**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 2 of 4 residents (Residents # 24 and 41) reviewed for MDS assessment accuracy. The facility failed to accurately code Resident # 24's and Resident # 41's nutritional status for weight loss on the MDS assessments. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #24's face sheet dated 08/07/2024 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included anorexia (an eating disorder characterized by an abnormally low body weight), debility (physical weakness), and Failure to Thrive (a syndrome that describes a gradual decline in physical and cognitive function that is characterized by weight loss, malnutrition, and debility). A review of Resident #24's weight records indicated she weighed 95.4 pounds on 01/08/2024. Resident # 24's weight on 07/02/2024 was noted to be 84.2 pounds, indicating a weight loss of 11.2 pounds (11.7%) in the last 6 months. A review of a dietary note completed by the RD on 07/12/2024 for Resident #24 indicated Resident #24's July 2024 weight reflected a loss of 11.2 pounds which calculated as a 11.7% weight loss in the last 6 months. A review of Resident #24's Dietary Quarterly Review completed by the facility's DM on 07/24/2024 indicated Resident #24 had no weight loss in the last 6 months. A review of Resident #24's Quarterly MDS assessment (Section K 0300) dated 07/31/2024 indicated Resident #24 had not had a weight loss of 10% in the last 6 months. 2. A review of Resident #41's face sheet dated 08/07/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, chronic obstructive pulmonary disease (a group of diseases that block airflow making it difficult to breathe), and pneumonia. A review of Resident #41's weight records indicated he weighed 124.8 pounds on 06/05/2024. Resident #41's weight on 06/24/2024 was noted to be 118.2 pounds, indicating a weight loss of 6.6 pounds (5.3%) in the last 30 days. A review of Resident #41's Quarterly/5-day MDS assessment dated [DATE] (Section K 0300) indicated Resident #41 had not had a weight loss of 5% in the last 30 days. During an interview with the MDS Nurse on 08/07/2024 at 10:45 AM/2024, she said the DM completed section K:Swallowing/Nutrition Status of the MDS assessments. During an interview with the DM on 08/07/2024 at 10:55 AM, she said she completed Section K of the MDS assessments. She said she also completed the Dietary Quarterly Reviews. She said she looked at the residents' weight records in the computer to determine if they had any weight loss. The DM said she did not know how to calculate the percentage of weight loss. During an interview on 08/07/2024 at 02:20 PM with the MDS Nurse and the DM, the MDS Nurse said that she and the DM had determined that the DM was not using a computer report that showed calculated weight changes. The DM said she had been using a computer report that listed the residents' weights but did not reflect any weight gains or losses. The MDS Nurse and DM said the MDS assessments completed on Residents # 24 and #41 were incorrect and did not reflect their weight losses. During an interview on 08/07/2024 at 03:15 PM, the MDS Nurse said the facility used the MDS 3.0 RAI Manual as their guide for completing the MDS assessments. She said incorrect coding of the MDS assessments could result in residents not receiving appropriate care and services. During an interview on 08/07/2024 at 03:40 PM the DON said the facility did not have a policy completing MDS assessments. She said the facility used the MDS 3.0 RAI as the guide for completing the MDS. She said incorrect coding of the MDS assessments could result in residents not receiving appropriate care and services. Record review of the MDS RAI 3.0 Manual Chapter 3: Section K: Swallowing/Nutritional Status indicated the following: Intent: The items in this section are intended to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately. MDS Section K 0300 indicated this section was to be coded for weight loss if a resident experienced a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 Residents (Residents #'s 24 and 41) reviewed for medical records accuracy. The facility failed to ensure the Dietary Manager accurately documented weight losses in the Dietary Quarterly Reviews for Resident #24 and Resident #31. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. A review of Resident 24's face sheet dated 08/07/2024 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included anorexia (an eating disorder characterized by an abnormally low body weight), debility (physical weakness), and Failure to Thrive (a syndrome that describes a gradual decline in physical and cognitive function that is characterized by weight loss, malnutrition, and debility). A review of Resident #24's weight records indicated she weighed 95.4 pounds on 01/08/2024. Resident # 24's weight on 07/02/2024 was noted to be 84.2 pounds, indicating a weight loss of 11.2 pounds (11.7%) in the last 6 months. A review of a dietary note completed by the RD on 07/12/2024 for Resident #24 indicated Resident #24's July 2024 weight reflected a loss of 11.2 pounds which calculated as a 11.7% weight loss in the last 6 months. A review of Resident #24's Dietary Quarterly Review completed by the facility's DM on 07/24/2024 indicated Resident #24 had no weight loss in the last 6 months. 2. A review of Resident #41's face sheet dated 08/07/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, chronic obstructive pulmonary disease (a group of diseases that block airflow making it difficult to breathe), and pneumonia. A review of Resident #41's weight records indicated he weighed 124.8 pounds on 06/05/2024. Resident #31's weight on 06/24/2024 was noted to be 118.2 pounds, indicating a weight loss of 6.6 pounds (5.3%) in the last 30 days. Resident #41's weight on 07/01/2024 was noted to be 118.0 pounds, indicating a weight loss of 6.8 pounds (5.4%) in the last 30 days. A review of medical records indicated a progress note dated 07/04/2024 wherein the DON noted Resident #41 had a 5% weight loss in the last month. A review of a the RD's Dietician Comprehensive Review dated 07/12/2024 indicated Resident #41's July 2024 weight showed a 6.8 pounds (5.4%) weight loss in the last 1 month. A review of Resident #41's Dietary Quarterly Reviews completed by the facility's DM on 07/24/2024 and 07/29/2024 indicated Resident #41 had no weight loss in the last 30 days. During an interview with the DM on 08/07/2024 at 10:55 AM, she said she completed the Dietary Quarterly Reviews. She said she looked at the residents' weight records in the computer to determine if they had any weight loss. The DM said she did not know how to calculate percentage of weight loss. She said she had not asked anyone how to calculate the percentage of weight loss. She said she used the information documented on the Dietary Quarterly Reviews to complete MDS assessments. She said incorrect Dietary Quarterly reviews could place residents at risk for incorrect MDS assessments. During interviews with the MDS Nurse and the DON on 08/07/2024 at 03:15 PM and 03:40 PM respectively, they said incorrect assessment data on the Dietary Quarterly Reviews could place residents at risk for having incorrect MDS assessments and not receiving appropriate care and services. During an interview on 08/07/2024 at 03:40 PM the DON said the facility did not have a policy on Dietary Reviews nor a policy on documentation/charting accuracy.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. There were no trash cans at both hand wash sinks. The dish machine was not sanitizing properly and the DW did not report so it could be repaired. Two thickened liquid cartons were not dated when opened. One 32 oz. carton of almond milk was out of date and being used. A drawer under the tea machine had dried brown substance in the bottom. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations and interviews on 08/05/24 of the kitchen the following was noted: *at 09:30 AM no trash can at the handwash sink in the dish room. There was a 55 gallon rolling trash can lined with a plastic bag which had no lid. *at 09:35 AM the dish machine sanitizer was checked by [NAME] A and the test strip came back white instead of purple, indicating the machine was not sanitizing the dishes after washing. [NAME] A looked at the strip and said it was not correct. She was holding the strip next to the sanitizer gauge chart on the strip container. DW B was asked about checking the machine during breakfast and he said the temperatures were all good but the sanitizer was not registering on the test strip. He said he did not tell anyone the test strips were not registering. He said he checked his sanitizing buckets with the test strips from the 3-compartment sink. He said he made a notation on the Temperature/Sanitizing log for the dish machine was sanitizing at 50 ppm when it was not registering. He did not seem to know the difference between the two types of sanitizer. *at 09:43 AM no trash can at the handwash sink adjacent to the 3-compartment sink. There was a 55 gallon rolling barrel adjacent to the 3-compartment sink that had an affixed lid that would need to be opened with previously washed hands, *at 09:50 AM in the Walk-In Cooler: 1-46 oz. Nectar Thick Cranberry Cocktail had no open date. The packaging indicated: After opening, may be kept up to 7 days under refrigeration. 1-46 oz. Nectar Thick Orange Juice had no open date. [NAME] B said they were supposed to put an open date on anything that had been opened. 