if needed to determine type of infection) (ordered 01/13/25). and 7. Bactrim DS (Double Strength) Oral Tablet 800- 160mg (Sulfamethoxazole- Trimethoprim, an antibiotic used to treat multiple infections including urinary tract infections). Give 1 tablet by mouth two times a day related to Escherichia coli (bacteria that can cause urinary tract infections) for 14 days (ordered 01/19/25). Record review of the facility's provider investigation report dated 01/17/25 reflected the facility notified the physician and the responsible parties for both residents as well as the local police department and the investigation findings were confirmed. The facility held an in-person in-service on abuse, neglect, and exploitation on 01/13/25 by the (previous) ADON and an in-person in-service on behavior chaining (the sequence of behaviors, events, situations, and interactions that led up to a particular event) by the (previous) ADON on 01/14/25. Observation and interview of Resident #1 on 5/14/25 at 10:43 am reflected Resident #1 was sitting in the dining room watching television with other residents. Resident #1 stated that he was doing good. Resident #1 did not recall the incident in January with Resident #2. Resident #1 stated he did not have issues with any other residents, and he liked living in this facility. Resident #1 stated he was not scared of any other residents or staff. In an interview on 05/14/25 at 11:49 am, the SW stated Resident #2 came to the facility from an out-of-town facility because he had family in this city. The SW stated she did a social history on Resident #2 and neither the transferring facility nor the RP gave any history of Resident #2 having aggressive behavior. The SW stated Resident #1 had a tendency to make gestures or say things to others. Resident #1 had bruising under his left eye, but not above it after the altercation with Resident #2. The SW stated witnesses said that Resident #1 said something or gestured something, and Resident #2 went at him and hit him. The SW stated Resident #2 was transferred to another facility shortly afterwards. In an interview on 05/14/25 at 12:30 pm, the DON stated Resident #1 said something to Resident #2 and Resident #2 was hitting Resident #1 ' s head on the wall then when the nurse stepped in and told him to stop, Resident #2 punched Resident #1 with a closed fist to the left side of his face. The DON stated Resident #1 initially had a quarter-sized bruise to his left cheek area. The DON further stated Resident #1 had no recollection of the incident after the day it occurred, and he was not fearful or withdrawn afterwards. The DON stated Resident #1 was evaluated by psychiatric services to determine if he had any distress from the incident and he did not. Resident #2 was transferred shortly after to another facility. The DON stated it was important for the facility to be free from abuse and neglect so the residents would feel safe because this is their home. The DON stated abuse or neglect could lead to physical, mental, or psychosocial harm, hospitalization, or even death. The DON stated abuse/neglect/exploitation was in-serviced every quarter and as needed as well as in the facility ' s online training every 2-3 months and the last abuse/neglect/exploitation in-service was in April. In an interview on 05/14/25 at 4:06 pm, LVN B stated on 01/13/25, she was walking past the nurse ' s station and heard a thumping sound. She stopped and looked around and realized it was coming from the front lobby area. She stated she looked in and saw Resident #2 had Resident #1 by the head and was banging his head against the wall and she said out loud, [Resident #2], Stop! LVN B stated, I told him to let him go and back away and that he could not do that and that was when he punched him and then walked away. He said, He [Resident #1] called me something, and I told him to just ignore it. Resident #2 then said he walked over to Resident #1 and told him that he (Resident #2) was a nice guy, and he should not talk to him like that. Resident #2 said Resident #1 raised his hand up and Resident #2 thought Resident #1 was going to hit him and that was why Resident #2 hit him. I told Resident #2 to go back to his room, and he walked to his room. LVN B stated she checked on Resident #1 and told him he had a little bruise, and she wanted to check him out and he said, No, I ' m OK in Spanish. LVN B stated Resident #1 had a small bruise near his eye, but he was not fearful, tearful, or withdrawn. LVN B stated she told Resident #1 she was going to call the doctor, and he told her he was fine and did not need the doctor called. LVN B stated LVN A had walked up at some point, and she told her she told Resident #2 to go to his room, and he went. LVN B stated LVN A took over from there. LVN B stated she had never seen Resident #2 do anything like that and afterwards he went back to being the same as before. LVN B stated Resident #2 had a lot of repetitive behaviors, like asking for chips and sodas, but never anything aggressive. LVN B stated, He was pretty chill. He could be a little intimidating at times because when he would talk to you, he would get really close, but he had never been violent. LVN B stated Resident #2 was put on one-to-one observation until he left. LVN B stated it was important that residents felt safe in this facility. LVN B named the abuse coordinator, stated the last abuse in-service was at the beginning of the year, and it was done quarterly in the facility ' s online training. In a telephone interview on 05/14/25 at 4:30 pm, LVN A stated Resident #1 and Resident #2 were in the lobby. She heard screaming and ran to the lobby area where she saw Resident #2 punch Resident #1 in the face. LVN A stated she had never seen Resident #2 do anything like that before and to her knowledge Resident #2 did not have any issues with Resident #1 prior to that. LVN A stated Resident #2 was usually in his room watching tv and did not have any issues with any other residents. LVN A stated after Resident #2 hit Resident #1, he was taken back to his room and the RP and doctor were notified about the incident. Resident #2 was put on one-to-one observation. Resident #2 did not get into any other fights afterwards and he had never done that before. LVN A stated the last in-service on abuse was at the beginning of the year they were done quarterly and as needed. In an interview on 05/14/25 at 1:09 pm, the admin stated Resident #2 had behaviors, but it was nothing aggressive; he would ask for chips and sodas all the time then staff would go in his room and find opened but not consumed bags of chips and cans of soda. On 01/13/25, after Resident #2 hit Resident #1, he was placed on one-to-one monitoring. The admin stated, After speaking with psychiatric services, we began looking for an inpatient psychiatric facility to transfer him to. It took a couple of weeks to find a facility to transfer him to and he remained on one-to-one monitoring during that time. Resident #2 did not have any further aggressive behaviors prior to his transfer. The admin stated it was important for residents to be free from abuse because this was their home, and they had a right to feel safe in their home. The admin stated he felt the facility was not at fault for Resident #2 hitting Resident #1 because Resident #2 had not shown aggressive behavior prior to this incident and staff immediately intervened, removed Resident #2 from the situation, and put interventions in place to prevent it from happening again. The admin stated the facility had in-services on abuse every three months and as needed in person and it was also part of the facility ' s online training every quarter. Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be an indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 to address the risk for falls and the fall mat. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs. The findings included: Record review of Resident #1's face sheet dated 12/14/24 reflected a [AGE] year-old female with an original admission date of 11/15/24. Her diagnoses included: hydrocephalus (buildup of fluid in the brain ventricles), encephalopathy (brain dysfunction), muscle wasting and atrophy, dysphagia (difficulty swallowing), cognitive communication deficit, acquired absence of unspecified breast, and gastrostomy status (opening in the stomach for feeding). Record review of Resident #1's fall risk evaluation dated 11/15/24 reflected a score of 7 which indicated a low risk. Record review of Resident #1's initial baseline care plan dated 11/15/24 reflected Resident #1 was not at risk for falls. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 did not have a BIMS conducted as she was never/rarely understood. Resident #1 was total dependence for bed mobility. Falls were not addressed on the MDS assessment. Record review of Resident #1's care plan dated 12/14/24 reflected risk for falls and the fall mat were not care planned. Interview and observation of Resident #1 on 12/14/24 at 12:00 PM revealed Resident #1 was non-interviewable. Resident #1 had a fall mat in place on the left side of her bed. Interview with CNA D on 12/14/24 at 12:50 PM revealed CNA D said Resident #1 had the fall mat in place, but she was not aware if Resident #1 had any falls. CNA D said maybe the fall mat was placed just as a precaution. Interview with LVN B on 12/14/24 at 1:10 PM revealed LVN B said Resident #1 had not fallen during her stay but she had a fall mat in place as a precaution. Interview with ADON P on 12/14/24 at 2:15 PM revealed ADON P said Resident #1 had not experienced any falls during her stay. ADON P said she was not sure why Resident #1 had a fall mat in place. Observation of Resident #1 on 12/18/24 at 11:20 AM revealed Resident #1 had a fall mat in place on the left side of her bed. Interview with MDS N on 12/18/24 at 1:10 PM revealed MDS N said Resident #1 did not trigger for risk of falls during the initial admission assessments. MDS N said the fall risk evaluation on 11/15/24 indicated Resident #1 was at low risk for falls. MDS N said the initial baseline care plan indicated that Resident #1 was not at risk for falls which would then not trigger the comprehensive care plan to include risk for falls. MDS N said the assessing nurse should have indicated Resident #1 was at risk for falls on the initial baseline care plan based on the fall risk evaluation, which would have triggered the risk for falls on the comprehensive care plan. MDS N said if there was a fall mat placed by the nurses, then the staff should have communicated that with the team so the care plan could be updated. MDS N said the team was not notified that the fall mat was implemented. MDS N said the nurses implemented interventions at times based on their nursing judgement. MDS N said she was not sure who placed the fall mat. MDS N said a fall mat would be considered an intervention and the fall mat would need to be care planned. MDS N verified the fall mat was not care planned for Resident #1 and a risk of falls was not care planned for Resident #1. MDS N said it was important for the fall mat and the risk for falls to be care planned so that staff were aware of the resident's needs, knew how to care for the resident, ensured the intervention was implemented, and to avoid any incident. Interview with the DON on 12/18/24 at 2:45 PM revealed the DON said Resident #1 had not experienced any falls. The DON said Resident #1 had the fall mat placed as a precaution. The DON said it had been brought to his attention that the care plan was not updated for Resident #1. The DON said the fall mat was implemented as a nursing judgment and should have been communicated to the team. The DON said the fall mat should have been care planned. The DON said Resident #1's initial fall risk assessment indicated she was at low risk for falls so the care plan should have included the risk for falls and the interventions which included the fall mat. The DON said although the risk was noted as low, the risk was still there and should have been care planned. The DON said Resident #1 was not negatively impacted by not having the risk for falls or the fall mat care planned. The DON said Resident #1 was at risk of the staff not knowing how to care for her. The DON said it was important for the fall mat and the risk for falls to be care planned to ensure the interventions were implemented and for the staff to know what to do for Resident #1 specific to her needs. Record review of Comprehensive Care Plans Policy date implemented: 10/24/22, reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3.a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 5 medication carts located at the nursing station observed for compliance. The facility failed to ensure one medication cart found at the nursing station for residents in the 500/600 hall was not left unlocked and unattended by RN A. This failure could place residents at risk of access and ingestion of non-narcotic medications. Findings were: During an observation on 9/24/2024, at 12:41 p.m., revealed one medication cart was unlocked at the nursing station without a supervised staff in view of the cart. The cart was left unlocked for less than 2 minutes until RN A returned to the cart, no one else was around the cart at the time, and all medications were non-narcotics. During an interview on 9/24/2024 at 12:41 p.m., RN A verbalized the unlocked cart was her cart. She verbalized she thought she locked it before walking to the kitchen. RN A stated it was proper process to lock the carts when the cart is not in view or when not being utilized. She also stated a resident could have accessed the medications in the drawers that were accessible. During an interview on 9/25/2024 at 1:08 p.m., the Director of Nursing (DON) stated it was the expectation of the facility for all staff passing medications to lock the medication carts. All carts are to be within the line of sight of the staff member utilizing the cart or locked. (He/she) stated locked carts prevent residents from obtaining access to improper medication. During an interview on 9/26/2024 at 12:305 p.m., the Administrator stated it was the policy of the facility to keep all medication carts locked. He stated following the policy keeps residents safe from receiving incorrect medication. A review of the Medication Carts and Supplies for Administering Meds policy dated 10/01/2019 revealed Do not leave the medication cart unlocked or unattended in the resident care areas. The cart must remain in your line of sight when it is not locked.

Based on observation, interview, and record review, the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members, and legal representatives for ten (Resident # 3,28,37,42,48,50,55,57,64, and 169) of ten residents interviewed for resident rights. The facility failed to ensure the most recent survey results were readily accessible to residents, family members, and legal representatives. This failure could place residents, family members, and legal representatives at risk of not being able to fully exercise their right to be informed of the facility's survey results and citation history. Findings included: In an interview on 06/26/24 10:02 AM in a group meeting with ten residents (Resident # 3,28,37,42,48,50,55,57,64, and 169), all ten residents stated they were not aware of nor had they seen a previous survey binder. Observation on 06/26/24 at 11:00am revealed the survey results book was not located in the common areas of the facility nor was there a sign that indicated where the survey results book could be found. In an interview on 06/26/24 at 11:13 AM, the ADON stated the survey results were posted up front. The Admin and the ADON went up to the front lobby and searched for the survey binder. The ADON located the binder in a drawer of the unattended reception desk. Record review on 06/26/24 at 11:24 AM of the survey binder that was located in the unattended reception desk drawer revealed a ½ inch white binder with an 8 ½ x 11 inch piece of paper slid in the front cover that had Full Book Survey April 2023 printed on it. Pages 1-3 were a letter a dated 04/24/23 from Texas Health and Human Services to the Administrator that stated in part the HHSC had conducted a health investigation on 04/06/23, and the survey found that the facility did not meet state licensure requirements and was not in substantial compliance with federal participation requirements. There was no information on what violations/deficiencies were cited. Pages 4-7 were a letter dated 03/04/22 from Texas HHSC that stated in part that the HHSC had conducted a Health and Life Safety Code Recertification Survey and a Health Complaint Investigation on 02/17/22 and the Life Safety Code survey found that the facility did not meet state licensure requirements and was not in substantial compliance with federal participation requirements and that the Health survey found that the facility was in substantial compliance with federal participation requirements. Page 8 was the CMS 2567 Form that had survey completion date 02/18/22 and stated in part that the facility was in compliance with federal requirements for long term care. Page 9 was the HHSC 3724 Form that had a survey completion date 02/18/22 and stated in part that the facility was in compliance with state licensure requirements. The following 12 pages listed the Life Safety Code violations. There was no policy provided by the facility regarding the availability of survey results to residents, family members, or legal representatives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 9 residents (Resident #32) reviewed for privacy. The facility failed to ensure RN A provided privacy by closing Resident #32's door or privacy curtain during administration of a subcutaneous insulin injection into Resident #32's abdomen on 06/25/2024 at 10:59 AM. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. The findings included: Record review of Resident #32's face sheet dated 06/26/2024 reflected a [AGE] year-old male with an original admission date of 06/14/2018 and a readmission date of 10/05/2021. Pertinent diagnoses include Type 2 Diabetes Mellitus (chronic condition that occurs when the body does not produce enough insulin or cells do not respond to insulin properly), Generalized Anxiety Disorder (feelings of extreme worry or nervousness even when there is little or no reason to have them), and Alzheimer's Disease (progressive brain disease that causes a mental decline affecting the quality of daily living). Record review of Resident #32's MDS dated [DATE] reflected a BIMS score of 11 (moderate impairment) Record review of Resident #32's care plan dated 06/26/2024 reflected Resident #32 had Diabetes Mellitus with daily insulin injections. Interventions listed include, but were not limited to, administering diabetes medication as ordered by doctor and observe/document for side effects and effectiveness, encourage resident to practice good general health practices, and compliance with treatment regimen. Record review of Resident #32's order summary report dated 06/26/2024 revealed an active order for Novolog FlexPen Solution (Insulin). During an observation of RN A performing medication administration on 06/25/2024 at 10:59 AM, RN A measured the blood glucose and gave a subcutaneous Novolog insulin injection to Resident #32 in his abdomen in his room while Resident #32 was sitting in his wheelchair. After RN A walked into the room, the door was left wide open, and throughout the medication administration, the privacy curtain was never utilized. No other residents or facility staff were present in the room at that time. RN A lifted Resident #32's shirt to expose Resident #32's skin and to have an exposed site to give the insulin injection. Resident #32 was in full view from the hallway by any individual walking by his room throughout the blood glucose test and insulin administration. In an interview with RN A on 06/25/2024 at 1:34 PM, RN A stated she has given insulin injections to residents in common areas before. RN A stated the DON and ADON have told her to not give injections in common areas. RN A stated some residents do not listen to her, and she struggles with balancing giving them the medication they need and protecting their privacy. RN A stated the door was open during the entire time she was in Resident #32's room for the blood glucose test and insulin injection. RN A stated she did not know she needed to shut the door or use the privacy curtain when administering insulin injections. RN A stated that residents may get agitated or it could make them feel more vulnerable and destroy rapport if their privacy was not protected. In an interview with the DON on 06/26/2024 at 12:56 PM, the DON stated that residents should be in their rooms when being administered any medication. The DON stated that in order to protect the privacy of the residents, their doors, curtains, and possibly blinds should be closed depending on what administration or procedure was taking place. The DON stated that it was not appropriate to give insulin injections to residents in their rooms without first closing the door or privacy curtain. The DON stated that not providing residents with privacy could impede on the resident's dignity and cause negative emotional effects. The DON stated that he has spoken to staff about administering medications with the appropriate protections for privacy, but does not remember a specific in-service. Record review of the facility's policy titled Medication Administration dated 10/24/2024 stated: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 7. Provide privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility nursing staff failed to demonstrate competencies and skills sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care, for one resident (Resident #14) of 24 residents reviewed, in that: -The facility failed to revise orders for Resident #14's code status from full code to DNR after receiving a DNR form from Resident #14's family member on [DATE]. Resident #14 had both CPR and DNR reflected in their orders. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. The findings included: Record review of Resident #14s face sheet dated [DATE] reflected a [AGE] year-old-female with an original admission date of [DATE]. Diagnoses included cerebral infarction (stroke that occurs when a blood vessel that supplies the blood to the brain is blocked), pneumonia (inflammatory condition of the lung(s) primarily affecting the small air sacs), and respiratory failure. Record review of Resident #14's care plan dated [DATE] and revised on [DATE] stated: As per responsible party I know Resident #14 was dealing with all sorts of health issues, she had a stroke in the past, at her age, her health will continue to decline so, the decision is no- CPR/ DNR. Interventions included: If resident has a cardiac arrest, do not call 911. Notify physician/responsible party and follow physician orders after notification. Record review of Resident #14's physician orders dated [DATE] stated: -Full Code as evaluated by social worker and instructed nurse to place as so until further notice. No directions specified for order. -DNR (Do Not Resuscitate) No directions specified for order. In an interview on [DATE] at 12:56pm the DON stated charge nurses were in charge of in putting initial orders for the resident and the DON and the ADON oversaw that orders were inputted correctly. The DON stated Resident #14's orders should not reflect both full code and DNR status. The DON stated resident changes were discussed daily during morning meetings. The DON stated at times he was out on the floor working and unable to attend all morning meetings and, in that case, either the SW, MDS, or anyone who attended the morning meeting were supposed to communicate and inform him of any changes that had occurred. The DON stated he was not informed of Resident #14's code status change and that it was overlooked. The DON stated Resident #14's code status would be corrected and updated immediately. The DON stated by having both code status for Resident #14 could make it hard to determine what actions to take in case of an emergency. MDS and medical records take part in looking for discrepancies and notifying DON and ADON. In an interview on [DATE] at 1:22pm the ADON stated every morning Monday through Friday resident orders were checked and audited for accuracy. The ADON stated whenever there was a change in code status, it was usually discussed in morning meetings and the ADON and DON made the changes needed. The ADON stated sometimes she and the DON could not attend morning meetings if they were needed out on the floor and believed that was how Resident #14's code status was not accurate. The ADON stated it was important Resident #14's code status was accurate as to avoid confusion on what procedures to take in case Resident #14 had an emergency. In an interview on [DATE] at 02:28pm MDS Coordinators E stated resident orders were reviewed in morning meetings to make sure care plans matched the orders. MDS Coordinators E stated if there was a discrepancy in the order, she or the other MDS Coordinator would alert the DON or ADON of the error so it could be corrected. MDS Coordinator E stated Resident #14's code status was overlooked. In an interview on [DATE] at 03:07 PM, the SW stated, once the initial advance directives were completed by her, then it was communicated to the charge nurses or to the DON/ADON to update in their computer system. The SW stated during the time Resident #14's code status was changed; she was out on leave and there was two other SW's covering for her during that time. The SW stated she did not know who the other SW's were as they were from different companies. The SW stated when a code status was changed, medical records was notified about a resident's code status either through morning meetings or through communication by administration and then updated in their computer system. The SW stated if a resident's code status was not entered, the SW would notify the DON/ADON or the charge nurses so it could be inputted in their system. The SW stated some residents were audited for code status when she returned to work but Resident #14 was missed and was an oversight. The SW stated there was no communication done once she returned from vacation and was unsure what was done or not done during her absence. The DON was asked by this surveyor for a policy on code status/ Following physician's orders multiple times and no policy was provided during the duration of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a comprehensive infection prevention and control program that included employing proper signage on the doors of resident's rooms to prevent the transmission of communicable diseases and infections for 2 of 28 residents (Resident #51 and Resident #19) reviewed for infection control. 1. The facility failed to place a readily visible EBP sign on the door of Resident #51 who was actively on EBP which requires an individual to don gown and gloves when performing patient care on 06/24/2024 at 11:35 AM. 2. The facility failed to place a sign on Resident #19's room door who was being tested for C. Diff(clostridioides difficile- a type of bacteria that is contagious and causes diarrhea and inflammation of the colon and can be life threatening) on 06/24/24. PPE such as gown and gloves was required to prevent cross contamination when providing care for residents with C-Diff. This failure could place residents at risk of cross contamination, infection, and illness. The findings included: 1) Record review of Resident #51's face sheet dated 6/24/2024 reflected a [AGE] year-old male with an original admission date of 05/17/2024 and a readmission date of 06/22/2024. Pertinent diagnoses include Functional Quadriplegia (condition that causes complete immobility due to a severe physical disability or frailty, not due to spinal cord damage or stroke), Heart Disease (general term for many conditions that affect the heart's structure and function), and Respiratory Failure (condition in which it is difficult to breathe on your own). Record review of Resident #51's MDS dated [DATE] reflected a BIMS score of 6 (severe impairment). Record review of Resident #51's care plan dated 06/24/2024 reflected Resident #51 required tube feeding. Interventions listed include, but were not limited to, the resident needs assistance with tube feeding and water flushes. During an observation outside Resident #51's room on 06/24/2024 at 11:35 AM, it was noted that assorted PPE was placed in the pockets of an apron hanging on the door. Other PPE was noted in a drawer just outside the room. No sign was visible from the hallway advising visitors or staff to wear PPE before entering Resident #51's room or when performing care on Resident #51. Further observation found that there was a sign in the apron hanging on the door that read STOP SEE NURSE BEFORE ENTERING. The apron hanging on the door had folded over itself, obscuring this sign from view unless the apron was physically moved by an individual. In an interview with MA on 06/24/2024 at 11:41 AM, MA stated that Resident #51 was on EBP. MA stated that the proper PPE to wear before providing care for Resident #51 was a gown and gloves. MA stated that the STOP SEE NURSE BEFORE ENTERING sign was not visible from the hallway before entering the room. MA stated that because the sign was not readily visible, anyone could walk in the room and not put on PPE before interacting with Resident #51. In an interview with RN A on 06/24/2024 at 3:38 PM, RN A stated that Resident #51 was on EBP, and that gown and gloves were required when providing care for EBP residents. In an interview with the DON on 06/26/2024 at 12:56 PM, the DON stated that Resident #51 was currently on EBP. The DON stated that gown and gloves were required when providing care and when touch was necessary. The DON stated that an orange EBP sign should be posted on all doors of residents that are on EBP. The DON stated that if the signs are not on the door, individuals could walk in the room and potentially spread infection to or from the resident. The DON stated that, for example, all residents with a PEG tube (surgery to place a tube directly into stomach), wound, tracheostomy (surgical procedure that creates an airway by making and incision in the neck), and receiving intravenous fluids are placed on EBP. The DON stated they have had several in-services on proper EBP care but could not remember any specific dates. The DON stated that the facility does not have a specific policy on EBP, but that they go by the guidance provided from the CDC. In an interview with CNA D on 06/26/2024 at 4:19 PM, CNA D stated that any resident with certain conditions such as tracheostomies, catheters and PEG tubes are on EBP. CNA D stated that she knows which rooms require EBP because they have a sign on the door and PPE outside the room. CNA D stated that the ADON puts the EBP signs on the door. In an interview with LVN E on 06/26/24 at 4:19 PM, LVN E stated that any resident with certain conditions such as tracheostomies, catheters and PEG tubes are on EBP. LVN E stated that he knows which rooms require EBP because they have a sign on the door and PPE outside the room. LVN E stated that the ADON puts the EBP signs on the door. In an interview with the ADON on 06/26/2024 at 5:05 PM, ADON stated it was her responsibility to ensure all residents that require EBP have the appropriate sign on the door and it was plainly visible. 2) Record review of Resident #19's face sheet indicated a [AGE] year-old female that was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Diagnoses included diabetes, high blood pressure, Alzheimer's disease, muscle wasting and atrophy (decrease in muscle size), lack of coordination, and need for assistance with personal care. Record review of Resident #19's annual MDS indicated she had a BIMS score of 5 (severe cognitive impairment). Record review of Resident #19's care plan on 06/25/24 indicated that she required extensive staff assistance with all ADLs and that she was incontinent of bowel and bladder. Observation on 06/25/24 at 09:39 AM revealed there was no sign on Resident #19's door that indicated the resident was on isolation precautions for possible c. diff. Record review of Resident #19's order summary on 06/25/24 at 09:49 AM revealed that she had a stool sample sent to the laboratory on 06/24/24 at 08:21 AM to be tested for c. diff. That order summary did not include an order for c. diff precautions. In an interview on 06/25/24 at 10:32 AM, the ADON stated when someone has a c. diff test pending, the resident should be placed on isolation precautions. The ADON stated she did not know why Resident #19 was not placed on isolation precautions. Record review of Resident #19's order summary report on 06/25/24 at 10:49 AM revealed a telephone order dated 06/25/24 to place resident on isolation precautions for possible C. Diff. Observation on 06/25/24 at 1:36 PM revealed a PPE holder hanging on Resident #19's door. Along with gowns and gloves, the holder had a sign that read, STOP SEE NURSE BEFORE ENTERING and a canister of disinfecting wipes, however it was not bleach wipes and the label on the canister did not indicate the wipes were effective against c. diff. In an interview on 06/25/24 at 1:43 PM, the MA stated that c. diff precautions meant contact isolation: gown, gloves, mask, shoe covers, and wash hands with soap and water when someone went into and out of the resident's room. The MA stated there were no other precautions that she could think of and did not state that bleach wipes were required for disinfection of non-porous surfaces in the resident's room. The MA stated if they did not wash hands or use PPE, it could cause the c. diff to be spread to other residents. The MA stated that c. diff could cause dehydration and possible death. The MA stated they did in service modules on the computer every month, but could not remember the last time she did actual contact, c. diff, droplet, or airborne precaution training. The MA stated she had hand washing and EBP in service in the last month. In an interview on 06/25/24 at 1:51 PM, CNA F stated c. diff precautions included gown, gloves, mask, and hand washing. CNA F stated that the red or blue bleach wipes were supposed to be used but that the ADON had them and did not give them to her. CNA F stated she did yearly in services on the different types of isolation precautions. In an interview with LVN C and RN B on 06/25/24 at 2:07 PM, LVN C stated Resident #19 was on isolation precautions because she had possible c. diff. LVN C stated c. diff precautions included gown, gloves, shoe covers, and masks. RN B stated that hand washing was to be done after resident care. LVN C stated that any equipment used for or on Resident #19 was to stay in the room with her to be used only on her. LVN C stated the equipment was to be disposed of after Resident #19 was no longer on isolation precautions to prevent the spread of infection to other residents. RN B stated hand washing with soap and water was required to get rid of the c. diff microbes and that hand sanitizer alone was not effective. RN B stated to use Sani Wipes to wipe surfaces. RN B stated if proper precautions were not taken, c. diff could be spread to other residents and could lead to an outbreak. The MA stated it could cause diarrhea, dehydration, and malnutrition which could lead to kidney issues, electrolyte imbalance, and possible death. Both the MA and RN B stated they did not remember when they were last in serviced on hand washing and that the last in-service on isolation precautions was possibly before Christmas. Observation on 06/25/24 at 2:17 PM of Resident #19's door revealed the ADON placed bleach wipes in the PPE holder. In an interview on 06/25/24 at 2:27 PM, the TN stated the last in-service on hand washing and isolation precautions was recently. The TN stated she was not aware that Resident #19 had c. diff results pending. The TN stated the PPE for c. diff precautions was gown, gloves, and hand washing. The TN stated she would keep the supplies for a resident that was on c. diff precautions separate from supplies used for other residents. The TN stated she thought the alcohol/ ammonium wipes were effective against c. diff. After the TN read the label of the alcohol/ ammonium wipes she stated she did not think they would be effective against c. diff. The TN stated the Clorox wipes were effective against c. diff. The TN stated if hands or equipment were not cleaned properly, it could lead to the infection being spread to other residents which could cause them to become dehydrated, ill, or could possibly die. In an interview with the ADON and the DON on 06/25/24 at 2:47 PM, the ADON stated the last in service on hand washing and different types of isolation was in May, about a month ago. The ADON stated a resident should be put on c. diff precautions as soon as it was suspected and stay on them until after the c. diff test results are back. The ADON stated if the resident was positive for c. diff, then the precautions have to stay in place until a negative c. diff test was received. The ADON stated that Resident #19 possibly having c. diff was not discussed in the morning meeting and it did not come out on the 24-hour report because it was placed on there 19 minutes after the morning report was run. The ADON stated the nurse who entered the c. diff test should have asked the physician for an isolation order when she requested the test. Then ADON stated the difference between contact and c. diff isolation was that regular wipes could not be used for c. diff. The DON stated bleach wipes had to be used with c. diff precautions and that hand washing with soap and water was required to eliminate c. diff spores. Record review of CDC guidance 483.80(a)(1) on EBP: A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards. Record review of the facility's Infection Prevention and Control Program Policy dated 05/13/23 stated in part: This facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. 13. Resident/Family/Visitor Education and Screening: c. Isolation signs are used to alert staff, family members, and visitors of transmission-based precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for three residents (Resident #14, Resident #30, and Resident #49) of 24 residents whose care plans were reviewed, in that: 1) Resident #14's comprehensive care plan was not revised after being prescribed Albuterol Sulfate Inhalation Nebulization Solution on 5/1/24 to reflect a respiratory plan of care. 2) Resident #30's comprehensive care plan was not revised after her quarterly safe smoking evaluations (assessments) changed. 3) Resident #49's comprehensive care plan failed to include he was a smoker. This failure could place residents at risk for inadequate care. The findings included: 1) Resident #14 Record review of Resident #14s face sheet dated 6/24/24 reflected a [AGE] year-old-female with an original admission date of 4/30/24. Diagnoses included cerebral infarction (stroke that occurs when a blood vessel that supplies the blood to the brain is blocked), pneumonia (inflammatory condition of the lung(s) primarily affecting the small air sacs), and respiratory failure. Record review of Resident #14's MDS dated [DATE] reflected Resident #14 had an active diagnosis of respiratory failure and pneumonia with the use of oxygen therapy. Record review of Resident #14's care plan dated 4/30/24 and revised on 5/13/24 did not reflect any respiratory condition or the use of Albuterol Sulfate Nebulization Solution. Record review of Resident #14's physician orders dated 5/1/24 stated: Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 application inhale orally via (by way of) nebulizer every 6 hours for Anti-asthmatic and Bronchodilator agents. In an interview on 06/26/24 at 1:08 pm the DON stated an order for albuterol should have been care planned for Resident #14 since Resident #14 was on respiratory treatments. The DON stated the care plan is necessary, so staff can monitor the goals of Resident #14 and access if the interventions need to be updated or revised. The DON stated the MDS Coordinators are the ones to audit care plans after the initial care plans have been entered by either charge nurses or administration. The DON stated he and the ADON oversee that care plans are up to date and accurate. The DON stated Resident #14's care plan was overlooked and missed. In an interview on 06/26/24 at 1:20pm the ADON stated Resident #14's care plan should have been updated to reflect the order of albuterol since it is person centered. The ADON stated it she and the DON oversee that care plans are up to date and accurate but Resident #14's care plan was missed. The ADON stated by not have Resident #14's respiratory plan of care updated, staff would not be aware of the goals and interventions if there were complications. In an interview on 06/26/24 at 2:18pm MDS Coordinator D stated care plans are reviewed and updated quarterly by both MDS Coordinators and the DON and the ADON are the ones to update acute changes in a resident's plan of care. MDS Coordinator D stated an order list, reflecting new resident orders, are printed out every business day and checked to see if there were any updates that need to be made on a resident's care plan. MDS Coordinator D stated it was an oversight and could not give an explanation on why Resident #14's change in medication was missed in the care plan. 2) Resident #30 Record review of Resident #30s face sheet reflected a [AGE] year-old-female with an initial admission date of 08/12/16 and a re-admission dated 12/30/20. Diagnoses included chronic obstructive pulmonary disease (COPD), Heart disease, Alzheimer's, dementia, diabetes, schizophrenia, psychosis, nicotine dependence, high blood pressure, and need for assistance with personal care. Record review of Resident #30's MDS dated [DATE] reflected Resident #30 had a BIMS of 1, indicating severe cognitive impairment. Resident #30 had unclear and slurred or mumbled speech and had a limited ability to make concrete requests. She responded to adequately to simple, direct communication only. She had impaired vision. She was ambulatory and required substantial assistance with oral care, moderate assistance with toileting and showering, supervision with dressing, and set-up assistance with eating. She was incontinent of bladder and occasionally bowel. She had an active diagnosis of cardiorespiratory conditions. Record review of Resident #30's care plan dated 05/06/24 and revised on 11/02/22 reflected she was a smoker. Interventions included wear an apron when out smoking initiated 09/25/23, and she required supervision while smoking initiated 12/04/20 and revised on 09/27/21. Next review date 08/04/24. Record review of Resident #30's quarterly safe smoking assessments dated 02/05/24 indicated she required supervision only and was no longer required an apron. This was not reflected in the most recent care plan dated 05/06/24. Observation of smokers in the designated smoking area on 06/26/24 at 1:30 pm revealed 4 of 7 smokers were smoking. Resident #30 was not wearing an apron. Resident #49 was smoking. Interview with the DON and ADON on 06/26/24 at 1:17 pm revealed the care plans were updated immediately after a change. The DON stated they go over changes in their daily morning meetings with all department heads. They stated safe smoking evaluations (assessments) should be done quarterly and reflected and updated in the care plans as soon as they found out. The DON stated safe smoking evaluations (assessments) were supposed to be done on admission and quarterly. They both stated smoking should be care planned, and Resident #30's care plan was not complete regarding whether she should wear an apron, but it was not documented anywhere. They both stated the safe smoking evaluations (assessments) were done to determine the level of supervision required, and that should be care planned. They stated Resident #30's care plan had not been updated as it should have been. They stated the social worker attended the daily morning meetings and they were responsible for the work they input. The DON stated everyone was doing something different and they were working on it. The DON stated staff should have been updating their own care plans-when there were changes or updates needed. The DON stated the MDS nurses had their own system. The DON stated he only updated the care plans when a situation presented itself. 3) Resident #49 Record review of Resident #49s face sheet reflected a [AGE] year-old-male with an initial admission date of 01/31/24 and a re-admission dated 05/07/24. Diagnoses included heart disease, diabetes, high blood pressure, malnutrition, amputations of his right leg below the knee and his left leg above the knee and need for assistance with personal care. Record review of Resident #49's MDS dated [DATE] reflected Resident #49 had a BIMS of 8, indicating moderate cognitive impairment. He was moderately hard of hearing and had visual impairment. He was dependent on staff for toileting hygiene and required substantial assistance with bathing, moderate assistance with dressing, supervision with dressing, and set-up assistance with eating and oral hygiene. He was occasionally incontinent of bladder and frequently incontinent of bowel. He had an active diagnosis of cardiorespiratory conditions. Record review of Resident #49's care plan dated 05/21/24 had initiation dates of 01/31/24 and revisions on 05/23/24. Smoking was not reflected in his care plan on any date. Record review of Resident #49's quarterly safe smoking assessment dated [DATE] documented cognitive loss, visual deficits, and dexterity problems. He could light his own cigarette and required supervision when smoking. Interview with the DON and ADON 06/26/24 at 1:17 pm revealed the care plans got updated immediately after a change. They stated smoking should be care planned, and Resident #49's care plan was not complete. They said Resident #49 did not start smoking until recently, but it was not documented anywhere. Record review of Care Plan Upon Status Change policy dated 10/24/24 stated: Policy The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedures for reviewing and revising the care plan when a resident experiences a status change: b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified. f. Care plans will be mortified as needed by the MDS Coordinator or other designated staff member. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. 1. The facility failed to ensure juice dispenser nozzles were sanitary. 2. The facility failed to ensure equipment was clean and sanitized. 3. The facility failed to ensure the kitchen staff was following their policies. These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on 06/24/24 beginning at 12:00 pm revealed 2 of 2 juice nozzle had a thick, sticky red substance that was congealed on and in the nozzles. Inside the nozzles, the same thick, sticky, congealed red substance was stuck to them. In an interview with the DA on 06/24/24 at 12:15 pm, she stated the juice nozzle were cleaned only at night. She stated the juice nozzle always looked like that, especially over the last four months. She stated there was a cleaning schedule the kitchen staff followed. In an interview with the DM on 06/24/24 at 12:20 pm, he stated he had the entire juice machine replaced, but the juice nozzle continued to become congealed over the last 4-6 months. He stated he called the man who serviced the juice machine, and he told him to call the company. He stated the procedure was that he would put work orders into the facility's electronic work order system, and the MS was supposed to call the company for the juice machine, but the company never came or responded. He stated he would change the cleaning schedule to daily cleaning for the juice nozzle. He stated bacteria could grow in the nozzles and make the residents sick. In an interview with the MS by way of an interpreter HR on 06/26/24 at 2:40 pm, he stated he did not know how to pull reports from the facility's electronic work order system. He stated sometimes the kitchen staff notified him regarding the juice machine/juice nozzle, but they did not enter the problem(s) into the facility's electronic work order system. When asked how many times the kitchen staff had notified him about the juice machine/juice nozzle in the last four to six months, he stated the company from the juice machine came regularly to check on it and he thought it was once a week, but he needed to check with the DM. He stated the machine was replaced on 10/01/23. He stated the company that checked the juice machine/juice nozzle once a week told him they were there to regulate the juice because sometimes they said it (the juice) was too condensed. He stated kitchen staff had been complaining about the juice machine/juice nozzle for two to three weeks and the company that checked the juice machine/juice nozzle would have to regulate the juice every time they were there. He stated he did not know why the juice machine/juice nozzle was not getting fixed, and he guessed the dietary aid was not notifying the company. He stated the company from the juice machine was not allowing him to touch the machine too much and when there was an issue, the company from the juice machine was to come in and fix it. He stated he had seen the dirty nozzles on the juice nozzle and shook his head side to side indicating no when asked if the nozzles looked like they had been cleaned daily. He stated the DM should be in charge of contacting the company from the juice machine. He stated he himself had never contacted the company for the juice machine. Then he stated the people from the juice machine company that came once a week did not look at the machine because they only delivered juice once a week, unless they let them know there was something wrong, they would look at it, but typically, they come in and delivered or change the juices. Record review of the cleaning schedules dated 01/01/24-06/24/24 revealed all spaces filled, indicating cleaning had been done regularly on kitchen equipment, but there was no space labeled juice nozzle or juice machine. Record review of the electronic work order system requests revealed Work order #6393 dated 03/14/24 Check Juice Machine the work order was created by the DM on 03/14/24 at 10:39 am and closed by the MS on 03/14/24 at 1:50 pm. This was the only work order in the facility's electronic work order system regarding the juice machine from 02/01/24-05/30/24. Record review of in-services for kitchen staff: 12/18/23-Use Oven Mitts, pay attention to Surroundings, 01/18/24-Tray line Temperatures, food receipts, eating in the kitchen, dish machine logs. 06/25/24-Level 4 spoon/fork test, 06/26/24-Juice machine cleaning; how to and signing cleaning log. Record review of the facility kitchen policy titled, Cleaning Schedules dated 10/01/18 revealed under Policy: The facility will maintain a cleaning schedule prepared by the nutrition and food service manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. Record review of the facility kitchen policy titled, Coffee machines and Juice Machines revised 06/01/2019 revealed under Policy: The facility will maintain coffee machines and juice machines in a clean and sanitized condition to minimize the risk of food hazards. Coffee and juice machines will be cleaned once per day. Under Procedure: 2. Juice machines should be cleaned following the manufacturer's instructions. The nozzle will be cleaned daily. References: TAC 554.1111 (b) The facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Service sanitation requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments, person-centered care plan to reflect the current condition for 1 of 11 residents (Residents #2) reviewed for care plan revisions. The facility failed to ensure Resident #2's care plan was comprehensive and updated to reflect Resident #2's fall preventions. This failure could place residents at risk of not receiving appropriate interventions meet their current needs. The findings include: Record review of Resident #2's admission records revealed an [AGE] year-old-female with an admission date of 07/28/22 and re-admission on [DATE]. Diagnoses included left femur (thigh)/hip fracture, heart failure, diabetes, osteoarthritis (severe bone degeneration), protein-calorie malnutrition, and muscle wasting. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 6 indicating severe cognitive impairment. Resident #2 was dependent for chair/bed to chair transfers and toileting transfer. Picking up objects, sit to stand or walking 10 feet was not attempted due to medical or safety reasons. Resident #2 required supervision with toileting, substantial assistance with footwear and dressing, rolling left and right, sitting to lying, lying to sitting on the side of the bed, wheeling her wheelchair 50 feet. Resident #2 was incontinent of bladder and bowel. She had a manual wheelchair she could self-propel. Record review of Resident #2's care plans only had partial Low risk interventions when Resident #2 was rated at a high risk for falls since her admission on [DATE]. Record review of Resident #2's comprehensive care plan dated 7/28/2022 indicated she was at risk for falls r/t Hx of falls: 8/16/22-witnessed fall/with skin tear to left side of lip/attempted unassisted transfer from bed to w/c Date Initiated: 07/28/2022 Revision on: 08/17/2022. Interventions were: Anticipate and meet Resident #2's needs. Date Initiated: 07/28/2022 Revision on: 08/17/2022 o Be sure Resident #2's call light is within reach and encourage to use it for assistance as needed. Date Initiated: 07/28/2022 Revision on: 08/17/2022 o Rehab referral related to 8/16/22 fall. Date Initiated: 08/16/2022. 8/16/22-staff to continue to anticipate and meet needs. Revision on: 10/02/2022. 7/19/23-Resident sitting on bathroom doorway. Stated she slipped sitting down when she tried to self-transfer and forgot to lock her wheelchair and she was wearing socks. Date Initiated: 07/19/2023 o Resident #2 will have no major injuries from fall. Date Initiated: 07/19/2023 Target Date: 05/14/2024 o Call bell within reach to call for assistance. Date Initiated: 07/21/2023 o Perform frequent rounds to anticipate resident's needs. Date Initiated: 07/19/2023 o Therapy to evaluate and treat. Date Initiated: 07/19/2023 o 02/23/24-Resident found on floor in seated position: unwitnessed fall. 02/01/24-Resident voiced that she wanted to go to restroom. did not use call light. Fell, c/o pain. Date Initiated: 02/23/2024 o Resident will have no major injuries from a fall. Date Initiated: 02/23/2024 Target Date: 05/14/2024 o Call bell within reach. Date Initiated: 02/23/2024 o Frequent rounds to anticipate resident's needs. Date Initiated: 02/23/2024 o Therapy to evaluate and treat. Date Initiated: 02/23/2024 o Resident #2 is High risk for falls r/t Hx of falls prior to admission Date Initiated: 02/09/2024 Revision on: 02/14/2024 o The resident will be free of falls through the review date. Date Initiated: 02/09/2024 Target Date: 05/14/2024 o Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 02/09/2024 o Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Date Initiated: 02/09/2024. Record review of Resident #2's Fall risk assessments dated 02/01/24 documented a score of 15 indicating a high risk for falls. Quarterly Fall risk assessments since 08/16/22 documented scores from 10-12, indicating a high risk for falls since her original admission on [DATE]. Record reviews of Resident #2's initial baseline care plan dated 02/09/24, comprehensive care plans dated 02/09/24 and 02/14/24 revealed Resident #2's Care plan dated 02/14/24. Resident #2 has acute pain r/t recent ORIF (open reduction internal fixation=plates and screws). During an interview with the DON on 05/08/24 at 1:40 pm, he stated interventions for high risk fall scores should be care planned and in the physician orders. During an interview with the DON on 5/10/24 at 12:40 pm, he stated, Fall precautions should be in the care plan. Revisions were overlooked by the DON after Intra Disciplinary Team (IDT) daily morning meetings. The DON stated, Fall mats, call lights and low bed positioning should be in the interventions in the care plans. They (staff) need to keep the patients safe, so all staff should be very vigilant. If there was not something in the care plan that was suggested, it is rated by what the resident needs. The DON stated, Staff and the IDT review the fall prevention policy and go by that. The DON stated, The 02/09/24 care plan was after [Resident #2's] fall on 02/02/24 and again on 02/23/24. It had appropriate interventions, but there could have been more because she had broken her hip then fell again. The DON stated, The interventions in [Resident #2's] care plan were not adequate. The DON stated the fall interventions of call bell within reach and encourage to use it for assistance as needed, anticipate and meet Resident #2's needs were inadequate for Resident #2's current condition. The DON stated he did not see the interventions for a fall mat or low bed. The DON stated, There could be 15 of them (interventions), but if they weren't using them all, they tried to use the ones that were more useful. After reviewing the resident's Fall risk Evaluations, the DON stated, Some of the other interventions would have helped her and helpful in preventing a fall. The DON acknowledged Resident #2 was a high fall risk since 11/07/22 and more interventions would have been helpful. The DON stated he was not sure of what the facility's fall prevention program policy outlined. The DON was unable to show where fall interventions were located in Resident #2's electronic chart. Record review of facility policy titled, Fall Prevention Program dated 08/15/22 reflected-Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy explanation and compliance guidelines: 1. a. The risk assessment categorizes residents according to low or high risk. 3. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. Low risk protocols: a. May implement universal environmental interventions, that decrease the risk of residents falling, including but not limited to: i. a clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. wheelchairs and assistive devices are in good repair. b. Implement routine rounding. c. Monitor for changes in resident's cognition, gait, ability to rise/sit and balance. d. encourage residents to wear shoes or slippers with non-slip soles when ambulating .g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. 5. High risk protocols: a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. b. Provide additional interventions ass directed by the resident's assessment, including but not limited to ii. Increased frequency of rounds, v. Low bed, vii. Scheduled ambulation or toileting assistance. 8. When any resident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated. f. Document all assessments and actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 resident (Resident #1) of 8 residents reviewed for quality of care. The facility failed to follow the physicians order on 08/16/2022 in accordance with the care plan for Resident #1's Wanderguard bracelet (device designed to prevent elderly individuals with dementia from wandering outside a perimeter) to be placed on her right arm. The Wanderguard bracelet was instead placed around her right ankle. This failure could place residents requiring supervision who had a Wanderguard at risk for injury and accidents. The findings included: Record review of Resident #1's face sheet dated 05/08/2024 reflected an [AGE] year-old female with an original admission date of 01/19/2022. Pertinent diagnoses includes dementia (mental decline that affects the quality of daily living) with exit seeking behaviors. Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 1 (Severe Cognitive Impairment). Record review of Resident #1's quarterly Wandering assessment dated [DATE] reflected Resident #1 was a moderate wandering risk. Record review of Resident #1's comprehensive care plan dated 01/28/2022 indicated a problem stating she was an elopement risk, wanderer, and disoriented to place. An intervention included for this problem was to check placement and function of safety monitoring device as per policy/orders. Record review of Resident #1's physician orders for Wanderguard dated 1/28/2022 and a revision physician order for Wanderguard to right arm on 8/16/22. In an interview with the DON on 05/08/2024 2:00 PM, it was revealed that on 10/17/2023, the day of an elopement by Resident #1, she had the Wanderguard bracelet on her right ankle making the Wanderguard system unable to detect the bracelet at floor level. In an interview with the MD on 05/08/2024 2:15 PM, it was revealed that as a resident with a Wanderguard device approaches a closed door equipped with the Wanderguard system, the door locks for 15 seconds. He further revealed that if the Wanderguard device crosses the threshold of an open door equipped with the Wanderguard system, an alarm sounds throughout the building. Observation on 05/08/2024 at 2:50 PM revealed that Resident #1 was wearing her Wanderguard bracelet on her right arm on. Resident #1 could not be interviewed due to history of dementia. In an interview with the ADON on 05/08/2024 3:04 PM, it was revealed Resident #1 was wearing her Wanderguard device around one of her ankles during the head-to-toe assessment of Resident #1 immediately following the elopement incident on 10/17/2023. The ADON stated a potential outcome of the incident was Resident #1 getting hit by a car. In an interview with LVN D on 05/10/2024 10:25 AM, LVN D stated that not following physician orders could lead to medical errors or poor patient outcomes. LVN D also stated that if she saw a resident wearing their Wanderguard bracelet in a different location from where it stated on the physician's order then she would inform the DON of the discrepancy and then get assistance to move it to the correct location based on the physician's order. Record review of a work order from a contractor dated 10/18/2023 8:42 AM revealed the following: WanderGuard at front door not alerting when tag is present. Requested by the Administrator for the front door WanderGuard system not working. The system was checked by tech and was adjusted to maximum coverage the system would allow. It was noted that the system has an external signal interference, that causes the bracelet, to not be picked up by sensor when close to the door. All adjustments were made and a resident was used to test door response. The resident had a tag applied to ankle. The nurse admin was notified that the tag was to close to the ground and was part of the reason the tag was not picked up by receiver. This person stated that it had been done that way and she would speak to Admin on his return. Job complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, observation, interviews, and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 2 of 22 residents (Residents #19 and #62) reviewed for self-determination in that: The facility failed to ensure Resident #19 received daily showers as requested. The facility failed to ensure Resident #62 receive daily showers as requested. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are important in their life and decrease their quality of life. The findings were : Resident #19: Record review of Resident #19's face sheet, dated 04/04/23, revealed a [AGE] year-old male admitted to facility 04/03/23 with diagnoses that included type II diabetes and paraplegia. Record review of Resident #19's Comprehensive MDS dated [DATE] revealed a BIMS score of 14 indicating he is cognitively intact . Section G0120. Bathing reflected 4. Total dependence Record review of Resident #19's Care Plan with an edit date of 02/27/23 revealed a problem of [Resident 19] has an ADL self-care performance deficit r/t Paraplegia The intervention in placed revealed BATHING/SHOWERING: [Resident #19] is totally dependent on 1 staff to provide shower and as necessary. Resident #62: Record review of Resident 62's face sheet, dated 04/13/23, revealed a [AGE] year-old male admitted to facility 10/26/22 with diagnoses that included multiple sclerosis (immune system disease) and intervertebral disc degeneration (loss of cushioning in the spine). Record review of Resident #62's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating he is cognitively intact . Section G0120. Bathing reflected 2. Physical help limited to transfer only Record review of Resident #62's Care Plan with an edit date of 11/03/22 revealed a problem of: [Resident #62] has an ADL self-care performance deficit r/t MS revealed an intervention of BATHING/SHOWERING: [Resident 62] is totally dependent on staff to provide shower as schedule and as necessary. During the resident council meeting on 04/05/23 at 10:00 AM, Resident #62 reported that he preferred to have his showers daily. He said he was told by the Activities Director and the Social Worker that he would no longer be able to have daily showers. He said he was told they do not have the staff. He said he wore a brief and he preferred to shower daily. He said being told he could not shower daily made him mad and that he did not feel clean if he did not shower every day. He said he could not do things for himself because if he could, he would. During an interview on 04/05/23 at 10:41 AM, the Activity Director said the facility changed from residents having daily showers to scheduled showers because the facility was challenged with staffing. She said a meeting was held with her (Activity Director) and the Administrator in March 2023. She said the options for showers were changed to every other day. She said before the shower schedule change only three residents preferred showers daily but only two had an issue with the change (Resident #62 and Resident #19). However, she said Resident #19 did not like it. She said Resident #19 wanted to shower daily, especially before Sunday's religious service. She said Resident #62 was mad and upset when the change occurred. She said Resident #62 exchanged bad words, but she did not specifically say what was said but that he was not happy with the decision. During an interview that occurred on 04/05/23 at 10:48 AM, Resident #19 said in the past he was allowed to take a shower daily. He said all of a sudden in March 2023 the daily showers stopped. He said the Administrator and Social Worker told him he could no longer take daily showers. He said he was not sure why the decision was made but that it made him feel bad when he could not shower daily. He said that he sweated a lot when he was in bed and that he wore a brief. He said he could not walk and care for himself and depended on staff to help him with daily activities. He said he was always in bed and felt better when clean. He said taking a shower every other day made him feel dirty. He said it made him feel like the staff treated him and the others who could not speak up for themselves like animals. He said they were not animals, but they were humans. He said he understood that he and the other residents were dying, but they were not dead and were human and should be able to shower every day. He said he needed to talk for himself and those who could not speak up. During an interview on 04/05/23 at 10:58 AM, the Social Worker stated the Activities Director was responsible for the shower schedule. She said the facility's process for showers included the Activities Director asking the residents when they wanted to take their showers. She said based on their response, that was when the residents were scheduled to take their showers. She said the change was made because of the lack of staff. She said the directive came from the Administrator after he spoke with the people above him. She said the Administrator explained to the residents they could not fulfill a service they did not have. She said that meant if the facility did not provide daily showers as a daily service, then they would not have to fulfill that service. She said the only options for showers were Monday's, Wednesday's, Friday's, or Tuesday's, Thursday's, and Saturday's. She said no showers were given on Sunday's. She said the potential negative outcome for residents not receiving their daily preferential showers was decreased quality of life and body hygiene. She said that was not a decision that she or the Activity Director made but that they were following the directive given by the Administrator that he received from upper management. During an interview on 04/05/23 at 11:10 AM, the ADM stated the change in showers occurred in March 2023. He said the options that were given to the residents were Monday's, Wednesday's, Friday's, Tuesday's, Thursday's, and Saturday's. He said PRN showers should have been given to any resident that became soiled or if they fell in the mud. He said the cancellation of daily showers is not a directive that came from him but a policy that his company had adopted. When asked why the change was made, he initially stated the change was made because of the lack of resources. When asked about what he meant by lack of resources, he said he did not mean to use the word resources. When asked why the change from daily showers to scheduled showers was made, he said he would have to get back to the investigator. When asked about the potential negative outcome for residents not receiving their preferential daily showers, he said he would have to get back with the investigator. He said when the change was made, he announced the bathing schedule options Resident Council. He said he announced the shower schedule in the resident council meeting. During an interview on 04/05/23 at 11:47 AM, the ADM said with the change in the policy, they tried to accommodate the residents the best they could. When asked which policy he referred to on the implemented change, he said he would get back to the investigator. During an interview on 04/05/23 at 11:49 AM, the DON stated when the change for scheduled showers was implemented, it was because they had a lot of residents. He said if residents wanted a shower after the scheduled showers were completed, the staff should have been given a shower. He said there was no existing policy for the implemented change that he could provide. He said all showers should be documented in the electronic medical system. During an interview with Confidential Staff A, they said they provided showers for the residents in the facility. They said in the past some residents received showers daily, but it was stopped because they were short-staffed. They said the Activity Director was responsible for the shower schedule, and they had been trained to follow the schedule. She said it was their understanding when they are fully staffed again, and they can go back to doing daily showers. They said they were told that the Social Worker and the Administrator talked to the residents about the change. They said no residents reported any issues directly to her, but she had heard that some residents did not like the change. They said a potential negative outcome is that the residents would feel bad. They said outside of the scheduled days for showers, the residents only received a shower before doctor appointments and family visits. They said other than that, the residents should receive a shower every other day regardless of their preference for a daily shower. They said they did not receive formal training but that the shower book was how they knew what residents and what days they shower. During an interview with Confidential Staff B, they said there was a shower book they went by and that was how they knew who was supposed to shower. They said the only time the schedule changes was if the resident changes halls. They said the residents could not have a shower every day because sometimes they were short-staffed. They said that Resident #19 had expressed to them that he would like a shower every day but they had told him that he could not have one daily, which made him mad. They said they had been trained to follow the schedule. They could not think of a potential negative outcome for the resident not being able to choose their shower days. During an interview with Confidential Staff C, they said they had provided residents showers while working. They said they followed the schedule in the binder at the nursing station. They said that Resident #62 had expressed that he would like to shower daily, but they told him that he would not be able to shower daily because he took an hour and a half and they did not have enough staff, so that was why the schedule was put in place. They said Resident #62 would get mad, and they would report to the DON when he was mad. They said when they told the DON he said he would talk to Resident #62. They said they were unaware if the DON had spoken with Resident #62. During an interview with Confidential Staff D, they said they had provided residents with showers. They said they gave residents daily showers if they asked for them in the past, but that had changed as of March 2023. They said they were not sure why it was changed but that they had been short staffed, and they thought this may have been the reason. They said Resident #62 had expressed that he liked to shower daily. They said that the ADM and the Social Worker talked to the residents to let them know about the changes and that the residents could no longer shower daily. They said Resident #62 was mad and upset about the changes. They said they tried to keep him from being so angry, and they would give Resident #62 bed baths and that kept him calm. They said Resident #62 expressed that he felt cleaner and appreciated when that was done. They said if they had time, they would still try to give showers on their unscheduled shower days, but if there was no time, the residents had to wait for their scheduled days. During an interview with Confidential Staff E, they said they provided showers to residents per their schedule and mostly on Saturday's because someone provided showers during the week. They said they knew who to shower by the binder, which was how she had been trained. They said that Resident #19 had expressed that he would like showers daily but that they had told him no because sometimes they were short staffed and the staff would have two halls. They said having two halls made it challenging to shower everyone. They said when they told Resident #19, he would get mad and threatened to call the state. During an interview with the DON on 04/06/23 at 11:24 AM, the DON clarified that the scheduled showers was not a change. He said it was something the company brought up. He said it was an attempt to accommodate everyone. He said the residents were uncomfortable a little bit. He said he was not in the resident council meeting when the announcement was made, so he could not say what was said during that meeting. He said it was his interpretation that they would have scheduled days for residents to shower, but the residents could shower daily if they wanted to. He said Resident #62 received daily baths, but it may be longer than he wants to wait, and Resident #62 would leave. He said he didn't believe there were in-services on the changes. He said he expected everyone to be showered according to the schedule, but they were supposed to provide daily showers if they wanted a shower daily. He said the potential negative outcome could be the same for receiving daily showers and not receiving daily showers. He said the resident could have dry skin and irritation. He said they did not have to train when the changes came because they had always had that schedule. He said no one complained to him about the change. He said the nurses make the shower schedule and revise it weekly to ensure everyone is on there, including new admissions. During an interview with the ADM on 04/06/23 at 11:50 AM he said, We had a change of policy. when he was asked if he gained clarification on why the change in shower schedules was implemented. When asked was a specific policy that was changed, his response was just a change of policy. When asked for the copy of the Resident Rights Policy that the facility admission packet referenced, the ADM stated there was a copy on the wall, and it was big. The ADM offered to take a picture of the rights. A physical copy was not provided. He said he was aware that the change upset some of the residents and specifically named Resident #19. He said Resident #19 asked if he could get a daily shower, and the ADM said he explained that he had showers on the scheduled days. The ADM said he considered bathing and showering a part of personal care. He said he did not at the time believe having scheduled shower days was a limitation because they told him he would get the shower on the scheduled days and would still shower on the other days. He said during the resident council meeting, they announced the shower schedule, and on the other days that the residents were not scheduled, showers should still occur if the resident fell in the mud or had an event. He said after that meeting, each resident could choose their preferential schedule. When asked how the staff were trained on the new change, the ADM responded, Just by the schedule. He said there was no in-service or documentation to support the change he could provide. He said nursing and activities were responsible for the shower schedule. He said he did not have any additional policies outside of the policies he provided. When asked about the potential negative outcome of the residents not receiving the daily showers, he responded, I do not have one. An observation made on 04/06/23 at 12:30 PM revealed a large poster with nursing facility resident rights: Freedom of Choice: Nursing facility requirements for licensure & Medicaid Certified Centers Residents have a freedom of choice. During an interview with the Activities Director on 04/06/23 at 1:17 PM she said that freedom of choice should have included being able to choose when the residents would shower. During an interview with the DON on 04/06/23 at 1:18 PM he said that freedom of choice should have included being able to choose when the residents would shower. During an interview with the Social Worker on 04/06/23 at 1:19 PM she said that freedom of choice should have included being able to choose when the residents would shower. During an interview with the ADM on 04/06/23 at 1:20 PM she said that freedom of choice should have included being able to choose when the residents would shower. Record Review of the Shower Schedule provided revealed the following: Resident #19 was scheduled for showers during the 6A-2P shift Monday's, Wednesday's and Friday's. Resident #62 was scheduled for showers during the 6A-2P shift Monday's, Wednesday's and Friday's. Record Review of Resident Council Meeting Minutes dated 03/06/23 revealed the following: New Business: Patient Education on the showers ( Monday, Wednesday, Friday or Tuesday, Thursday Saturday)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to, based on a resident's comprehensive assessment, ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 5 residents with gastrostomy tubes (Residents #53 and #57); in that: 1) (Resident #53 and #57 had G-tube feedings that were not administered according to physician's orders, and 2) G-tube flushing equipment (flushing syringes) was not stored in a sanitary manner after use (Residents #53 and #57). These problems could result in the residents on feeding tubes experiencing feeding tube associated complications which could include aspiration pneumonia, discomfort, and inadequate nutrition. The findings include: Resident #53: Record review of the Order Summary Report dated 4/6/23 for female Resident #53 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as dysphasia (swallowing disorder) following other cerebral vascular disease (heart disease), encounter for attention to gastrostomy (g-tube), unspecified dementia, adult failure to thrive, unspecified, protein-calorie malnutrition (inadequate nutrition), Type 2 diabetes mellitus with hyperglycemia (elevated blood sugar). Further record review of the Orders Summary Report revealed the following physician's orders: Enteral Feed Order every shift flush tube with 125 mls of water every six hours. Order Date 12/31/22. Start date 12/31/22 . Enteral Feed Order every shift Glucerna 1.2 at 50 MLS x 18 hours via peg-tube stationary pump. Downtime 7A-1 P (May substitute with Nestlé's Diabetisource 1.2) Ordered Date 2/21/23. Start date 2/21/23 Record review of the annual MDS for Resident #53, dated 7/13/22, documented that the resident had a Nutritional Approach which included parenteral/IV feeding while not a resident. It was also documented that the resident had a feeding tube while not a resident and while being a resident. The resident was identified as having diagnoses that included cerebral vascular accident/stroke, dementia, and malnutrition. The resident had no BIMS score and was identified as being severely impaired cognitively. Record review of the quarterly MDS dated [DATE] for Resident #53 documented the resident had a Nutritional Approach that included having a feeding tube while a resident. The resident was identified as having diagnoses that included cerebral vascular accident/stroke, dementia, and malnutrition. The resident had no BIMS score and was identified being severely impaired cognitively. Record review of the current undated care plan for Resident #53 revealed the following Problem (Resident) requires tube feeding R/T dysphasia. Date initiated: 7/30/21. Revision on: 9/17/21. Interventions listed revealed the following: (Resident) is total dependent with tube feeding and water flushes. See MD orders for current feeding orders. Date initiated: 7/31/21. Revision on: 7/8/22 . Observe/document/report PRN any S/SX of: aspiration . Date initiated: 7/30/21 .Water flushes as ordered. Date initiated: 2/17/22. Revision on: 10/2/22 On 4/04/23 at 11:18 AM Resident #53, was observed in a lower air bed, and had a G-tube feeding labeled On at 1 PM off at 7 AM. 50 mL/hr, Glucerna Carbready 1.2 Cal and the level was at 550ml. The flush/water bag for the G-tube was at a level of approximately 700ml. It was labeled 125 mL (flush). The pump was off. On 4/4/23 at 1:18 PM an interview was conducted with LVN A, charge nurse for hall 200 regarding her residents. She stated the following: Resident #53's G-tube was continuous and off from 7 AM to 1 PM. On 4/5/23 at 9:22 AM Resident #53 was observed in bed on an air bed. She was awake and confused. The G-tube pump was turned off and the feeding was Glucerna 1.2 at 950 mL level. The flush/water bag was at 800ml level. The head of bed had a slight elevation. The resident's flushing syringe, for the G-Tube, had the plunger stored in the barrel and stored together in a bag. The syringe was dirty and had a white substance in the tip. On 4/6/23 at 8:57 AM Resident #53 was observed in bed asleep. The G-tube pump was on. The flushing/water bag was labeled On at 1 PM and off at 7 AM. The feeding rate was documented at 50 ml/hour flush 125 mls every six hours on the display on the pump. The Glucerna 1.2cal feeding bottle was labeled 4/6/23 On at 1 PM off at 7 AM. The resident's head of bed was elevated. Observation on 4/6/23 at 9:06 AM revealed the G-tube pump for Resident #53 was still on. On 4/6/23 at 9:38 AM Resident #53 was observed in bed. The resident's flushing syringe, for the G-Tube, had the plunger stored in the barrel and stored together in a bag. The syringe was dirty and had a white substance in the tip. The bag was dated 3/6/23. The g-tube pump was off. Resident #57: Record review of the Order Summer Summary Report for male Resident #57 dated 4/6/23 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The diagnoses listed for the resident were: post COVID-19 condition, unspecified, unspecified, cirrhosis of the liver (liver damage), unspecified, severe protein - calorie malnutrition (inadequate nutrition), gastrointestinal hemorrhage, unspecified (intestinal bleeding), encounter for attention to gastrostomy (g-tube), hemiplegia and hemiparesis following cerebral infarction (heart attack), affected right dominant side (paralysis), and dysphasia following cerebral infarction (swallowing disorder). Further record review of the Order Summary revealed the following orders: Enteral Feed Order every shift - observe for signs of intolerance, i.e., Diarrhea, nausea and vomiting, constipation, abdominal distention/cramping, dehydration, fluid overload, aspiration, increased gastric residual, or hypo/hyper glycemia (low or high blood sugar). Order date 12/11/22. Start date 12/11/22 . Enteral Feed Order every shift. Enteral 1. - Feeding: administer Glucerna, 1.5 per peg tube via pump. Rate: 65 MLS/hour, for 18 hours/day. On at 1 PM stop 7A. Order Date 12/11/22. Start Date 12/11/22 . Enteral Feed Order every shift for hydration bolus with 350 ML of water every six hours for hydration and tube patency. Order Date 12/11/22. Start Date 12/11/22 . Record review of the significant change MDS for Resident #57 dated 5/16/22 documented the resident had a BIMS score of four indicating that the resident was cognitively impaired. Further documentation of the significant change MDS revealed that the resident's primary medical condition was a stroke. Other diagnosis documented was aphasia (language disorder), hemiplegia (paralysis), and malnutrition. Further documentation on this MDS revealed that the resident had a Nutritional Approach that included parenteral/IV feedings while not a resident and feeding tube while not a resident and while a resident. Record review of the quarterly MDS dated [DATE] documented that Resident #57 had a primary medical condition of a stroke. Other diagnoses documented was aphasia (language disorder), hemiplegia (paralysis), and malnutrition. Further documentation on this MDS revealed that the resident had a Nutritional Approach that included parenteral/IV feedings while not a resident and feeding tube while not a resident and while a resident. The resident had a BIMS score of six indicating that the resident was cognitively impaired. Record review of the current undated care plan for Resident #57 documented the following Problem, (Resident) requires tube feeding related to dysphagia. Date initiated: 5/12/22. Revision on: 5/16/22. Goals listed revealed the following: (Resident) will be free of aspiration through the review date. Date initiated: 5/16/22. Revision on: 5/26/22. Target date: 6/16/23. (Resident) will remain free of side effects or complications related to tube feeding through review date. Date initiated: 5/16/22. Revision on: 5/26/22. Target date: 6/16/23 . Interventions listed included: Bolus of water as ordered for hydration and tube patency. Date initiated: 5/19/22. Revision on: 3/30/23 .Formula feeding as ordered. Date initiated: 5/19/22. Revision on: 12/23/22. Further record review of the current undated care plan for Resident #57 revealed a Problem reflecting, (Resident) is at risk for malnutrition related to alcohol abuse and cirrhosis of the liver. Date initiated: 3/17/22. Revision on: 3/17/22. Interventions included, Formula feeding via peg tube as ordered. Date initiated: 9/26/22. Revision on 12/23/22 On 4/04/23 at 11:13 AM Resident #57 was observed. The resident had a G-tube and the feeding was Glucerna 1.5 cal and it was at a level of 1000 cc. The G-Tube was turned off. The rate reflected on the feeding was 65 ml/hour. It was also labeled that the start time was 700 (7:00 AM), 4/4/23. The flushing/water bag was labeled continuous 350ml rate Q6 hours. The level on the water bag was 1000 mls. The resident was verbal but appeared confused. On 4/4/23 at 1:18 PM an interview was conducted with LVN A charge nurse for hall 200 regarding her residents. She stated the following: Resident #57 had a G-Tube, continuous. Off from 7 AM to 1 PM. The resident also consumed food orally. He had no weight loss and she was unsure if he was confused. On 4/5/23 at 9:12 AM Resident #57 was observed in bed asleep, and the G-tube pump/feeding was off. The flushing syringe for the G-tube was stored in a bag and had been used. The plunger was stored in the barrel. There was a white substance in the tip of the syringe. The resident had Glucerna 1.5 Cal at approximately 550 mls level and the flushing/water bag was at 1000 mL level. The resident's head of bed was elevated. On 4/6/23 at 8:51 AM Resident #57 was observed awake with the head of bed elevated. The resident's G-Tube was on and running. The Glucerna 1.5 cal bottle was labeled On 1pm off at 7 AM. Hung at 5 AM 4/6/23, 65 ml/hour. The flushing/water bag level was at 950ml. It was also observed that the plunger was stored inside the flushing syringe barrel. The syringe was soiled with a white substance. On 4/6/23 at 9:03 AM, while in Resident #57's room, an interview was conducted with the ADON (acting charge nurse for hall 200) regarding why the G-tubes were still running for Resident #53 and #57. He stated he was not sure why and was getting report from the night nurse who had been in charge of the hall, (RN A). On 4/6/23 at 9:06 AM observation of the G-tube pump for Resident #57 revealed it was still on. On 4/6/23 at 9:36 AM Resident #57 was observed, and his flushing syringe had the plunger stored in the barrel and wet with a white substance in the tip. The bag was dated 4/5. The pump was off. On 4/6/23 at 9:10 AM an interview was conducted with RN A who was the charge nurse for hall 200 on the night shift and had stayed into the day shift as charge nurse due to a staff call-in. She stated she did not see or check the G-tubes at 7:00 AM because she was checking on resident safety and oxygen needs. She added that a lot of things were going on at 6:45 AM such as day shift staff coming in that she did not know. She stated she wanted to keep residents safe and peaceful. She stated she should have known to check the G-tubes but was worried about safety and went into triage mode. She added there were two nurses and three CNAs on duty during the night shifts. She further stated she should call the residents' doctors about the G-tube feedings not being administered as ordered and should adjust the feeding two hours back and check the residual. Regarding what could result from a G-tube not being administered according to physician's orders and running too long, she stated she felt safe for Resident #53, who she had checked on, but residents could regurgitate from having too much feeding. Regarding her training/orientation at the facility, she stated she did several trainings, but could not recall which ones. She further stated she had worked in nursing homes for six years and worked at the facility six months. On 4/6/23 at 9:58 AM an interview was conducted with the DON regarding the G-tubes being left running and not according to the physician's order. Regarding why the G-tubes were left on, he state, staff told him RN A was behind on her work. He stated he told RN A to call the doctor and wait for a further response regarding the G-tubes. Regarding any competency checks for the nurses, he stated competency was checked on nurses. He added the facility had nurses go through a checklist and check off their competencies. The DON stated the nurse would identify what they were not competent on, and they were offered training by nurse management. He further stated that new employees received one to two weeks of orientation. Regarding whom was responsible to ensure that staff follow G-tube orders, he stated the nurses bring problems to nurse management, and the problems were addressed by the DON, ADON and sometimes the MDS nurse. He stated residents could experience dehydration and malnutrition if they do not get enough of the feeding as ordered or aspiration if it the G-tube feeding went on too long. Regarding care and storage of the flushing syringes, he stated when finished use, staff should clean it, and store the plunger and barrel separately and dry. He stated bacterial growth could result from storing the plunger and barrel together and dirty. Regarding why he thought the g-tube issues occurred, he stated people overlook things; staff habits. The DON stated nursing management needed to make more rounds and ensure staff were conducting care properly. On 4/6/23 at 1:15 PM an interview was conducted with the DON regarding the competency evaluation for RN A. He stated the old management company had a form about competencies, but RN A was hired after the transition to the new management company. He added RN A would have the current competency/orientation sheet. He further stated he was not sure where her current competency/orientation sheet was for RN A. Record review of the facility's current undated ORIENTATION form for RN/LPN revealed that the Topics/Essential Job Function, included prevention and control of infections, but did not specifically address G-tube care. On 4/6/23 at 12:54 PM an interview was conducted with Administrator regarding G-tube issues. He stated there was a potential for a negative outcome for residents if g-tube feedings were not administered according to physician's orders and flushing syringes were improperly stored. On 4/6/23 at 1:52 PM the DON was interviewed about G-tube in-services. He stated he was hired in October 2022, and had not conducted any in-services regarding G-tubes. Record review of the facility policy, titled Care and Treatment of Feeding Tubes, copyright 2022, revealed the following documentation, Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding, and its caloric value, volume, duration, mechanism of administration, and frequency of flush. 7. Direction for staff on how to provide the following care will be provided. d. Use of infection control precautions, and related techniques to minimize the risk of contamination. f. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders. 10. The facility will notify and involve the physician or designated practitioner of any complications, and in evaluating and managing care to address the complications and risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that two of seven residents (Resident #4 and Resident #58) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #4 continued to have a PRN order for Lorazepam(anti-anxiety) 0.5mg after 14 days without an evaluation by the physician for continued treatment. - Resident #58 continued to have a PRN order for Lorazepam(anti-anxiety) 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. The findings include: Resident #4 Record review of Resident #4's face sheet, dated 04/04/23, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Alzheimer's disease (memory disease), type 2 diabetes mellitus and lack of coordination. Record review of Resident #4's physician orders, dated 04/04/23, revealed an order for Lorazepam 0.5 mg 1 tablet by mouth every 4 hours as needed for increased agitation/anxiety with a start date of 03/07/23 and no end date. Record review of Resident #4's quarterly MDS, dated [DATE], revealed Section N - Medication Section N0410 - Medications Received: B - Antianxiety - Given 0 out of 7 days. Record review of Resident #1's MAR from March 2023 revealed Lorazepam 0.5mg give 1 tablet by mouth every 4 hrs. as needed for anxiety with a start date of 03/07/23. Record review of the pharmacy consultant book from January 2023 to March 2023 revealed no pharmacy recommendations related to Resident #4's PRN Lorazepam. Record review of progress notes for Resident #1 revealed no documentation or rationale for the extended PRN Lorazepam order. Resident #58 Record review of Resident #58's face sheet, dated 3/23/23, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: malignant neoplasm of liver (liver cancer) and traumatic brain injury. Record review of Resident #58's physician orders, dated 04/04/23, revealed an order for Lorazepam 0.5mg 1 tablet by mouth PRN every 4 hours as needed for anxiety with a start date of 03/17/23 and no end date. Record review of Resident #58's quarterly MDS, dated [DATE], revealed Section N - Medication Section N0410 - Medications Received: B - Antianxiety - Given 0 out of 7 days. Record review of Resident #58's MAR from March 2023 revealed Alprazolam 0.5mg 1 tab PO PRN was currently ordered with a start date of 03/17/23 and an indefinite end date. Record review of the pharmacy consultant book from January 2023 to March 2023 revealed no pharmacy recommendations related to Resident #58's PRN Lorazepam. Record review of progress notes for Resident #58 revealed no documentation or rationale for the extended PRN Lorazepam order. Interview on 04/05/23 at 12:18 PM, the DON stated that he was responsible for ensuring PRN antipsychotic medications were not extended beyond 14 days. The DON stated that both residents were on hospice services and the orders were just looked over. The DON stated he was not sure the last time medications were checked for PRN antipsychotic medications. The DON stated the residents had an increased risk for sedation and over-medication due to an extended PRN antipsychotic medication order. Interview on 04/06/23 at 11:26 AM, the ADM stated it was the responsibility of the DON to check on PRN psychotropic medications. The ADM stated he does not know how this failure occurred and believes the orders were overlooked due to the residents being on hospice. The ADM stated that the residents were at risk of over sedation related to the psychotropic PRN medications. Record review of facility policy titled, Psychotropic Medication with a date of 08/15/22 reflected the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to the medication(s). Policy Explanation and Compliance Guidelines: .9. PRN orders for all psychotropic drugs shall be used only when the medication in necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 6 of 22 residents (Residents #3, #30, #31, #35, #57 and #59) reviewed for advanced directives. Resident #3, #30, #31, #35, #57 and #59 were incorrectly filled out or missing required information. Residents #3, #30, #31, #35, #57, and #59 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included : Resident #3 Record review of Resident #3's dated [DATE] face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include covid-19, dementia, type 2 diabetes mellitus and obesity. Record review of Resident #3's physician's order summary dated [DATE] revealed an order ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #3's care plan, dated [DATE], revealed a care plan for DNR. Record review of Resident #3's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Physician's Statement, no date or physician's license number noted on the form. Resident #30 Record review of Resident #30's dated [DATE] face sheet revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include covid-19, peripheral vascular disease (poor blood circulation) and muscle weakness. Record review of Resident #30's physician's order summary dated [DATE] revealed an order ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #30's care plan, dated [DATE], revealed a care plan for DNR. Record review of Resident #30's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Person's full legal name, no signature, date or printed name noted on form. Resident #31 Record review of Resident #31's (dated [DATE]) face sheet revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (disorder of movement) Record review of Resident #31's physician's order summary dated [DATE] revealed an order Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #31's care plan, dated [DATE], revealed care plan for Advance Care Plan: No CPR/DNR. Record review of Resident #31's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Declaration by a legal guardian agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication did not reveal how the named person was related. Furthermore, the Physician Statement and the License # and date were blank. Resident #35 Record review of Resident #35's face sheet dated [DATE] revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include primary oseto arthritis, dementia and hypertensive heart disease. Record review of Resident 35's physician's order summary dated for [DATE] revealed an order ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #39's care plan, dated [DATE], revealed a care plan for DNR started [DATE]. Record review of Resident #35's Out of Hospital Do Not Resuscitate form dated (undated) revealed under the Physician Statement the doctor's printed name, date and the License # was blank. Resident #57 Record review of Resident #57's face sheet dated [DATE] revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include traumatic brain injury, hypertensive heart disease, and cirrhosis of liver. Record review of Resident #57's physician's order summary dated [DATE] revealed an order ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #57's care plan, dated [DATE], revealed a care plan for DNR. Record review of Resident #57's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Person's full legal name, no date of birth and no indication whether the resident is female or male. Under area for legal guardian, agent or proxy, no date or printed name noted on form. Resident #59 Record review of Resident #59's face sheet dated [DATE] revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes. Record review of Resident #59's physician's order summary dated [DATE] revealed no order for DNR. Record review of Resident #59's care plan, dated [DATE], revealed a care plan for DNR that started [DATE]. Record review of Resident #59's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the Physician Statement the doctor's printed name and the License # was blank. During an interview with the Social Worker on [DATE] at 11:01 AM, she said she was responsible for the DNRs. She said the facility process is she would meet with the resident to determine their cognition, complete a social history, and address the advance directive choice. She said if the resident is uncomfortable with the topic, she would use information from the hospital face sheet and the resident's representative. She said a DNR is valid or official when the resident or responsible party has signed it. She said the signature of the doctor makes it valid. She said she had never been questioned on the completion of her DNRs. She said every space applicable needed be completed . She said the potential negative outcome for an incomplete DNR was the nurse staff being first in line and unable to determine if the resident's wish was to be full code or a DNR, which could cause harm to the resident. She said the staff would only be able to provide care or respect the resident's wishes if the DNR was complete d correctly. She said there was no system to review the DNRs outside of her review. She said the medical records staff is responsible for sending the document to the doctor and ensuring that all the doctor's information is there. She said she is responsible for the resident and family portion. She reviewed the following DNRs and reported the following: Resident #35 She said Resident #35's DNR was incomplete because there was no date and no physician license to the doctor . However, she said she did not know why it was incomplete because she gave it to medical records. Resident #31 She said Resident #31's DNR was incomplete because it was missing the doctor's information, and the family member signed in the wrong place. However, she said she was unsure why it was incomplete or incorrect because she was not present during the resident's admission. Resident #59 She said Resident #59 was not correct because the doctor's printed name and license number were missing. She said she was not sure why that was not done. She said her portion was completed. Resident #30 She said Resident #30's DNR was invalid because there was no printed name, and the resident's name was not legible. She said she was not sure why it was done incorrectly . She said the previous Business Office Manager and assistant completed the DNR. She said both of those people no longer worked for the facility. Resident #3 She said Resident #3's is invalid because the doctor's portion has no date or license. However, she said she is not sure why it was not done as it was done before her employment. Resident #57 She said Resident #57's DNR was invalid because the responsible party portion did not have a relationship with the resident. She said she knew the relationship, but all portions should have been completed. She said she was unsure why it was not checked on the form. During an interview with the DON on [DATE] at 11:24 AM he said all staff was responsible for DNRs. He said the DNR process started with Admissions and the Social worker, but ultimately they should all be reviewing the status of the residents. When asked if there is a system to monitor DNRs, he said DNRs were discussed in the daily meetings, but no problems had been identified. The DON said after it is completed, medical records, social services, and the DON and ADON should review it. He said a DNR was complete when the family and doctor had signed the form. He said he expected that all fields on the form be completed, or it may create a discrepancy. He said the potential negative outcome for the resident was their wishes might not be followed. He said he was unaware of a problem with the DNRs, but it was brought to his attention since the surveyors had been in the facility. After reviewing all DNRs, the DON agreed that they were not complete. During an interview with the ADM on [DATE] at 11:50 AM, he said the Social Worker is responsible for completing DNRs. He said the facility process is to ask family and the resident what their advance directive preferences were on admission , and once they are completed, the completed document is uploaded into the system. When asked if there was a system to monitor DNRs, the ADM said they had just completed an audit a week ago and had a few residents with incomplete DNRs; it was his understanding that those had been corrected. He said Medical Records is responsible for audits, which would then be given to the appropriate disciplines to follow up on. When asked what the potential negative outcome was, his response was, We have a potential for a negative outcome. When asked what his expectation for DNRs in his facility, his response was, If there are blanks, then the DNR is not activated. When asked what he meant by the term activated, he clarified and said that it meant that the DNR was not effective or valid. During an interview with Medical Records on [DATE] at 1:31 PM, she said the Social Worker is responsible for the DNRs. She said the process was the Social Worker would complete her portion, then when it would be given to her, and this would be when she would send it to the doctor. She said when it was returned to her, then she would scan it. She said she typically did not review it before she scanned it. She said sometimes she would sign as a witness. She said she believed whoever completes the form is responsible for the form. She said the doctor's signature has to be there for the DNR to be valid. She said if it is not signed, she would send it back and tell the doctor they must sign it. She said if all appropriate areas are not completed, then the form is not valid. She said an incomplete DNR form would mean the resident must be full code against their wishes. She said she was unaware of the issues with incomplete DNRs until the Social worker told her of the issue on the previous date (04/05)23). She said she had not received formal training on completing the form. She said she knew the doctor's signature had to be on the form. She said she could not explain why the DNRs were not complete. Record review of the facility policy, Resident Rights Regarding Treatment and Advance Directives, dated [DATE], revealed the following documentation: Review of the policy did not reveal any information regarding the completion of the OOH-DNR Order. Record Review of the Instructions For Issuing An OOH-DNR Order (undated) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. This Order does NOT affect the provision of other emergency care, including comfort care. APPLICABILITY: This OOH-DNR Order applies to health care professionals in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C. Section D - If the person is incompetent and his/her attending physician has seen evidence of the person's previously issued proper directive to physicians or observed the person competently issue an OOH-DNR Order in a nonwritten manner, the physician may execute the Order on behalf of the person by signing and dating it in Section D. Section E - If the person is a minor (less than [AGE] years of age), who has been diagnosed by a physician as suffering from a terminal or irreversible condition, then the minor's parents, legal guardian, or managing conservator may execute the OOH-DNR Order by signing and dating it in Section E. Section F - If an adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, proxy, or available qualified relative to act on his/her behalf, then the attending physician may execute the OOH-DNR Order by signing and dating it in Section F with concurrence of a second physician (signing it in Section F) who is not involved in the treatment of the person or who is not a representative of the ethics or medical committee of the health care facility in which the person is a patient. In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in Section F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for13 of 22 residents (Residents #4, #12, #19, #20, #28, #30, #31, #33, #42, #45, #47, #56, and #59) reviewed for care plans as follows: Resident #4 did not have a care plan for behavior. Resident #12 did not have a care plan for vision and dehydration. Resident #19 did not have a care plan for communication, falls and dehydration. Resident #20 did not have a care plan for vision, communication and dental care. Resident #28 did not have a care plan for dehydration. Resident #30 did not have a care plan for mood and dental care. Resident #31 did not have a care plan for vision and communication. Resident #33 did not have a care plan for vision and pain. Resident #42 did not have a care plan for dehydration. Resident #45 did not have a care plan for vision, communication, activities of daily living, falls and dehydration. Resident #47 did not have a care plan for vision. Resident #56 did not have a care plan for vision and pain. Resident #59 did not have a care plan for vision. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Resident #4 Record review of Resident #4's dated 04/04/23 face sheet revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's disease (memory problems) essential hypertension (high blood pressure) and peripheral vascular disease (poor blood circulation). Record review of Resident #4's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 0, which indicated the resident's cognition was severely impaired . Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 09. Behavioral Symptoms Section E 1100. Changes in Behavior or Other Symptoms Enter Code: 2 - Worse. Record review of Resident #4's care plan, dated 03/09/23, revealed no care plan for behavior symptoms. Resident #12 Record review of Resident #12's face sheet dated 04/04/23 revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include obstructive pulmonary disease (lung disease) Record review of Resident #12's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely impaired . B1000. Vision 1. Impaired Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual 14. Dehydration Record review of Resident #12's care plan, dated 02/28/23, revealed no care plan for vision and dehydration. Resident #19 Record review of Resident #19's face sheet dated 04/04/23 revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include type 2 diabetes mellitus, paraplegia, generalized anxiety disorder, and muscle weakness. Record review of Resident #19's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was cognitively intact. Section B 0700. Makes Self Understood Enter Code: 1 - Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Section B 0800. Ability To Understand Others Enter Code: 1 - Usually understands - misses some part/intent of message but comprehends most conversation Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 04. Communication 11. Falls 14. Dehydration Section B 0700. Makes Self Understood Enter Code: 1 - Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Section B 0800. Ability To Understand Others Enter Code: 1 - Usually understands - misses some part/intent of message but comprehends most conversation Record review of Resident #19's care plan, dated 02/03/23, revealed no care plan for communication, falls or dehydration. Resident #20 Record review of Resident #20's face sheet dated 04/04/23 revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include type II diabetes and hypertensive heart disease without heart failure. Record review of Resident #20's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 6, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual 04. Communication 15. Dental Care Record review of Resident #20's care plan, dated 03/28/23, revealed no care plan for vision, communication and dental care. Resident #28 Record review of Resident #28's dated 04/04/23 face sheet revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include angina pectoris (chest pain), morbid obesity, anxiety disorder, and essential hypertension (high blood pressure). Record review of Resident #28's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 14. Dehydration Record review of Resident #28's care plan, dated 11/22/22, revealed no care plan for dehydration. Resident #30 Record review of Resident #30's face sheet dated 04/04/23 revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include COVID-19, hemiplegia and hemiparesis following cerebral infarction (disrupted blood flow to the brain) affecting left non-dominate side (left-sided weakness), and peripheral vascular disease (poor blood circulation). Record review of Resident #30's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was cognitively intact. Section D0300 Total Mood Severity Score Enter Score: 04 Section L 0200 Dental. Check all that apply B. No natural teeth or tooth fragments. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 08. Mood 15. Dental Care Record review of Resident #30's care plan, dated 01/23/23, revealed no care plan for mood or dental care. Resident #31 Record review of Resident #31's face sheet dated 04/04/23 revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (movement disorder) Record review of Resident #31's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual 04. Communication Record review of Resident #31's care plan, dated 03/07/23, revealed no care plan for vision and communication. Resident #33 Record review of Resident #33's dated 04/04/23 face sheet revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness), aphasia (language disorder), pressure ulcer of sacral region (wound to buttocks area) and major depressive disorder. Record review of Resident #33's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was cognitively intact. Section B 1000. Vision Enter Code: 2- Moderately Impaired - limited vision; not able to see newspaper headlines but can identify objects Section J 0100. Pain Management A. Enter Code: 1 - Yes, received scheduled pain medication regimen. B. Enter Code: 1 - Yes, received PRN pain medications OR was offered and declined. Section J 0300 Pain Presence Enter Code: 1 - Yes Section J 0400 Pain Frequency Enter Code: 3 - Occasionally Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 19. Pain Record review of Resident #33's care plan, dated 01/24/23, revealed no care plan for vision impairment or pain management. Resident #42 Record review of Resident #42's face sheet dated 04/04/23 revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia. Record review of Resident #42's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 14. dehydration Record review of Resident #42's care plan, dated 01/31/23, revealed no care plan for dehydration. Resident #45 Record review of Resident #45's face sheet dated 04/04/23 revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include pulmonary fibrosis (thickening or scarred tissue in the lungs). Record review of Resident #45's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact. B1000. Vision 1. Impaired Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual 04. Communication 15. Activities of Daily Living 11. Falls 14. Dehydration Record review of Resident #45's care plan, dated 01/03/23, revealed no care plan for vision, communication, activities of daily living, falls and dehydration. Resident #47 Record review of Resident #47's face sheet 04/04/23 revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include type II diabetes. Record review of Resident #47's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired . B1000. Vision 2. Moderately impaired Record review of Resident #47's care plan, dated 01/03/23, revealed no care plan for vision. Resident #56 Record review of Resident #56's dated 04/04/23 face sheet revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (lung disease), generalized anxiety, peripheral vascular disease (poor blood circulation) and pneumonia (lung infection). Record review of Resident #56's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was cognitively intact. Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Section J 0100. Pain Management A. Enter Code: 1 - Yes, received scheduled pain medication regimen. B. Enter Code: 1 - Yes, received PRN pain medications OR was offered and declined. Section J 0300 Pain Presence Enter Code: 1 - Yes Section J 0400 Pain Frequency Enter Code: 2 - Frequently Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 19. Pain Record review of Resident #56's care plan, dated 03/13/23, revealed no care plan for vision impairment or pain management. Resident #59 Record review of Resident #59's face sheet 04/04/23 revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include type II diabetes. Record review of Resident #59's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 5, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual B1000. Vision 2. Moderately Impaired Record review of Resident #59's care plan, dated 02/16/22, revealed no care plan for vision. During an interview with MDS Nurse A on 04/06/23 at 9:09 AM, she said everyone was responsible for the care plans. She said anybody could add to the care plan. She said the IDT discussed resident care plans during the morning meeting. She said anyone could add to the resident's goals, problems, and interventions. She said she had training from nursing schools but not company training. She said they received updates from the company but mostly from nursing school was where she learned about care plans. She said a care plan was a problem or an issue that was going on with the resident. She said it must be addressed through goals and interventions. She said the care plan was implemented to avoid or prevent problems. She said everyone used the care plan to care for the residents. She said if staff had a question about the resident , they should have been able to go to the resident charts. She said new staff could also add interventions if they notice things. She said there was no system she knew of for the review of the care plan. She said she does not believe the care plans were reviewed after completion. She said that it was her understanding that the facility expected the care plan to include active diagnoses, medications that contribute and side effects, and the triggered MDS CAAS from section V. She said the resident care plan was also to include things such as the resident's eating habits and behaviors. She reported the following regarding the missing care plans for each resident: Resident #42 She said regarding Resident #42 that she completed the care plan. After reviewing the care plan dated 01/31/23, she confirmed dehydration was not care planned. She said she did not have a reason why she did not complete the care plan for dehydration but that the potential negative outcome for dehydration was the resident could get a urinary tract infection. Resident #12 She said that she completed the care plan and confirmed after looking at the care plan that the resident did not have a care plan for vision and dehydration. She said she did not have a reason for missing it. She said the potential negative outcome for dehydration could be infection, UTI, and regards to vision the resident could be at risk for falls. She said she iwas not sure why it was not care planned. She said a negative outcome could be a UTI for the resident. Regarding vision, she said he has a diagnosis of diabetes, he can develop glaucoma and poor vision as a part of the diagnosis. She said without a care plan staff might not know how to address the resident regarding this issue of vision and dehydration. Resident #47 She said that she was the one who completed the care plan for Resident #47. After reviewing the care plan, she confirmed the resident did not have a care plan for vision. She said vision triggered because of his diagnosis of diabetes, but he did not have a diagnosis related to vision. She said she only typically care planned if there is an actual diagnosis with treatment by the nurse. She confirmed that according to the facility policy, that vision should have been addressed in the care plan. She did not have a reason why it was not done. She said Resident #47 was at risk for poor vision and the lack of a care plan staff may not know how to respond appropriately. Resident #45 She confirmed the care plans for vision, communication, activities of daily living, falls, and dehydration was not included , and she was the nurse that completed the care plan. She does not have a reason as to why they were not done. She said the resident was very independent, so she said she did not care plan the ADLS, but he triggered in the MDS assessment because of the need for set-up assistance. She said the triggered items should have been care planned. Resident #31 She stated she completed the care plan. She confirmed that the care plan was not there for vision, but she did not care plan it because he did not have a diagnosis of vision that needed treatment. She said it triggered because the MDS assessment reflected his impaired vision. Resident #59 She confirmed after looking at the care plan there was no care plan for vision. She said Resident #59 does not have a dx nor treatment for impaired vision. She stated according to the policy, it should have been care planned. She said the resident could potentially fall and that Resident #59 is susceptible to fractures. Resident #20 She said she completed and reviewed the care plan for Resident #20 She confirmed the resident did not have a care plan for vision, communication, or dental care . She said she did not care plan vision because the resident did not have a vision dx that required treatment, but according to the facility policy, it should have been care planned. She said she did not have a reason why the other triggered areas were not care planned. She said no dental care plan could result in weight loss or infection for the resident. Resident #56 She stated she was the person that completed and reviewed the care plan and that vision and pain were not care planned. She said the potential negative outcome for vision is falls and injury or decline in ADL because of the pain for the resident. Resident #30 She confirmed that mood and dental care were not care planned. She did not have a reason why the areas were not care planned. She said that she missed them. She said the potential negative outcomes could be infection and unmet needs for the resident. Resident #28 She confirmed that dehydration was not care planned and the potential negative outcome could be a UTI for the resident. She said she did not have a reason why the care plan was not completed for the resident. Resident #19 She confirmed the resident did not have a care plan for falls and dehydration. She said the potential negative outcome was increased falls. She said the resident had paraplegia and required a mechanical lift with two staff. She said not addressing the triggered dehydration put the resident at risk for a UTI. She said no care plan for communication could lead to the resident's needs not being met because staff may not know how to communicate with the resident. Resident #33 She confirmed there was no care plan for pain. She did not have a reason for not having a care plan, but the resident did not have a diagnosis that required treatment. She said not addressing the triggered pain could cause the resident to decline in activities of daily living because of pain. Resident #4 She confirmed she did not see a care plan for behavior. She said the resident would refuse to eat. She said the staff might not know how to meet her needs and address or communicate with her without the care plan. During an interview with MDS Nurse B on 04/06/23 at 9:30 AM, she said the process had recently changed. She said in the past, she and MDS Nurse A had separate duties regarding assessments and the care plan, but with the change of the new company, they were assigned essentially by halls. She said she had received most of the training from nursing school in general but not specific company training. She said a care plan was the ideal situation that residents had for staff to treat the resident better and to be able to care for them. She said everyone uses the care plan. She said there was no system she knew of to monitor the care plan outside of her and the MDS Nurse completing them. She said she believed the facility expectation was to include active diagnoses, medications that contribute and side effects, and the triggered MDS CAAS from section V. She said eating habits and behaviors would have also been included. In regards to the incomplete care plans, she reported the following: Resident #42 She said that she was the person that completed the care plan for Resident #42. She said the resident did trigger for dehydration, according to the comprehensive care plan dated 05/02/22. She said that she should have been care planned. She said the resident is at risk for UTI without the dehydration care plan. Resident #12 She confirmed after looking at the comprehensive MDS dated [DATE] that the resident was triggered for cognitive loss, vision, and dehydration. She said she would have completed the comprehensive assessment. Resident #47 She confirmed she was the person who completed the MDS assessment dated [DATE] and stated the resident did trigger for vision. She said that should have been care planned. Resident #45 She said she was the person who completed the comprehensive MDS assessment dated [DATE] and confirmed he triggered for vision, communication, ADLs, falls, and dehydration. In general, she said the negative outcome for not care planning these items could be increased falls and UTIs. Resident #31 She said she was the person who completed the MDS assessment dated [DATE] and confirmed he triggered for vision. She said the resident could not see small print, and without staff knowing that, staff may not know that information and provide him with the material he could not see. Resident #59 She completed the comprehensive MDS assessment dated [DATE] and confirmed that he triggered for vision. Resident #20 She confirmed the resident triggered for vision, communication, and dental care after reviewing the comprehensive MDS Assessment that she completed on 12/13/22. She said the lack of communication could result in him being unable to voice his needs and needs not being met. Resident #56 She confirmed she completed the comprehensive MDS Assessment on 12/13/22, and he triggered for vision and pain. She said lack of care planning those items could result in injury and discomfort for the resident. Resident #30 She said she completed the comprehensive MDS assessment dated [DATE] and that the resident had triggered for mood and dental care. She said failure to care plan those items would have had a potential negative outcome of his needs not being met for dental, and there was a possibility for infections. Resident #28 She said she completed the comprehensive MDS dated [DATE]. She confirmed the resident triggered for dehydration. She said the lack of care planning could result in UTIs for the resident. Resident #19 She said she completed the comprehensive MDS assessment dated [DATE] and confirmed the resident triggered for communication, falls, and dehydration. She said the potential negative outcome for communication would be the staff's inability to meet the resident's needs. In addition, she said the resident could have increased falls and is at risk for UTIs. Resident #33 She said she completed the comprehensive MDS assessment dated [DATE] and confirmed the resident triggered for vision and pain. She said the resident's potential negative outcome would be injuries, falls, and increased pain. Resident #4 She said that she completed the comprehensive MDS assessment dated [DATE] and confirmed the resident triggered for behavior. She said the resident would refuse to eat. She said without a care plan, staff would not know how to meet her needs and address or communicate with her. During an interview with the DON on 04/06/23 at 11:24 AM, he said both MDS nurses, ADON, and DON were responsible for care plans. He said he had been trained regarding care plans, but it has been about four years and mostly on the job training. He stated he had not had any formal training regarding care plans. He said a care plan was a plan of care for a resident stay. He said everybody used the care plan, which was how the staff guided themselves when caring for the resident. He said it was what they would do for the resident during their stay at the facility. When asked if there was a system to monitor the completion of care plans, he said they have daily meetings and go over new admissions, readmits, and change of conditions. He said those residents are the focus. He said they try to review as many care plans as they could but their meeting in the mornings was only an hour long. He said they track and continue the process each morning and they are able to work on the ones they had not seen during the previous meetings. He said he expected the care plan to include the resident's activities of daily living, any difficulties they may have, assistance, or information the resident needs during meals, medications, and wounds, if applicable. He said he is unfamiliar with the CAAs generated from the MDS assessment, but that is where MDS nurses would address that portion. He said he was unaware that some residents were missing care plans. He said the only reason areas would not be care planned would be because it was not brought to the attention of the nursing staff. He said a potential negative outcome for care areas not being care planned would be a decline in status in the area not care planned. He said the resident could end up in the hospital with other issues. During an interview with the ADM on 04/06/23 at 11:50 AM, he said the nurses are responsible for care plans for the residents in the facility. He said he had care management people that updated care plans. He said the care management people are the MDS nurses in the facility. He said he knew what a care plan was, but as an ADM, he had limited practice with them. He said he had some care plan training in the past. He said a care plan was a plan that helped them take care of the resident while the resident was at the facility. He said the IDT and nurse aides used the care plan. He said the nurses also use the care plan. When asked if there is a system to monitor care plans after the MDS workers completed them, he said care plans are reviewed in the morning meetings and he was unaware of any issues before the surveyors entrance. He said his expectation was for the care plan to support the resident being taken of. He said he had looked at his care policy but that clinical was more familiar and that the question of the expectation was more of a clinical question. He said he is responsible for all activity in the facility as the administrator. When asked what the potential negative outcome of not care planning triggered care areas from the comprehensive MDS assessment was, his response was, If they are not care planning something that is triggered, the resident could have a negative outcome. That is my answer. Record review of the facility policy Care Plans, Comprehensive Care Plans, implemented 10/24/22, revealed the following documentation: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, in that: One of one medication rooms was unlocked and unattended on four different occasions. LVN A left medications on storage cart unlocked and unattended in the hallway. These failures could result in the theft or misuse of medications. The findings include: 4/4/23 at 8:39 AM an observation was made of the hall 300 medication room entrance door. The door was ajar unlocked, and the room was unattended. 4/4/23 at 12:24 PM, an observation was made of the hall 300 medication room unlocked and unattended. 4/4/23 at 1:59 PM an observation was made of the hall 300 medication room, and the door was a jar, unlocked, and the room was unattended. 4/4/23 at 2:07 PM an observation was made of the hall 300 medication room, and the door was still ajar and the room was unattended. During an observation of medication pass on 4/5/23, LVN A left medications on top of the cart unlocked and unattended while she administered medications in the resident's room. Interview on 4/5/23 at 12:22 PM, LVN A stated she should not have left medications on the cart unlocked and unattended. LVN A stated one of the resident's could have taken the medications. LVN A stated she has been trained to keep the medications locked in the cart but doesn't remember the last time she was trained. Interview on 4/6/23 at 10:15 AM, the DON stated that the medication room should be locked at all times and the medications should never be left on the medication cart unlocked and unattended. The DON stated the medications being accessible is a risk for misplaced or mishandled medications. Record review of the facility policy titled, Medication Administration, with a revised date of 10/01/19 reflected the following: Procedure: 2. The medication cart is locked at all times when not in use. 3. Do not leave the medication cart unlocked or unattended in the resident care areas

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 3 of 3 meals. 1) The facility failed to provide food that was palatable for 3 of 3 meal observed (4/04/23, lunch and dinner) and 4/05/23, lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings include: During the Resident Council Meeting on 4/05/23 at 10:00 AM, residents were confidentially interviewed about food palatability. Two of 6 residents voiced concerns about the temperature and flavor of the food served. One resident stated the food was always cold. The resident further stated he ate in his room and the tortillas were not cooked well and were soggy. Another resident stated the food was always cold; all meals were cold. - The following observations were made, and interviews conducted during a kitchen tour on 4/4/23 that began at 11:50 AM and concluded at 12:58 PM: On 4/4/23 at 12:18 PM temperatures were taken on the service line by Dietary Staff B. Purée meat/Carne Guisada was 135°F and had a coarse/grainy appearance Puréed potato tots were 124°F and had a coarse/ grainy appearance Puréed mixed vegetables were 140°Fand had a coarse/ grainy appearance On 4/4/23 at 12:50 PM puréed foods were sampled. The results of the test were as follows: The puréed potato tots were coarse and chunky. The puréed, mixed vegetables were grainy, coarse, and had bits of whole vegetable. The puréed Carne Guisada/ground beef was grainy, coarse and had bits of gristle. On 4/4/23 at 12:52 PM an interview was conducted with Dietary Staff B regarding training she received related to puréed foods. She stated she was told it should be like pudding and a spoon should stand up in it. On 4/4/23 at 1:08 PM an observation was made in the dining room. Three residents received puréed foods and were being fed by staff. Residents #18, #11, and #43 were seated at the same table and served a purée diet. They received pureed bread, pureed mix vegetables, puréed meat/carne guisada and puréed potato tots. On all three trays the puréed vegetables were visibly coarse with strings and grainy. The purée meat was coarse and grainy. The purée tots were visibly coarse. Record review of the Order Summary Report dated 4/5/23 for female Resident #43 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as muscle wasting, not elsewhere classified, unspecified, Alzheimer's disease (dementia disorder), unspecified and dysphasia, unspecified (swallowing disorder) and unspecified proteins - calorie malnutrition (lack of proper nutrition). Further record review of the orders revealed that the resident had an order of, Regular diet, puréed texture, regular liquids consistency for diet. Order date 6/10/20. Start date 6/10/20. Record review of the Order Summary Report for female Resident #11, dated 4/5/23, revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of: chronic kidney disease, stage three unspecified, unspecified, Alzheimer's disease, unspecified (dementia disorder), abnormal weight loss, and primary open angle, glaucoma, left eye, moderate stage (vision disorder). Further record review of the Order Summary Report revealed a diet order of, Regular diet, puréed texture, regular liquid consistency, prune juice with meals, encourage fluid intake. Order date, 9/20/22. Start date 9/20/22. An additional order documented, SPEECH THERAPY: 92610 Dysphagia Evaluation and Treat. Prescriber Written Active 11/03/2021. Order Date 11/03/21 Record review of the Order Summary Report for female Resident #18 dated 4/5/23 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of bipolar disorder, unspecified (mental disorder), Type 2 diabetes mellitus without complications (blood sugar disorder), mild proteins - calorie malnutrition (lack of proper nutrition), Alzheimer's disease (dementia), unspecified. Further record review of the Order Summary Report revealed the resident had a diet order of NAS (no added salt) diet puréed texture, regular liquid consistency, lactose free. Order date 10/2/22. Start date 10/2/22. On 4/6/23 at 12:23 PM an interview was conducted with the DON regarding the reason Resident #18 was on a purée diet. He stated the resident rolled food in her mouth with any other texture of food, other than puree. - The following observations were made during a kitchen tour on 4/04/23 that began at 3:43 PM and concluded at 5:33 PM: On 4/4/23 at 5:02 PM temperatures were taken on the service line by Dietary Staff C. Puréed, macaroni cheese and ham dish was 110°F and ham bits were visible On 4/4/23 at 5:26 PM the surveyor requested to sample the puréed foods of the puréed macaroni cheese and ham dish. The puréed macaroni cheese and ham dish had whole pieces of diced ham and was coarse in texture. The purée was shown to the Visiting Dietary Manager. On 4/4/23 at 5:41 PM an observation was made of the dining room and the same three residents, Residents #11, #18 and #43 were seated together and fed by staff. All three received a puréed diet which included puree carrots, puree bread and purée macaroni cheese and ham dish. Observation of the pureed macaroni cheese and ham dish revealed that bits of ham were visible. - The following observations were made, and interviews conducted during a kitchen tour on 4/05/23 that began at 11:35 AM and concluded at 1:22 PM: On 4/05/23 at 11:35 AM the Dietary Manager was informed that a test tray would be requested from dining room service and corridor service. On 4/05/23 at 12:12 PM observations were made of foods on the steam table and of Dietary Staff B taking temperatures with the following results: The puréed chicken was 163°F. The mashed potatoes was 140.4°F. The puréed green beans was 157°F. There were bits of a brown substance observed in the food and it appeared coarse. The mechanically altered chicken was 159.5°F. The green beans were 180°F The regular tarragon chicken was 175°F. The diced potatoes were 150°F. The mashed potatoes were192°F. The baked Fish was 132°F and then was later reheated. No temperature was taken. The brown gravy was 153°F. The puréed bread on the counter at the service line at room temperature and not on any source of heating or cooling. No temperature was taken. Observation on 4/5/23 at 12:40 PM the meal tray for Resident #37 was observed being prepared. She received puréed chicken, mashed potatoes with gravy, purée bread, and puréed green beans. The pureed green beans had visible hulls/bits and skins. Record review of the Order Summary Report for female Resident #37, dated 4/5/23, revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of functional quadriplegia (paralysis), dysphasia (swallowing disorder), following other cerebrovascular disease (heart disease), and Alzheimer's disease (dementia), unspecified. Further record review of the Order Summary Report revealed a diet order of, NAS (no added salt) diet, purée texture, regular liquid consistency. Order date 10/21/22. Start date 10/21/22. Observation on 4/5/23 at 12:56 PM the meal tray for Resident #49 was observed being prepared. She received puréed chicken, mashed potatoes with gravy, purée bread, and puréed green beans. The pureed green beans had visible hulls/bits and skins. Record review of the Order Summary Report for male Resident #49 dated 4/5/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of epilepsy, unspecified, not intractable, without status epilepticus (convulsions), dehydration (reduced hydration), dysphasia, following cerebral infarction (swallowing disorder), and muscle wasting and atrophy. Further record review of the Order Summary Report revealed a diet order of, Regular diet, puréed texture, regular liquids consistency. Order date 2/3/23. Start date 2/3/23. The last dining room tray was served at 12:55 PM. The test tray preparation began at 12:55 PM. The test tray prep was completed at 12:59 PM and left the kitchen at this time. - On 4/05/23 at 1:02 PM, surveyors tested the test trays with the following results: The mashed potatoes were 116°F, lukewarm and bland. The puréed chicken was 120°F, lukewarm and coarse. The puréed beans were 120°F, had a tart flavor and had hulls/skins. The diced potatoes were lukewarm and 98°F. The green beans were bland, cold, and 111.2°F. The fish was 104°F, tough, salty/spicy and cold. The roll was burned and hard. Testing ended at 1:10 PM. Observation of the Hall 100 tray prep revealed it began at 1:13 PM. The last tray for hall 100 was prepared at 1:18 PM. The test tray prep for hall 100 began at 1:19 PM and the hall 100 cart left the dining room at 1:22 PM. The cart arrived on the unit at 1:23 PM. The last tray was served on hall 100 at 1:29 PM. One staff member was serving trays on the hall. - On 4/05/23 at 1:31 PM, surveyors tested the test trays with the following results: The fish was 100°F, cool and tough. The roll was hard and burned. The puréed chicken was 128°F, warm but coarse. It needed to be chewed. The mashed potatoes were 111°F, lukewarm and bland. The green beans were 110°F, bland and lukewarm. The diced potatoes were 113°F and bland The puréed green beans were 116°F, coarse with hulls, skins, and strings The mechanical altered chicken was cool, bland and 104.7°F. The testing ended at 1:39 PM. On 4/4/23 at 9:46 AM an interview was conducted with Dietary staff B. Regarding training, she stated that she had worked in the facility three weeks. She added she shadowed another cook for three or four days and then slowly she was allowed to work by herself. On 4/5/23 at 2:24 PM an interview was conducted with Dietary staff B regarding observations in the kitchen. Regarding food palatability and purées for all three meals, she stated she thought the tater tot skins were a problem and she should have use mashed potatoes. She added the vegetables were hard to purée, and one vegetable dish contained broccoli. She further stated beef was hard to purée. She stated residents who consumed improperly pureed foods could choke on it. She added that staff watched for chunks in the food. On 4/5/23 at 4:49 PM an interview was conducted with a Dietary staff C regarding issues in the kitchen. She stated she started working as a cook approximately two weeks ago, and she worked as a dishwasher since November 2022. Regarding puréed food and food palatability, she stated staff were trained that puréed food should not be too soggy or watery. Dietary staff C stated a spoon should stand up in it and it should be pudding consistency. Regarding the pureed foods served, she stated it was possible staff did not puree the food long enough, or it might be a problem with the processor blades. She stated residents who consumed improperly pureed foods could choke. On 4/6/23 at 11:00 AM an interview was conducted with a Dietary Manager regarding issues found in the dietary department. Regarding food palatability and puree preparation, she stated the processor may have been a faulty blade. She added staff puréed long and some vegetables were not good to purée. Regarding training related to pureeing, she stated she had not given any formal training for puréed foods. The Dietary Manager stated staff did not sign an in-service form and it was a verbal training only. She stated she instructs staff that pureed foods should be like baby food; smooth, not dry, not too wet. She added if a spatula is used, it should stand in the food. She stated she and the cook were responsible to ensure that purées were produced correctly. She further stated residents could choke as a result of improperly pureed foods. Regarding food palatability related to the test trays, she stated maybe the facility needed a warmer, but there was no space for a warmer. She added that staff serve as fast as they can. She further stated she tells staff to season the food. She added that when she cooks vegetables seasonings were used. She stated she was responsible to ensure that the food was palatable. She added that residents would not eat the food and could get angry if foods were not palatable. Regarding resident communication related to palatability of the foods, she stated if residents were happy the resident care aides tell the dietary staff. She stated she had attended three or four resident council meetings since being hired. On 4/6/23 at 12:54 PM an interview was conducted with Administrator regarding dietary department issues. Regarding food palatability and puree issues in the dietary department, he stated residents may not eat foods that were not palatable. He added that he sampled the food in the facility. Record review of the facility's guidelines, titled National Dysphasia Diet Level 1: Purée, dated July 14, 2021, revealed the following documentation, The Level 1: Purée diet follows the regular diet menu items whenever possible with the modification of puréeing the food item. Foods are modified to a consistency that is pudding like. Considerations for specific food items. Fried potatoes and potatoes with peels - the potato peel is restricted and smooth mashed or puréed potatoes without any lumps are served as the substitute. Food Groups. Proteins Foods. Avoid. Tough, dry, whole, or ground, red meat, (beef, pork, lamb). Tough, dry, whole or ground poultry, (chicken and turkey). Record review of the facility policy, titled, Policy: Menu Planning, Policy Number: 01.002, Date revised: June 1, 2019, revealed the following documentation, Policy: the facility believes that nutrition is an important part of maintaining the well-being and health of its residents, and is committed to providing a menu that is well-balanced, nutritious and meets the preferences of the resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs, for 3 of 3 meals observed for 5 of 5 residents with orders for pureed diets (Residents #11, 18, 37, 43 and 49); in that: 1) The facility failed to provide food that was in a form to meet resident needs during 3 of 3 meal observed (4/04/23, lunch and dinner) and 4/05/23, lunch) for 5 of 5 residents with orders for pureed diets (Residents #11, 18, 37, 43 and 49). These failures could place residents at risk of decreased food intake and choking. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 4/4/23 that began at 11:50 AM and concluded at 12:58 PM: On 4/4/23 at 12:18 PM temperatures were taken on the service line by Dietary Staff B. Purée meat/Carne Guisada was 135°F and had a coarse/grainy appearance Puréed potato tots were 124°F and had a coarse/ grainy appearance Puréed mixed vegetables were 140°Fand had a coarse/ grainy appearance On 4/4/23 at 12:50 PM puréed foods were sampled. The results of the test were as follows: The puréed potato tots were coarse and chunky. The puréed, mixed vegetables were grainy, coarse, and had bits of whole vegetable. The puréed Carne Guisada/ground beef was grainy, coarse and had bits of gristle. On 4/4/23 at 12:52 PM an interview was conducted with Dietary Staff B regarding training she received related to puréed foods. She stated she was told it should be like pudding and a spoon should stand up in it. On 4/4/23 at 1:08 PM an observation was made in the dining room. Three residents received puréed foods and were being fed by staff. Residents #18, #11, and #43 were seated at the same table and served a purée diet. They received pureed bread, pureed mix vegetables, puréed meat/carne guisada and puréed potato tots. On all three trays the puréed vegetables were visibly coarse with strings and grainy. The purée meat was coarse and grainy. The purée tots were visibly coarse. Record review of the Order Summary Report dated 4/5/23 for female Resident #43 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as muscle wasting, not elsewhere classified, unspecified, Alzheimer's disease (dementia disorder), unspecified and dysphasia, unspecified (swallowing disorder) and unspecified proteins - calorie malnutrition (lack of proper nutrition). Further record review of the orders revealed that the resident had an order of, Regular diet, puréed texture, regular liquids consistency for diet. Order date 6/10/20. Start date 6/10/20. Record review of the Order Summary Report for female Resident #11, dated 4/5/23, revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of: chronic kidney disease, stage three unspecified, unspecified, Alzheimer's disease, unspecified (dementia disorder), abnormal weight loss, and primary open angle, glaucoma, left eye, moderate stage (vision disorder). Further record review of the Order Summary Report revealed a diet order of, Regular diet, puréed texture, regular liquid consistency, prune juice with meals, encourage fluid intake. Order date, 9/20/22. Start date 9/20/22. An additional order documented, SPEECH THERAPY: 92610 Dysphagia Evaluation and Treat. Prescriber Written Active 11/03/2021. Order Date 11/03/21 Record review of the Order Summary Report for female Resident #18 dated 4/5/23 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of bipolar disorder, unspecified (mental disorder), Type 2 diabetes mellitus without complications (blood sugar disorder), mild proteins - calorie malnutrition (lack of proper nutrition), Alzheimer's disease (dementia), unspecified. Further record review of the Order Summary Report revealed the resident had a diet order of NAS (no added salt) diet puréed texture, regular liquid consistency, lactose free. Order date 10/2/22. Start date 10/2/22. On 4/6/23 at 12:23 PM an interview was conducted with the DON regarding the reason Resident #18 was on a purée diet. He stated the resident rolled food in her mouth with any other texture of food, other than puree. - The following observations were made during a kitchen tour on 4/04/23 that began at 3:43 PM and concluded at 5:33 PM: On 4/4/23 at 5:02 PM temperatures were taken on the service line by Dietary Staff C. Puréed, macaroni cheese and ham dish was 110°F and ham bits were visible On 4/4/23 at 5:26 PM the surveyor requested to sample the puréed foods of the puréed macaroni cheese and ham dish. The puréed macaroni cheese and ham dish had whole pieces of diced ham and was coarse in texture. The purée was shown to the Visiting Dietary Manager. On 4/4/23 at 5:41 PM an observation was made of the dining room and the same three residents, Residents #11, #18 and #43 were seated together and fed by staff. All three received a puréed diet which included puree carrots, puree bread and purée macaroni cheese and ham dish. Observation of the pureed macaroni cheese and ham dish revealed that bits of ham were visible. - The following observations were made, and interviews conducted during a kitchen tour on 4/05/23 that began at 11:35 AM and concluded at 1:22 PM: On 4/05/23 at 11:35 AM the Dietary Manager was informed that a test tray would be requested from dining room service and corridor service. On 4/05/23 at 12:12 PM observations were made of foods on the steam table and of Dietary Staff B taking temperatures with the following results: The puréed chicken was 163°F. The mashed potatoes was 140.4°F. The puréed green beans was 157°F. There were bits of a brown substance observed in the food and it appeared coarse. Observation on 4/5/23 at 12:40 PM the meal tray for Resident #37 was observed being prepared. She received puréed chicken, mashed potatoes with gravy, purée bread, and puréed green beans. The pureed green beans had visible hulls/bits and skins. Record review of the Order Summary Report for female Resident #37, dated 4/5/23, revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of functional quadriplegia (paralysis), dysphasia (swallowing disorder), following other cerebrovascular disease (heart disease), and Alzheimer's disease (dementia), unspecified. Further record review of the Order Summary Report revealed a diet order of, NAS (no added salt) diet, purée texture, regular liquid consistency. Order date 10/21/22. Start date 10/21/22. Observation on 4/5/23 at 12:56 PM the meal tray for Resident #49 was observed being prepared. She received puréed chicken, mashed potatoes with gravy, purée bread, and puréed green beans. The pureed green beans had visible hulls/bits and skins. Record review of the Order Summary Report for male Resident #49 dated 4/5/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of epilepsy, unspecified, not intractable, without status epilepticus (convulsions), dehydration (reduced hydration), dysphasia, following cerebral infarction (swallowing disorder), and muscle wasting and atrophy. Further record review of the Order Summary Report revealed a diet order of, Regular diet, puréed texture, regular liquids consistency. Order date 2/3/23. Start date 2/3/23. The last dining room tray was served at 12:55 PM. The test tray preparation began at 12:55 PM. The test tray prep was completed at 12:59 PM and left the kitchen at this time. - On 4/05/23 at 1:02 PM, surveyors tested the test trays with the following results: The puréed chicken was 120°F, coarse and needed to be chewed. The puréed beans were 120°F, had hulls/skins. Testing ended at 1:10 PM. Observation of the Hall 100 tray prep revealed it began at 1:13 PM. The last tray for hall 100 was prepared at 1:18 PM. The test tray prep for hall 100 began at 1:19 PM and the hall 100 cart left the dining room at 1:22 PM. The cart arrived on the unit at 1:23 PM. The last tray was served on hall 100 at 1:29 PM. One staff member was serving trays on the hall. - On 4/05/23 at 1:31 PM, surveyors tested the test trays with the following results: The puréed chicken was 128°F, coarse. It needed to be chewed. The puréed green beans were 116°F, coarse with hulls, skins, and strings The testing ended at 1:39 PM. On 4/4/23 at 9:46 AM an interview was conducted with Dietary staff B. Regarding training, she stated that she had worked in the facility three weeks. She added she shadowed another cook for three or four days and then slowly she was allowed to work by herself. On 4/5/23 at 2:24 PM an interview was conducted with Dietary staff B regarding observations in the kitchen. Regarding food purées for all three meals, she stated she thought the tater tot skins were a problem and she should have use mashed potatoes. She added the vegetables were hard to purée, and one vegetable dish contained broccoli. She further stated beef was hard to purée. She stated residents who consumed improperly pureed foods could choke on it. She added that staff watched for chunks in the food. On 4/5/23 at 4:49 PM an interview was conducted with a Dietary staff C regarding issues in the kitchen. She stated she started working as a cook approximately two weeks ago, and she worked as a dishwasher since November 2022. Regarding puréed food, she stated staff were trained that puréed food should not be too soggy or watery. Dietary staff C stated a spoon should stand up in it and it should be pudding consistency. Regarding the pureed foods served, she stated it was possible staff did not puree the food long enough, or it might be a problem with the processor blades. She stated residents who consumed improperly pureed foods could choke. On 4/6/23 at 11:00 AM an interview was conducted with a Dietary Manager regarding issues found in the dietary department. Regarding puree preparation, she stated the processor may have been a faulty blade. She added staff puréed long and some vegetables were not good to purée. Regarding training related to pureeing, she stated she had not given any formal training for puréed foods. The Dietary Manager stated staff did not sign an in-service form and it was a verbal training only. She stated she instructs staff that pureed foods should be like baby food; smooth, not dry, not too wet. She added if a spatula is used, it should stand in the food. She stated she and the cook were responsible to ensure that purées were produced correctly. She further stated residents could choke as a result of improperly pureed foods. She stated she was responsible to ensure that the food was palatable and in the correct form. She added that residents would not eat the food and could get angry if foods were not palatable. On 4/6/23 at 12:54 PM an interview was conducted with Administrator regarding dietary department issues. Regarding food palatability and puree issues in the dietary department, he stated residents may not eat foods that were not palatable. He added that he sampled the food in the facility. Record review of the facility's guidelines, titled National Dysphasia Diet Level 1: Purée, dated July 14, 2021, revealed the following documentation, The Level 1: Purée diet follows the regular diet menu items whenever possible with the modification of puréeing the food item. Foods are modified to a consistency that is pudding like. Considerations for specific food items. Fried potatoes and potatoes with peels - the potato peel is restricted and smooth mashed or puréed potatoes without any lumps are served as the substitute. Food Groups. Proteins Foods. Avoid. Tough, dry, whole, or ground, red meat, (beef, pork, lamb). Tough, dry, whole or ground poultry, (chicken and turkey).

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 5 of 5 staff (Dietary staff A, B, C, D and E) and 1 of 1 kitchen, in that: 1) Dietary staff failed to store, serve or process foods in a manner to prevent contamination, 2) Dietary staff failed to handle food contact equipment in a manner to prevent contamination, 3) Dietary staff failed to ensure food contact surfaces were clean, 4) Dietary staff failed to perform sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 5) Dietary staff failed to use good hygienic practices, including incorrect handwashing techniques, 6) TCS/PHF foods were not maintained at 41 degrees F and below or 135 degrees F or above 7) The dial probe thermometers were not accurate 8) Wiping cloth quaternary sanitizer solutions were not at required levels and was not tested correctly 9) Food contact equipment storage areas were not maintained in a clean and sanitary manner 10) Dietary staff restroom did not have a functioning hand sink 11) Staff failed to effectively prevent the entry of pests/flies in the kitchen 12) Foods were spoiled and past their recommended expiration/use dates 13) Food preparation area nonfood contact surfaces were not clean, and 14) Foods were not thawed in a safe manner. These failures could place residents at risk for food contamination and foodborne illness. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 4/4/23 that began at 9:25 AM and concluded at 10:45 AM: Dietary staff B was observed washing her hands in the two-compartment sink. Dietary staff A was observed touching the trashcan lid and then handling clean trays. There was one of two sets of lights that were unshielded in the dishwasher area. The dishwashing area refrigerator had an opened zip top bag of three bean salad and an opened zip top bag of mixed vegetables. Both opened to air. The oven area walls were dirty with a heavy accumulation of dried spills and the kitchen return air vents had a buildup of grease. Observation and interview on 4/04/23 at 9:40 AM there were 2 wiping cloth buckets observed near the kitchen 2 compartment sink, one was green, and one was red. There were cloths in both. Dietary staff B took a chlorine test strip and tested the liquid in the red bucket. The results was 0 ppm. Regarding the contents of the red bucket, she stated at this time she did not know what solution was in it, and that other staff set up the buckets for them. Observation of the lower wooden kitchen cabinetry revealed that the shelving was scarred and had peeling paint. The doors and exterior of the cabinetry had a buildup of encrusted dried food and dirt. On 4/4/23 at 9:46 AM an interview was conducted with Dietary staff B. She stated she had worked at the facility three weeks and shadowed another cook for three or four days. Dietary staff B stated staff slowly allowed her to work alone. The hand sink in the kitchen employee's restroom was lying on the floor. On 4/4/23 at 9:49 AM an interview was conducted with Dietary staff A regarding the broken restroom hand sink. She stated, the hand sink fell off the wall on Sunday (4/02/23). She further stated they would have to wait until the Maintenance Supervisor came back to get it repaired. She added the Maintenance Supervisor would be off duty this week. Dietary staff A was observed handling soiled dishes, then washed her hands in the dishwasher area two compartment sink at the same time Dietary staff B was washing a colander in the same two compartment sink. Dietary staff B then washed her hands in the two-compartment sink in the dishwasher area which had dirty pans in it. After washing her hands, she disposed of the paper towel on top of a large trashcan. There was a large tube of frozen hamburger in a pan on a counter at the kitchen two compartment sink. There was a small amount of water in the pan, but the hamburger was not submerged in the standing water. The lower shelf of the stove area prep table was heavily soiled with grease buildup. The kitchen's three door refrigerator had a half a block of margarine that was uncovered exposed to air. There was also a zip top bag of small peppers that had six of the peppers that were molded and black. The zip top bag was labeled 1/11/23. There was also a 32-ounce container of Dannon yogurt that was labeled by the facility Use by 3/6/23. The manufacturer's label on the yogurt reflected, Best if used by December 26, 2022. Observation of the metal cabinetry drawers and bins revealed the scoop and ladle storage drawers were lined with heavily soiled paper. There were dried spills and scarring on the exterior of the drawers and bins of the cabinetry. In the pantry there was a large bag of brown sugar and a box of lentils that was open exposed to air. There was one 4-ounce container of Imperial Thickened Apple Juice from Concentrate that was stored on a shelf with current foods. The container's manufacture's label reflected Used by 2/02/23. The interior flashing of the icemaker had dried spills/smears. On 4/4/23 at 10:13 AM the large tube of frozen hamburger was now on a pan with no water in the pan at the kitchen two compartment sink. On 4/4/23 at 10:18 AM an interview was conducted with Dietary staff B regarding the frozen hamburger. She state, the hamburger would be used to make Carne Guisada for the noon meal. Dietary staff A was observed washing her hands in the two-compartment sink in the dishwasher area. She turned off the water with her bare hands She then dried her hands with a paper towel. Next, she handled clean dishes and put them away. On 4/4/23 at 10:22 AM Dietary staff B was about to prepare the puréed mixed vegetables. At that time the surveyor asked to see the interior of the processor and the blade before the food was added. The blade was dirty and had puréed beans on the lid. The lid stirrer was also dirty. Dietary staff B then took the processor back to the two-compartment sink and washed the lid with water only. She then placed it on the processor wet, placed the mixed vegetables in the processor pot and puréed them. Dietary staff A opened the kitchen exit door to the outside and left it open as a visitor was standing in the doorway. This action could allow flies/insects to enter the kitchen. Dietary staff B was washing her hands at the two-compartment sink and then she turned off the sink water with a paper towel. She then continued to dry her hands with the same paper towel. - The following observations were made, and interviews conducted during a kitchen tour on 4/04/23 that began at 11:50 AM and concluded at 12:58 PM: On 4/4/23 at 11:57 AM Dietary staff C and Dietary staff D were standing in the opened kitchen doorway to the outside entrance. They stood there from 11:57 AM to 11:59 AM. At that time a fly was observed, landing on uncovered bowls of peaches in the kitchen. Dietary staff D entered the kitchen and washed his hands in the two-compartment sink in the dishwasher area. He turned off the water then dried his hands with a paper towel. Next, he continued dietary duties. There were also soiled dishes in that two-compartment sink at the time. On 4/4/23 at 12:18 PM temperatures were taken on the service line by Dietary staff B. She used a dial probe thermometer. At this time, she stated, she was not sure how often the thermometer was calibrated for accuracy. The following were the temperatures taken: The mixed vegetables were 150°F. The potato tots were 142°F. The carne guisada was 140°F. The purée meat/Carne guisada was 135°F. The puréed potato tots were 124°F. The puréed mixed vegetables were 140°F. The puréed bread was 90°F and had been placed on the kitchen prep table at room temperature and not on any heat or cooling source since 11:50 AM when first observed by the surveyor. The breaded pork patty was 126°F and was not reheated to 165°F or maintained at 135°F. prior to meal service. On 4/04/23 at 12:25 PM, an interview was conducted with Dietary staff B regarding the preparation of the pureed bread. She stated she prepared the pureed bread using bread and milk. On 4/4/23 at 12:35 PM, the calibration on the facility's dial thermometer was checked with Dietary staff B. The surveyor's and the facility's thermometer were placed in ice water and the facility dial thermometer read 25°F and the surveyor's digital thermometer read 32.7°F. - The following observations were made, and interviews conducted during a kitchen tour on 4/04/23 that began at 3:43 PM and concluded at 5:33 PM: On 4/04/23 at 3:43 PM the puréed bread was in a container at room temperature on the counter near the steam table and not on any heating or cooling source. Dietary staff D was handling soiled dishes at the dishwasher and then washed his hands at the dishwasher area two compartment sink and then put away clean dishes. There were pots in the sink basin where he washed his hands. Dietary staff D handled soil dishes at the dishwasher and then handled clean dishes and insulated lids and did not wash his hands between the soiled and clean duties. Dietary staff C placed macaroni and cheese and ham in the processor pot. The surveyor intervened and pointed out that the lid to the processor and scraper/stirrer had a buildup of food. At this time the Visiting Dietary Manager took the lid and washed it, but it still had food debris on it. The Visiting Dietary Manager then washed it again and it was clean. On 4/4/23 at 4:00 PM an interview was conducted with Dietary staff C regarding the puréed bread. She stated she made the pureed bread with bread, milk, and cinnamon. On 4/4/23 at 4:09 PM an interview was conducted with the Visiting Dietary Manager regarding the green bucket and the red bucket that had wet wiping cloths in them. She stated the green bucket contained soap, and the red bucket contained sanitizer. At that time she tested the red bucket for quaternary sanitizer (Autochlor Solution QA) with quaternary test strips. The level of quaternary sanitizer was 0 ppm. The Visiting Dietary Manager changed out the sanitizer and it was 200 ppm. Observation and record review of the label of Auto Chlor System Solution Q A Sanitizer revealed the following documentation, . Sanitizing Food Contact Surfaces: . 200 ppm, active of this product for sanitizing and cleaning of equipment and utensils in restaurants, bars, and institutional kitchens. There was a live fly in the kitchen area. On 4/4/23 at 5:02 PM temperatures were taken on the service line as follows: The macaroni cheese and ham dish was 165°F at the time Dietary staff C wiped the probe of the thermometer with a wet paper towel between each food. The carrots were165F°. The puréed macaroni cheese and ham dish was 110°F and reheated to 175 degrees F. The puréed carrots were 120°F and reheated to 167°F. The puree bread was at room temperature on the counter and was 80°F. The puréed macaroni and ham without cheese was 165°F. The regular ham and macaroni dish without cheese was 163°F. On 4/4/23 at 5:05 PM Dietary staff C was interviewed regarding her use of a wet paper towel to clean the thermometer probe between foods. She stated the paper towel only had water on it. Dietary staff C was observed grasping and touching the stove area preparation tabletop and edge with both hands. She then took one bare hand and flipped flour tortillas on a small skillet on the stove. - The following observations were made, and interviews conducted during a kitchen tour on 4/05/23 that began at 11:35 AM and concluded at 1:10 PM: Two of 2 drink guns had a buildup of syrup and debrison the spout. The walls in the oven area and two compartment sink area in the kitchen were dirty with splatter and dried spills and the return air vents were thick with dust and dirt. The dishwasher area had one of two sets of lights unshielded. The kitchen employee's restroom sink was off the wall and on the floor. Flies and gnats were observed in the kitchen area. There was a large bag of brown sugar that was open in the pantry and exposed to air. Observation of the kitchen area metal cabinetry revealed that there was peeling, and chipping paint and the interior of the drawers were lined with dirty paper. The icemaker interior flashing had dried spills. The lower wooden storage cabinets had doors and shelving that were scraped, had peeling paint, dirt buildup and dried spills. On 4/5/23 at 12:05 PM Dietary staff C was standing in an open exit door to the kitchen, and it was not closed until 12:06 PM. A fly was landing on an uncovered tray of marshmallow and chocolate pudding desserts. On 4/5/23 at 12:12 PM the service line temperatures were taken with a digital thermometer . The Puréed bread was on the counter at the service line at room temperature and not on any heating or cooling source. No temperature was taken. On 4/5/23 at 12:37 PM an interview was conducted with Dietary staff B, regarding how she made the puréed bread. She stated she used bread, milk, and cinnamon. On 4/5/23 at 2:24 PM an interview was conducted with Dietary staff B regarding observations in the kitchen. Regarding dietary sanitation she stated she had not been trained on testing sanitizer. She stated she had been told that the green bucket contained soap and the red contained sanitizer. She stated staff did not specify what type of sanitizer and said to change it every two hours. Regarding handwashing, she stated staff usually washed their hands at the kitchen hand sink. Regarding cleaning of the walls and cabinetry, she stated the cabinets doors and walls were cleaned after lunch. Regarding the thawing techniques, she stated staff tried to place the foods in the refrigerator to thaw. She stated she was not on duty the day before 4/04/23. She added to quick thaw food the foods were usually placed under running water in the (2 compartment) large sink, but the large sink was full of food equipment. Regarding the soiled processor blade, she stated she usually used the processor and then placed it in the dishwasher. She added that she was nervous due to the survey. Regarding potentially hazardous foods not at the proper temperature, she stated, the (pureed) bread should be at room temperature by lunchtime. Regarding calibrating thermometers, she stated she was not trained to calibrate thermometers. She added that the digital thermometer used today was a personal one that belonged to Dietary staff A. Regarding what could result from the dietary sanitation issues that occurred, she stated she did not want residents to be sick and foods off temperature (between 41 degrees F and 135 degrees F) could make residents sick. Regarding why these dietary sanitation issues occurred, she state, she was not prepared after having days off. On 4/5/23 at 4:49 PM, an interview was conducted with a Dietary staff C regarding issues in the kitchen. Regarding staff use of the two-compartment sink for handwashing purposes, she stated there's no reason why it was done. She stated that staff had not received any in-service training on correct handwashing procedures. Regarding the door left open to the outside she stated staff had been told to close the door and not leave it open for long periods of time. Regarding the puréed bread, she state, she was told to have puréed bread at room temperature. Regarding cleaning of the thermometer probe, she stated the facility had sanitizer wipes to clean them, but she could not find them. She stated staff were told to check the cleanliness of the processor and processor parts. Regarding bare hand contact while cooking/warming the flour tortillas, she stated staff were never told not to turn tortillas with their bare hands. She further stated that she started working as a cook approximately two weeks ago, and she worked as a dishwasher in the facility since November 2022. On 4/5/23 at 4:41 PM an interview was conducted with Dietary staff D. He stated he had been working in the facility approximately two weeks. Regarding handwashing in the two-compartment sink, he stated staff had not been instructed not to use the two-compartment sink to wash their hands. He stated he had been told just to wash his hands. He further stated he had not been taught the correct handwashing procedure. Regarding his training for the dietary department, he stated it lasted two or three days. He stated each day he was shown new things. He stated residents could get sick if staff washed their hands incorrectly. - The following observations were made, and interviews were conducted during a kitchen tour on 4/06/23 that began at 10:48 AM and concluded at 11:46 AM: On 4/06/23 at 10:48 AM the Dietary Manager stated the only employees using the kitchen restroom were kitchen staff. Dietary staff E was observed preparing to pureed beans. She placed the beans in the processor which was wet on the interior. On 4/6/23 at 10:52 AM Dietary staff A was interviewed regarding handwashing in the 2-compartment dishwasher area hand sink. She stated staff did not want to bring germs into the kitchen, so they washed at the dishwasher area 2 compartment sink. On 4/4/23 at 12:04 PM an interview was conducted with Dietary staff A. She stated she had been employed in the facility since 12/01/21. Observation of the three-door refrigerator revealed that the zip top bag of sliced ham was labeled by the facility Use by 3/23/23. Dietary staff E was observed washing the processor in the 2-compartment sink. Observation of the lid, after washing, revealed that it had food debris on the scraper/stirrer and the processor pot had food debris. The surveyor intervened, and Dietary staff E washed the lid again. Observation of the lid revealed that it was still dirty with food in places on the processor and lid. The surveyor intervened again, and the processor and lid were washed again. On 4/6/23 at 11:00 AM an interview was conducted with a Dietary Manager regarding issues found in the dietary department regarding the cleanliness of walls and cabinets. She stated she had been hired on 5/28/22 and the walls and cabinetry were in the same condition as now. She added that staff had tried to clean it, but the surface came off the wall. Regarding the timetable when walls and cabinetry were cleaned, she stated staff had not scrub them because they did not have the time. She stated staff applied some degreaser on the walls and cabinets and wiped it off. Regarding the soiled processor parts and processing foods when the processor was wet, she stated she had told staff to let it dry, but the dietary department did not have enough help. Regarding the soiled interior of the icemaker, she stated staff cleaned it every six months. Regarding the identification and incorrect level of quaternary sanitizer in the red bucket, she stated she had always told staff it contained the sanitizer in the red bucket. She stated the label had come off the red bucket and the sanitizer level should be 150 to 200 ppm. Regarding the exit door to the outside being left open, she stated the flies had entered the kitchen even with the zapper (electronic insect exterminator). Observation during this interview with the Dietary Manager revealed that Dietary staff E was washing her hands in the 2-compartment sink at the same time. When it was pointed out to the Dietary Manager, she stated staff should have wash their hands in the (kitchen) hand sink. She stated she knew staff used the two-compartment sink for handwashing. She further stated that she believed the staff had seen the soap and paper towel dispensers installed at the 2-compartment sink and were prompted to use it as a hand sink. Regarding handwashing in the two-compartment sink, she stated it had been easier for staff to wash their hands at the hand sink located in the kitchen, but staff will not do it since it is too far away. Regarding incorrect handwashing technique, she stated she had told staff to dry their hands, using the paper towel, and then turn off the water and dispose of the paper towel in the trashcan. Regarding staff not washing their hands between soiled and clean dishwashing duties, she stated she had told staff when they handle the soiled dishes, they need to wash their hands, then handle the clean. Regarding the broken hand sink in the restroom, she stated she had been aware of it and reported it through the facility's online maintenance reporting system. She stated she did not know how it happened or when the facility would have it repaired. Regarding bare hand contact with food, she stated she had told staff they should turn tortillas with tongs or a spatula. Regarding outdated foods, she stated the cook would be in charge when the Dietary Manager was absent, and they should check food dates and dented cans. She stated that was the responsibility of the Dietary Manager when present. Regarding thermometer accuracy, she stated, she had calibration instructions posted on the wall at the sink. She stated the dial thermometer was the one used by staff. Regarding cleaning thermometers, she stated staff should have cleaned the thermometer probe with sanitizer wipes. Regarding the improper thawing techniques, she stated she had told staff to thaw foods in the refrigerator in a pan on a lower shelf the day before use. She further stated she had not reviewed with staff any faster methods of thawing such as under running water. Regarding potentially hazardous food/TCS foods not maintained at 41 degrees F or below or 135 degrees F or above, she stated she preferred to make pureed bread with water and did not know why staff used milk. Regarding why all these dietary issues occurred, she stated it had been a lack of training and staff needed more monitoring due to her increased job duties. She stated she had conducted in-services within the past 3 months with one addressing dishwashing. She stated the Dietary Manager, and the cook were responsible to ensure that all functions in the kitchen were performed correctly. She further stated the dietary department did not have enough staff. Regarding what could result from the issues observed in the dietary department regarding dietary sanitation, she stated residents could get sick, especially with incorrect handwashing and temperatures. On 4/6/23 at 12:54 PM an interview was conducted with Administrator regarding issues in dietary. Regarding dietary sanitation, he stated the restroom hand sink broke recently, and he fixed it today. He stated he had no excuse for the delay in repairing the hand sink. He stated there could be a negative outcome as a result of the issues in the dietary department regarding dietary sanitation. On 4/6/23 at 2:13 PM an interview was conducted with the Dietary Manager regarding the repair of the kitchen restroom hand sink. She stated it was repaired at approximately 12:30 PM today. Observation, at this time of the hand sink in the kitchen restroom revealed that it had been repaired. Record review of the dietary in-services held from December 2022 thru April 2023 revealed there were only two. On 12/15/22 the Dietary Manager held an in-service on Handwashing. Dietary staff A and C attended. On 1/20/23 the Dietary Manager held an in-service on Use of Gloves. Dietary staff A, B, C and E attended. Record review of the facility policy titled Policy: Cabinets, Drawers, And Shelving, Policy Number: 04.008, Date Approved: October 1, 2018, revealed the following documentation, Policy: The facility will maintain cabinets, drawers and shelving free of food particles and dirt, to minimize the risk of food hazards. Cabinets, drawers, and shelving will be cleaned a minimum of every week or as needed. Procedure . 6. Do not use shelf liners in drawers, cabinets or shelving. Record review of the facility policy titled Policy: Employee Sanitation, Policy Number: 03.0 4.001, Date Approved: 12/01/11, revealed the following documentation, Policy: The consultant dietitian will monitor each facility to ensure that the facility uses good sanitation practices in accordance with the state and federal food codes. Guidelines . 6. Handwashing. a. Employees wash their hands and exposed portions of their arms at designated handwashing facilities at the following times: . 2. After using the toilet room. 4. Immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped, single service, and single used articles. 5. During food preparation, as often is necessary to remove soil, and contamination, and prevent cross-contamination when changing tasks. 7. After engaging in other activities that contaminate the hands. Record review of the facility policy titled Policy: Handwashing, Policy Number: 04.002, Date Approved: October 1, 2018, revealed the following documentation, Policy: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will practice good handwashing practices in order to minimize the risk of infection and foodborne illness. Procedure: 1. Handwashing stations. b. Make sure there are handwashing stations in all areas that employee's hands may become contaminated, including food preparation areas, service areas, dishwashing areas, and restrooms. d. Sinks used for food preparation or washing utensils, or a service sink or curbed cleaning facility used to dispose of mop water or similar waste cannot be used as a handwashing station. 2. Hands should be washed after the following occurrences: a. Using the restroom. k. Touching unsanitized equipment, work surfaces are washcloth. 3. Hand washing steps. a. Wet hands and exposed arms with hot water at least 100°F. b. Apply soap. c. Scrub hands, expose arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction. d. Rinse hands and expose arms thoroughly under hot running water. e. Dry hands and arms with a paper towel. f. Turn off the faucet with a paper towel to avoid contaminating hands and discard the towel. Record review of the facility policy titled Policy: Food Holding, And Service, Policy Number: 03.005, Date Revised: June 1, 2019, review in the following documentation, Policy: To ensure that all food served by the facility is a good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. Procedure: 1. Serve all hot foods at a temperature of 135°F or greater and all cold food at 41°F or less. 4. If hot food drops below 135°F, reheat to 165°F for a minimum of 15 seconds. 5. Take cold food items from the refrigerator only as needed. Ice down milk for use at meal services Record review of the facility policy titled Policy: Food Storage, Policy Number: 03.003, Date Revised: June 1, 2019, review of the following documentation, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators . d. Date, label and tightly seal all refrigerated foods, using clean, nonabsorbent, covered containers, that are approved for food storage. Record review of the facility, policy, titled Policy: Food Preparation and Handling, Policy Number: 03.004, Date Revised: June 1, 2019, revealed the following documentation, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handle according to the state and US Food Codes and HACCP guidelines. Procedure: 1. General guidelines. a. Use clean, sanitize surfaces, equipment, and utensils. b. Wash hands properly before beginning food preparation. c. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. 2. Thawing foods. a. Thaw meat, poultry, and fish in a refrigerator at 41°F or less. b. Foods may be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70°F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow. ii. In a microwave oven using the defrost mode and immediately transferred to a conventional cooking equipment with no interruption in the process. iii. As part of the cooking process.