1- 32 oz. almond milk was marked as being opened on 07/13/24 (23 days). The packaging on the carton indicated: Use within 7-10 days after opening. [NAME] B said the almond milk belonged to a resident who was lactose intolerant and his family member provided it to the facility. He said the kitchen gave him the milk for his cereal in the morning and used it to prepare items that needed milk such as pudding. He discarded the almond milk. *at 10:00 AM the drawer under the tea dispenser had the entire bottom covered with dark brown dried substance. [NAME] B removed the drawer to be washed. *at 10:01 AM [NAME] A had plates that needed to be re-washed and sanitized for lunch at the 3 compartment sink. She said the dish machine vendor had been called and would hopefully be at the facility by lunchtime. *at 11:25 AM no trash cans at either handwash sink. During an interview on 08/07/2024 at 10:37 AM, the DM said staff knew to date all food packaging when they were opened and would need to be stored. She said staff had been trained on dishwashing procedures and checking the sanitizing solutions on the dish machine and the 3-compartment sink. She said she would re-train staff and include information on reporting any discrepancies or issues. Review of an undated facility policy on Dishwashing Procedures indicated .dishwashing machine uses chemical sanitizing, where a chemical such as chlorine is dispensed into the rinse water .the dietary staff must check the rinse water during each dishwashing period to assure at least 50 ppm of sanitizing solution in the rinse water. Review of an undated facility policy on Food Storage indicated .items such as salad dressings, cottage cheese, etc. should be dated as opened.

Based on interview, the facility failed to ensure the residents received mail for 3 of 3 residents reviewed for rights to forms of communication. The facility did not implement a system for delivering mail on Saturday. Resident #s 12, 24 and 35 said the mail is not delivered on Saturday. This failure could place residents who received mail at risk of not receiving mail in a timely manner and a diminished quality of life. Findings included: During interviews on 07/11/2023 at 9:30 a.m., in a resident council meeting, Resident #s 12, 24 and 35 said they received their mail during the week, but they do not receive their mail on Saturdays. They said they believe they receive it on Monday. During an interview on 07/11/2023 at 10:45 a.m., the Activity Director said this was her second day with the facility and she was not sure how the mail was handled on Saturday. During an interview on 07/11/2023 at 11:05 a.m., the Business Office Assistant said she believed mail delivered on the weekend was held over until Monday, but she was not sure. During an interview on 07/11/2023 at 11:13 a.m., the Administrator said he handles the weekend mail. He said when he comes in on Monday, he sorts the mail that came in over the weekend. He said he keeps the business mail for the facility, and he gives the resident mail to the transportation aide to distribute to the residents . When asked, the Administrator said they did not have a policy on mail.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meals (lunch meal) reviewed for menus and nutritional adequacy. Dietary staff did not serve bread during the noon meal on 07/10/23 to any residents eating food provided by the dietary department. This failure could place residents who eat food from the kitchen at risk of not having their nutritional needs met. Findings included: The planned menu dated 07/10/23 for the noon meal was herb roasted chicken, creamy noodles, garlic green beans,1 slice of bread, and banana pudding for dessert. The diet spreadsheet for the noon meal indicated residents were to receive Herb Roasted Chicken 3 oz., Creamy Noodles 4 oz., Garlic [NAME] Beans 4 oz., Banana Pudding, #8 dip (3.75 oz. or 1/2 cup), 1 slice Bread/Margarine 1 tsp. Residents on pureed diets were to receive Pureed Herb Roasted Chicken #8 dip (3.75 oz. or 1/2 cup; Pureed Creamy Noodles #12 dip (2.875 oz. or 1/3 cup); Pureed Garlic [NAME] Beans #12 dip (2.875 oz. or 1/3 cup); ; Pureed Banana Pudding #8 dip (3.75 oz. or 1/2 cup); Pureed Bread # 20 dip (1.875 oz. or 3.5 tablespoons) During an observation of the dietary department on 07/10/22 at 11:45 AM the dietary carts contained trays for each resident receiving food from the kitchen. Each tray had silverware/napkin, dietary slip, banana pudding, a single serving container of margarine, and a beverage of the resident's choice. There was no sliced bread or pureed bread on the trays. During an observation on 07/10/23 at 12:28 PM, tray line service began and continued until 01:04 PM and the following was observed: *At 12:40 PM the dining room cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 12:53 PM the hall 100 cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 01:02 PM the hall 200 cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 01:04 PM the hall300/400 cart left the kitchen and no sliced bread were placed on any trays. There were no residents on these halls receiving a pureed diet. During an interview on 07/10/23 at 01:07 PM [NAME] A said he was responsible for preparing the pureed bread and he did not prepare any. During an interview on 07/10/23 at 01:08 PM, the DM said the cook was responsible to put the bread on the trays whether it was sliced bread, rolls, cornbread, or pureed breads. She said she expects bread to be served to residents if it was part of the menu or if a resident requested bread. Review of a facility Diet Roster dated 07/10/2023 indicated there were 50 residents receiving food from the kitchen. Review of a facility menu policy dated 10/2017 indicated Menus are developed ad prepared to meet established national guidelines for nutritional adequacy. And .1. Menus meet the nutritional needs of the residents in accordance with the recommended dietary allowances . and .9. If a food group is missing from a resident's diet, the resident is provided an alternate means of meeting his or her nutritional needs

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Baking sheets had thick, black burned on substances that were greasy and transferred grease when wiped with paper toweling. Cook A and DA B did not wear a beard restraint when in the kitchen or while serving food and preparing food trays. Mechanically altered chicken removed from the steam table by [NAME] A and placed on a insulated cover was returned to the pan on the steam table. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 07/10/23 of the kitchen the following was noted: *At 10:07 AM at the pan rack by the stove: 5 full size baking sheets were encrusted with thick, black burned substances. They were stacked together and were greasy to touch and when wiped with a paper towel transferred a greasy brown substance. There were 4 half-size baking sheets with a slight build-up of burned on substances, they were stacked together and greasy to the touch, and when wiped with a paper towel transferred a greasy brown substance. *At 10:15 AM DA B had a full facial beard and moustache. He was not wearing a beard restraint to contain facial hair and was preparing food trays for residents. During an observation on 07/10/23 at 11:45 AM [NAME] A had a full facial beard and moustache and was not wearing a beard restraint to contain his facial hair. He was cooking food and placing food on the steam table. DA B was not wearing a beard restraint to cover his beard and moustache and was placing items on residents' meal trays. During an observation on 07/10/23 at 12:55 PM [NAME] A scooped a serving of mechanically altered chicken from the steam table pan and placed it on an insulated plate holder instead of a plate. He dumped the chicken back into the steam table pan from the plate holder. He continued to serve the mechanical chicken to halls 200, 300 and 400. During an interview on 07/10/23 at 01:05 PM [NAME] A said he should not have put the chicken back into the steam table pan from the insulated holder. He said he realized it when he did it. He said he should have removed that chicken from the steam table and prepared fresh chicken to serve to the residents. During an interview on 07/10/23 at 01:08 PM the DM said when the cook contaminated the mechanical chicken he should have prepared more fresh chicken. She said she did not have any beard guards for the men to wear. She said they were not wearing them when she came to work at the facility last year and she asked them if they wore them and they told her they did not. She said she did not get any for them to wear. She said the baking sheets were fairly thick with burned on substances and she was not sure if she could get it all off so she said she would order new baking sheets. Review of a facility Food and Nutrition Services Staff Policy dated 10/2017 indicated 1. The food and nutrition services staff under the supervision of the dietitian and/or the food and nutrition services manager, will safely and effectively carry out the functions of the food and nutrition services department. Review of a facility Food Preparation and Service Policy dated 04/2019 indicated .7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Review of a facility Preventing Foodborne Illness Policy dated 10/2017 indicated 1. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness .12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . Review of a facility Sanitation Policy dated 10/2008 indicated .3. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .