**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 of 4 residents (Resident #39) reviewed for care plans. The facility failed to update Resident #39's care plan to reflect current needs for heel protectors to be worn at all times. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). Record review of Resident # 39's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #39 was never/ rarely understood and was not capable of completing the BIMS questions. His cognitive patterns were assessed by the staff. Resident #39 had poor short- and long-term memory recall. His decision-making abilities was severely impaired. Resident #39 was dependent on staff for all his ADL's. Resident #39 was also assessed to be at risk for developing pressure ulcers/ injuries. Resident #39's MDS also reflected he required a pressure reducing device for chair and for his bed. Record review of Resident #39's Comprehensive Care Plan, dated 03/14/2024, reflected Resident #39 had alteration in skin integrity related to incontinence, physical limitations, and cognitive impairment. Interventions: monitor skin during showers for any areas of redness or excoriation and report to nurse. Off load (using a pillow or wedge under the calf to leave the foot suspended above the mattress) bilateral heels at all times. Resident #39 had ADL self-care deficit related to severe cognitive deficits. Resident #39 was also assessed to require total assistance with dressing, personal hygiene, toileting, and shower. He required 2-person Hoyer lift for transfers. Record review of Resident #39's Physician Order for the month of 04/2024 reflected a physician order dated 04/10/2024 wear heel protectors at all times; offload right heel when in bed. In an interview and record review on 04/10/2024, LVN C stated Resident #39 had an official physician order in the electronic medical record on 04/10/2024. She viewed Resident #39's physician order and care plan during the interview. She stated on the care plan, it reflected Resident #39 was to offload his heels when in bed. LVN C also stated the care plan date was 03/14/2024 and it was the most current care plan. She stated the care plan was completed prior to the new physician order dated 04/10/2024 for Resident # 39's heel protectors to be used at all times. She stated Resident #39's care plan had an intervention of offloading heels. However, this was different than wearing heel protectors. LVN C stated the interventions for the staff to follow required to be very specific. LVN C stated anytime there was a change in a resident care or any new order for any device the residents' care plan was expected to be updated. She reviewed Resident #39's care plan during the interview and stated the care plan was not updated to reflect the new physician order for the resident to have heel protectors on his feet. She stated care plan said to offload his heels but the care plan was written prior to him developing the red area on his right heel and offloading was not the same as wearing heel protector. She stated someone would probably update the care plan to reflect he needed heel protectors. She stated someone in the nurse administration department would review Resident #39's care plan and add the heel protectors to the care plan. LVN C also stated it was the MDS Nurse, the DON or the ADON revised the care plan. In an interview and /record review on 04/11/2024 at 9:30 AM, CNA F stated there was a form in Resident #39's room explaining the care he required. She stated the CNAs referred to the form for any changes in Resident #39's care. CNA F stated LVN E gave her report that morning about Resident #39 and to place heel protectors on him at all times. She stated if she saw offloading heels at all times documented, she would not know exactly what it meant. She stated she would need further guidance from the nurse to ensure she knew what to do if she saw the residents' heels needed to be offloaded. CNA F stated if she saw heel protectors on any of Resident #39's forms, she would know exactly what to do and she would place heel protectors on his feet. In an interview and record review on 04/11/2024 at 8:40 AM, the Director of Nurses stated as she was reviewing the Resident #39's care plan during the interview the interventions was not revised to reflect he was to wear heel protectors at all times. She stated the last care plan was revised on 3/14/2024 and the new physician order for heel protectors was dated 04/10/2024. She stated, in the perfect world the care plan would be revised. She also stated the care plan was the record the staff referred to when developing person center care for each resident. She stated offloading heels was on the care plan and that was when staff would use pillows under residents' feet. She stated again in a perfect world the care plan would be revised. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated the care plan for Resident #39 did not reflect specific heel protectors on the care plan. He stated the care plan had offloading and he believed offloading and heel protectors was the same thing but he was not a nurse. He also stated he was not going to discuss the potential negative outcome of a resident not wearing heel protectors because he was not a nurse. Record review of the facility's policy on Goals and Objectives, Care Plans dated 2009 reflected objectives were entered on the resident's care plan so that all disciplines have access to such information and were able to report whether or not the desired outcome were being achieved. Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 40 and Resident # 63) reviewed for quality of life. The facility failed to ensure Resident #40 and Resident #63's nails were cleaned. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 40 Face Sheet dated 04/11/2024 reflected Resident #40 was admitted on [DATE] with diagnosis of muscle weakness (lack of strength in muscles), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and age-related osteoporosis without current pathological fracture (reduce bone mass). Record review of Resident #40's Quarterly MDS Assessment, dated 02/26/2024, reflected resident was rarely/never understood. The staff completed Resident #40's cognitive status. Resident #40 was assessed to have poor short- and long-term memory recall. She was also assessed to have poor decision-making ability. Resident #40 was dependent on staff for all ADLS including personal hygiene. Resident #40 did not reject care. Record review of Resident #40's Comprehensive Care Plan dated 01/18/2024 reflected Resident #40 had an ADL self-care deficit related to general weaknesses, and cognitive deficits. Intervention: Explain to Resident #40 all care being given to her. Observation and Interview on 04/09/2024 at 1:19 PM Resident #40 had a blackish/brownish hard substance underneath the nails on her fore finger and middle finger on her left hand and underneath the nails on her middle finger and ring finger on her right hand. Resident #40 was not interview able. Record review of Resident # 63's Face Sheet dated 04/11/2024 reflected Resident #63 was admitted to the facility on [DATE] with diagnosis of: down syndrome (a condition in which a person has an extra chromosome or an extra piece of a chromosome), dementia in other diseases classified elsewhere, unspecified severity (lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement), and delusional disorders ( unshakeable belief in something that is not true). Record review of Resident #63's Quarterly MDS dated [DATE] reflected Resident #63 rarely/ never understood others. Her cognitive assessment was completed by staff. She was assessed to have poor short- and long-term memory recall and her decision-making ability was severely impaired. Resident required assistance with all ADLs. Record review of Resident #63's Comprehensive Care Plan dated 03/07/2024 reflected Resident #63 had ADL self-care deficit related to cognitive deficits. Care plan reflected Resident #63's ADL needs will be met. Observation and Interview on 04/09/2024 at 1:11 PM Resident #63's middle and forefinger nails on her right had had blackish/brownish hard substance underneath the nails. Resident #63 was not interview able. In an interview on 04/11/2024 at 9:15 AM, LVN E stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN E stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated the CNAs reported to nurses of any diabetic resident's nails to be cleaned. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the Cans usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN E stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. She stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #40 or Resident #63 refusing nail care. In an interview on 04/11/2024 at 9:30 AM, CNA F stated CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails could be cleaned or trimmed by nurses or CNAs as needed. CNA F stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA F stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated there was a possibility a Resident may need to be assessed at the emergency room if they became severely ill. She stated she gave care to Resident #40 and Resident #63, and with her experience they did not refuse nail care. In an interview on 04/11/2024 at 10:40 AM, the Director of Nurses stated it was the nurse's responsibility to trim/clean residents with a diagnosis of diabetes. She stated CNAs were expected to give nail care to other residents during showers or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. Director of Nurses stated if staff saw a blackish substance underneath a resident's nails, he expected the nails to be cleaned immediately. She stated only nurses were assigned to trim or clean residents nails with a diagnosis of diabetes. In an interview on 04/11/2024 at 3:25 AM, the Administrator stated nail care was overseen by nurses and the CNAs assisted with nail care directed by the nurse. He stated the nurses were expected to keep the residents' nails trimmed, cleaned, and filed. He stated he was not a nurse and could not speculate what may happen to a resident if the resident ingested some type of bacteria. Record review of the facility's policy on Fingernails/Toenails, dated February 2018, reflected nail care included daily cleaning and regular trimming. Clean the nail bed and keep the nails trimmed, and to prevent infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development of pressure ulcers for one of three (Resident # 39) reviewed for pressure ulcers. The facility failed to ensure Resident #39 received his physician ordered heel protectors at all times. This failure could place residents at risk for developing a pressure ulcer leading to pain, discomfort, and potential infections. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 -year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). Record review of Resident # 39's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #39 was never/ rarely understood and was not capable of completing the BIMS questions. His cognitive patterns were assessed by the staff. Resident #39 had poor short- and long-term memory recall. His decision-making abilities were severely impaired. Resident #39 was dependent on staff for all his ADL's. Resident #39 was also assessed to be at risk for developing pressure ulcers/ injuries. Resident #39's MDS also reflected he required a pressure reducing device for chair and for his bed. Record review of Resident #39's Comprehensive Care Plan, dated 03/14/2024, reflected Resident #39 had alteration in skin integrity related to incontinence, physical limitations, and cognitive impairment. Interventions: monitor skin during showers for any areas of redness or excoriation and report to nurse. Off load (using a pillow or wedge under the calf to leave the foot suspended above the mattress) bilateral heels at all times. Resident #39 had ADL self-care deficit related to severe cognitive deficits. Resident #39 was also assessed to require total assistance with dressing, personal hygiene, toileting, and shower. He required 2-person mechanical lift for transfers. Record review of Resident #39's Physician Order for dated 04/10/2024 reflected for the resident to wear heel protectors at all times; offload right heel when in bed. Record review of Resident #39's skin assessment dated on 04/03/2024 reflected Resident #39 had pressure on his bilateral heels (no measurements on the skin assessments). Record review of Resident #39's Nurse Practitioners notes dated 04/11/2024 reflected Resident #39 was seen on 04/09/2024. Resident #39's chief complaint was reports of redness to bilateral heels. Right heel medial aspect with approximately 2.5 x .2.5 purplish slightly blanchable area to heel. Assessment/Plan: Pressure injury of heel- suspect pressure related. Add heel protector booties at all times. Offload Right heel when in bed. Pressure Ulcer of unspecified heel, unspecified stage. Signed by Nurse Practitioner. Record review of Resident #39's skin assessment dated [DATE] reflected Resident #39 did not have any skin concerns. Record review of Resident #39's skin assessment dated [DATE] revealed Resident #39 did not have any skin concerns. Record review of Resident #39's skin assessment dated on 03/30/2024 revealed Resident #39 did not have any skin concerns on his right heel. Record review of Resident #39's skin assessment dated on 04/03/2024 revealed Resident #39 had pressure (sore) on his bilateral heels. Record review of Resident #39's skin assessment dated on 04/11/2024 revealed Resident #39 had pressure (sore) on his right heel with measurement 1.7 cm x 1.3 cm. Observation on 04/10/2024 at 10:30 AM revealed Resident #39 was in the common tv area in his specialized wheelchair. Resident #39 was not wearing heel protectors. In an interview on 04/10/2024 at 10:45 AM, CNA D stated she received report from LVN C during report at the beginning of her shift on 04/10/2024 to ensure Resident #39 was wearing his heel protectors when out of bed and to ensure he had pillows underneath his heels when he was in bed. She stated when she assisted Resident #39 out of his room to the common tv area, she forgot to place the heel protectors on his feet. CNA D stated the heel protectors was available in Resident #39's room. She stated if he did not wear his heel protectors, the areas on right heel may develop into a wound. CNA D stated the heel protectors were used to prevent him having a pressure wound. In an interview/record review on 04/10/2024 at 11:05 AM, LVN C stated the Nurse Practitioner was at the facility on 04/09/2024 and checked Resident #39's heels. She stated a verbal order was given to her from the Nurse Practitioner to place heel protectors on Resident #39's heels to prevent pressure ulcer to his right heel. She stated she thought she documented about the order in the nurses notes or the physician orders. LVN C viewed the physician orders and the nurses note during the interview. She stated she did receive a verbal order to place heel protectors on Resident # 39's heels on 04/09/2024 but she did not document this order. LVN C stated the order was entered into the electronic medical record on 04/10/2024. She stated the staff had been offloading Resident #39's heels when he was in bed. She stated offloading heels and placing heel protectors on the heels were two different interventions. She stated offloading heels was an intervention of placing a pillow underneath the residents' feet. LVN C stated it had to be very specific when placing heel protectors on residents' feet to prevent skin breakdown. She stated he had been wearing heel protectors on 04/09/2024 due to the Nurse Practitioner gave her a verbal order to place the heel protectors on his feet. LVN C stated Resident #39 was expected to have heel protectors on when he was in the common area on 04/10/2024. She stated she gave report to the CNAs to place heel protectors on Resident #39 heels when he was out of bed and to offload his heels when he was in bed by using a pillow. In an interview/observation on 04/11/2024 at 9:15 AM, LVN E stated she worked with Agency and this was the first day she had worked at the facility in a few months. She stated Resident #39 was required to wear heel protectors related to a small new area on his right heel. LVN E also stated he was to wear heel protectors at all times. She stated the heel protectors was better for him than offloading his heels with a pillow. She stated the night nurse (she couldn't remember the nurse's name) gave her report on 04/11/2024 when she came to the nurse's desk at the beginning of her shift. LVN E stated the night nurse told her in report Resident #39 was offloading his heels on a pillow and now he had a new order to wear heel protectors. LVN E stated she discussed this information with the CNAs after she received her report from the nurse on night shift. LVN E stated Resident #36 did have heel protectors on his feet when she made rounds on 04/11/2024. LVN E stated Resident #39 was in his room and when entered Resident #39's room he was wearing heel protectors while he was in bed. LVN E stated the heel protectors were to be worn at all times in bed and out of bed. She stated the heel protectors was a different intervention than offloading heels on a pillow. In an interview on 04/11/2024 at 9:30 AM, CNA F stated she was informed Resident #39 was expected to wear heel protectors when out of bed, during the morning report when she began her shift on Resident #39. She stated she was informed Resident #36 was expected to wear heel protectors when in bed and out of bed. She stated this was a new order for this week. She stated prior to this week, the staff was placing pillows underneath his feet and he was not wearing heel protectors. In an interview on 04/11/2024 at 10:40 AM, the Director of Nurses stated there was a new order on 04/10/2024 for Resident #39 to wear heel protectors. She stated if Resident #39 was sitting in the common area on 04/10/2024, he was expected to be wearing heel protectors. The Director of Nurses stated when a resident had a red area on heel the intervention of wearing heel protectors was prevent the area from developing into a wound/pressure ulcer. She stated the staff was expected to place heel protectors on Resident #39. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated if there was an order for Resident #39 to wear heel protectors, he expected the heel protectors to be on resident per physician order. He stated he could not respond to the question of what possibly may occur to the resident if he did not wear heel protectors. He stated he was not a nurse. Record review of the facility's policy on Support Surface Guidelines, dated 2011, reflected support surfaces were to promote comfort for all bed, chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by contract staff in the direct care of one of four residents (Resident # 80) reviewed for infection control in that: 1. The facility failed to ensure the Hospice Nurse LVN B sanitized or wash her hands after touching contaminated items while feeding of Resident #80. 2. The facility failed to ensure the Hospice Nurse did not touch Resident #80 tip of straw and side of Resident #80's mouth. These failures could place residents at risk of cross contamination which could result in physical illness. Findings include: Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (parts of the brain that control thought, memory, and language), diseases of lips (can make it difficult to eat, drink, or even smile. Cold sores cause by bacteria can be a common symptom), anxiety disorder (mental disorder that causes constant fear and worry), Down's syndrome (a condition in which a baby is born with an extra chromosome 21. The extra chromosome is associate with delays in the child's mental and physical development, as well as increased as an increased for health problems. Record review of Resident # 80's Significant Change MDS Assessment, dated 02/14/2024, reflected Resident #80 was never/ rarely understood and was not capable of completing the BIMS questions. Her cognitive patterns were assessed by the staff. Resident #80 had poor short- and long-term memory recall. Resident #80 required for the staff to do more than half the effort with feeding. Record review of Resident #80's Comprehensive Care Plan reflected Resident #80, dated 02/22/2024, reflected she had ADL self-care deficit related to decreased cognitive status. Intervention: Eating- assist resident to the dining room, set up meals and provide verbal cueing as needed. Resident was assessed to require hospice services related to Alzheimer's disease (parts of the brain that control thought, memory, and language). Intervention: will maintain communication between hospice and the caregivers of facility to meet the needs of the resident. Observation on 04/09/2024 at 12:05 PM- 12:10 PM, the Hospice nurse (LVN) B was feeding Resident #80 in the dining area on D hall. During feeding, Hospice LVN B placed the palm and fingers of her right hand at the top of her ponytail and went to the end of the ponytail. Her ponytail was approximately at her shoulders. After this, she touched the handles and back of Resident #80's wheelchair. She also touched Resident #80's clothing. Hospice LVN B did not sanitize or wash her hands and began to give Resident #80 her protein shake. When she picked up the protein shake, she placed the tip of her forefinger on her right hand on the tip of the straw and placed that portion into Resident #80's mouth. When she was holding the protein shake, the tip of her ring finger of her right hand touched Resident #80's left side of her mouth. The Hospice Nurse LVN B picked up the spoon from the bowl of chocolate pudding and touched the inside of the bowl with her middle and ring finger on her right hand and fed Resident #80. In an interview on 04/09/2024 at 12:25 PM Hospice LVN B stated she sanitized her hands when she was in the hall walking toward the dining area. She stated she placed her bag on the floor and sanitized her hands again. Hospice LVN B stated when she began to feed Resident #80, she grabbed her ponytail with her right hand and run her fingers and palm of her hand through her hair. She also stated she touched Resident #80's wheelchair and clothing. She stated her hair, Resident #80's clothing and wheelchair would not be considered sanitized. She stated there was a possibility that bacteria were on Resident #80's clothing and wheelchair. She also stated her hair had hair products and possibly bacteria. Hospice LVN B stated she did not wash or sanitize her hands while feeding resident and after she touched these items (wheelchair, clothes, and hair). She stated she was to follow proper hygiene protocol when feeding or giving any type of care to a resident in the facility. She also stated there was a potential she may have cross contaminated the straw used for Resident #80 when she placed her fingers on the tip of the straw and when she placed fingers on her right hand by residents' mouth during feeding. Hospice LVN B stated there was a possibility of Resident #80 ingested bacteria from her fingers on her right hand the resident my become physically ill with a stomach issue and may have symptom of vomiting. She stated she had been in -serviced by the Hospice Agency she worked for on infection control and hand hygiene. She stated all nurses learned, in nursing school, proper hand hygiene when giving any type of care including feeding someone. She stated she made a mistake and she should have sanitized or washed her hands when feeding Resident #80 and she did not follow proper hand hygiene protocol. In an interview on 04/09/2024 at 1:20 PM, the Director of Nurses stated the hospice nurse was to follow proper hand hygiene when giving care to residents in the facility. She stated any nurse giving care whether it was a nurse employed at the facility or a nurse from another agency such as hospice giving care to a resident in this facility, were all to follow proper hand hygiene. She stated if the hospice nurse touched her own hair, touched Resident #81's wheelchair and clothes, she was expected to wash her hands prior to feeding Resident #80. She stated hand hygiene is basic nursing training. The Director of Nurses also stated any nurse learned proper hand hygiene protocol in nursing school and whenever given infection control in-service. She stated if a nurse touched anything considered contaminated was to wash or sanitize their hands immediately prior to given any care to a resident including feeding. She stated the hospice nurse did not practice good hand hygiene. In an interview on 04/10/2024 at 11:05 AM, LVN C stated any hospice staff who came into the facility to give care to any residents was expected to follow nursing protocol of hand hygiene. She stated she was in the dining room when Hospice Nurse LVN B was feeding Resident #80. She stated she was feeding another resident and was not watching Hospice Nurse LVN B. She stated if Hospice Nurse LVN B did not sanitize or wash her hands after touching her hair, someone else's clothing and parts of a wheelchair and continued to feed Resident #80, she did not follow nursing protocol of hand hygiene. She stated hand hygiene is what every nurse learns in nursing school and it is a part of the infection control protocol at every facility and agency. She also stated if Resident #80 ingested bacteria from Hospice LVN B's hands, Resident #80 possibly could become ill with any type of stomach issues. In an interview on 04/10/2024 at 1:04 PM, Director of Quality Assurance RN /BSN stated Hospice Nurse LVN B was required to follow the infection control protocol. She also stated hand hygiene for nurses was a standard protocol. She stated if a nurse had contaminated hands and gave any type of care to a resident , the nurse was expected to wash or sanitize their hands immediately before continuing care. She also stated this included feeding a resident. Director of Quality Assurance stated Hospice Nurse LVN B did not practice proper hand hygiene when feeding Resident #80 at the facility. She stated hand hygiene in-service was given to all nursing staff including Hospice Nurse LVN B. She also stated it was a possibility resident may become physically ill such as: the flu, respiratory issues, and a lot of different physical illnesses. Director of Quality Assurance RN/ BSN stated it deepened on the bacteria. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated Hospice Nurse LVN B was expected to follow hand hygiene protocol when in the facility. He stated he was not a nurse and did not know all the specifics of what possibility could happen to Resident #80. He also stated hand hygiene protocol was expected to be known to all nurses who went to nursing school. Record review of the facility's policy on Hospice Program, dated 07/2017, reflected the facility staff (clinical nurse manager) provided orientation on the policies and procedures of the facility. Record review of the facility's Policy on Hand Hygiene in the Dining Room, not dated, reflected It is the policy of [FACILITY] to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting resident with eating. hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. The facility failed to ensure the food was safely stored in the freezer and the pantry. This failure could place residents at risk of being served food that could had been crossed-contaminated, frost bitten, and foodborne illness. Findings included: Dry pantry observation on 04/09/2024 at 8:55am revealed an undated plastic container of Fiber. Dry pantry observation on 04/09/2024 at 9:00am revealed an opened bag powered milk, exposed to open air, and not sealed. Refrigerator observation on 04/09/2024 at 8:59am revealed a box of mushrooms in the refrigerator, exposed to open air and not sealed. Kitchen observation on 04/09/2024 at 8:46am revealed a cell phone in a pink protective case sitting on the rolling cart next to the prep table , directly across from the kitchen entry doorway. Kitchen observation on 04/09/2024 at 8:51am revealed a cloudy, chunky, brown liquid substance in the drain receptacle of the ice machine nearest to the steam table. Kitchen observation on 04/09/2024 at 8:53am revealed a greasy substance, food crumbs and other unidentifiable particles on the bottom shelf of the prep table where the spices and bottled sauces were stored. Pantry observation on 4/09/2024 at 8:57am revealed two small containers of Chicken Flavored Base sitting on top of a large 5-gallon bucket of Ultra San sanitation product. Pantry observation on 04/09/2024 at 8:57am revealed individual sized yellow packets of artificial sweetener, a Styrofoam cup, and other unidentifiable debris on the floor in the dry storage pantry, between the defrost refrigerator and a stack of boxes. Kitchen observation on 04/09/2024 at 9:05am revealed debris and trash, multiple divided plates, bowls, bubble cups, drinking glasses and multiple disposable containers under steam table. Kitchen observation on 04/09/2024 at 9:05am revealed cloudy, greasy water that contained food particles such as an Asian dumpling, a green bean and a French fry in the three wells of the steam table. Kitchen observation on 04/10/2024 at 11:37am revealed a cell phone, a smart watch, keys and an unopened can of soda on the rolling blue cart beside steam table. On top of the cart contained plastic bags with bread and serving trays. Kitchen observation on 04/10/2024 at 11:38am revealed a cloudy, chunky liquid substance in the drain receptacle of the ice machine nearest to the steam table. Appears to be the same liquid that was present yesterday. Kitchen observation on 04/11/2024 at 9:06am revealed a cell phone, keys, key fob, and a facility name tag. There was a pan of food sitting on the rolling tray. Kitchen observation on 04/11/2024 at 9:06am revealed on opened energy drink sitting next to a loaf of bread on a rolling cart. Kitchen observation on 04/11/2024 at 10:27am revealed debris and trash, multiple divided plates, bowls, bubble cups, drinking glasses and multiple disposable containers under steam table. Kitchen observation on 04/11/2024 at 11:20am revealed two kitchen staff wearing earbuds and one cell phone was ringing in the kitchen. The location of the cell phone was not identified, and kitchen staff ignored the ringing. Kitchen observation on 04/11/2024 at 12:31pm revealed small pieces of breakfast bacon and egg particles on the steam table, while lunch was served. Interview on 04/11/2024 at 2:30pm with the DA revealed she was trained by the KS. She said the kitchen cleaning checklists should be updated every day and all kitchen staff were responsible for this task. She confirmed she has read the policy on Kitchen Sanitation. She said she felt like the kitchen was clean. She said personal items are kept on the wall in the hallway, between the kitchen and the dry storage. She said this is important for sanitation purposes. She said items in the refrigerator should be stored in the container with the lid on top. She said all kitchen staff are responsible for ensuring all food items are safely stored and have an open date, to prevent the potential for bugs and other debris getting into the food. She said not storing food items properly could get the resident's sick. Interview on 04/11/2024 at 2:40pm with the KS revealed she was trained by her last company. She said cleaning checklists should be completed daily and she was aware the cleaning checklists had not been updated since the State had entered the facility. She said whoever complete d the cleaning task is responsible for documenting on the cleaning checklist. She said she read the Kitchen Sanitation policy when she was hired by the facility. She said her expectation is for things to be cleaned when something was dirty. Regarding cleanliness, she said, Currently, the kitchen could be better. She said that staff's personal items should be kept in the hallway, or her the supervisor's office. She said it is important to keep the kitchen free of personal items to prevent cross contamination with the food area. She said, staff are not allowed to wear ear buds in the kitchen due to safety regulations . Regarding the ice machine by the steam table, she said, It does not drain well. Maintenance has looked at it and it is a gravity issue. It is a non-functional ice machine and must be manually loaded with ice. I put Bleach in it at night. She said the steam wells should have been cleaned every day, usually by the night shift. She said food items should be sealed and closed with an opened and discard by date. She said the cooks and aides on each shift are required to label and date their own items that they prepared. She said it is important for food to be sealed and stored properly because it guaranteess freshness and nothing breeds bacteria that could cause food poisoning, spread contagion, cross contamination, and food allergies. Interview on 04/11/2024 at 2:50pm with the DM revealed that she held a Food Kitchen Managers Certification, she is an RD, and had classes in food management and production while in school. She said all kitchen staff are required to complete the cleaning checklist after they complete that task. She said she read the policy on Kitchen Sanitation when she was hired. When asked if the kitchen cleanliness met her expectations, she replied, For daily production measures, yes. That is always our highest priority. We cover our basics, cleaning all food and kitchen prep areas thoroughly. One area of focus in which we could improve, would be getting on your knees, cleaning the floors, etc. She said personal items should be kept in the hallway, on the hooks or on the fridge. She said it is important to keep the kitchen prep and line free of personal items to reduce cross contamination, safety and the correct level of cleanliness and it is not acceptable for staff to wear earbuds in the kitchen. She said staff knows not to wear earbuds in the kitchen. Regarding the ice machine near the steam table, she said, One or two times a week we empty the container. It's not hooked up to drain. Regarding the steam table wells, she said, That's a less frequent task, the cooks check off on that, one to two times a week. Regarding proper storage of food items, she said, Raw meat should be on bottom, anything with dripping juices on bottom, fresh produce on top, everything sealed in original packaging, or sealed with saran wrap or in a Ziplock. That is the responsibility of whoever opened the item. She said proper storage is important to prevent cross contamination with other foods and prevent foodborne illness, compromised immune systems in this population, insects, and foodborne intoxication. Interview on 04/11/2024 at 3:10pm with the RD revealed that the cooks and aides were responsible for updating the cleaning checklists when they complete a task. She said she has read the policy on Kitchen Sanitation, and she thinks if it is dirty, it should be cleaned. She said the kitchen does not meet her expectation for cleanliness. She said staff should keep personal items in the hallway or the mangers office. She said it is important to keep personal items out of the kitchen to prevent cross contamination. She does not like to see kitchen staff wearing earbuds, but I do see them when they are doing certain chores, like washing dishes. She said the ice machine drain pan should be dumped and cleaned every day. She said staff should label, date, and store items properly to ensure freshness and make sure the oldest items are used first. Interview on 04/11/2024 at 3:50pm with the ADM revealed his concern was constant turnover of kitchen staff. He was aware the kitchen is not as clean as it should be. He said he believes feeding the residents is the highest priority and the kitchen prep areas are clean and sterile. He said, The kitchen staff have to prioritize their duties, and no one is going hungry or has become ill. Review of the facility's Sanitization Policy revised November 2022) revealed the following: Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas are kept clean, free of debris and protected from rodents and insects. 10. I0ce machines and storage containers are drained, cleaned, and sanitized per manufacturer's instructions. Review of the facility's Food Receiving and Storage policy revised November 2022 revealed the following: Policy Statement: Foods shall be received and stored in a manner that complies with food handling practices. Policy Interpretation and Implementation: Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 9. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #55) reviewed for care plans. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff, and this was not included in a behavioral care plan. This failure placed residents at risk of not attaining their higest practicable well-being. Findings included: Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia. Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so. Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan. During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Residents #5) reviewed for pressure ulcers. 1. The facility failed to ensure the provider treatment plan for Resident #5 was implemented. 2. The facility did not provide wound care as ordered by the provider for Resident #5. These failures placed residents at risk of pain, worsening of wounds and wound infection. Findings included: Record review of Resident #5's Face Sheet dated 03/07/23 reflected Resident #5 was a [AGE] year-old male, and he was admitted to the facility on [DATE]. Resident #5 had diagnoses of Dysphagia (difficult to swallow), Parkinsonism, Chronic pain, Deficiency of B and D vitamins, Allergic rhinitis due to pollen, Epilepsy, Constipation, Intellectual disabilities, Muscle Weakness, Need for assistance with personal care, Psychosis, Pain in left Foot, Pain in left knee and Pressure-induced deep tissue damage of left heel. Record review of Resident #5's MDS assessment dated [DATE] reflected Resident #5 had slurred or mumbled words and limited ability to make concrete requests. Resident #5 also had a BIMS score of 11, indicated Resident #5 had moderate cognitive impairment. He required to have full staff performance every time during entire 7-day period. Resident #5 was incontinent for both bowel and bladder. The MDS assessment indicated Resident #5 had one or more unhealed pressure ulcers/injuries and treatment included pressure reducing device for chair and bed and pressure ulcer/injury care. Record review of Resident #5's Care Plan dated 02/03/23 reflected no statement of any pressure ulcer. Record review of Resident #5's weekly skin assessment dated [DATE] reflected Resident #5 had left heel wound measuring 3cm L x 2cm W x 0cm D with clear drainage. Resident informed he had a burning sensation from that. Resident#5's left toe had a blackish colored spot above the toenail measuring 1cm L x 1cm W x 0 cm D. Record review on 03/7/23 of the evaluation of the wounds of Resident #5 on 2/22/22 at 1:53pm by APRN, stated: Wound #1, Date of onset: 2/22/23, Location: left heel (2 areas), Description: Medial Area:1.5cm x 1.4cm and 0.8cm x0.7 cm. Etiology: DTI, Treatment plan: change treatment to: Apply skin prep and cover with sock. Continue booties. Wound #2, Location: left great toe. Description: Proximal Area:0.8cm x0.6 cm. Etiology: DTI. Treatment plan: change treatment to: Apply skin prep and cover with sock. Apply booties. Record review of clinical physician's order on 03/07/23 dated 02/22/23 at 1:07pm by APRN, stated: Left heel wound: Apply skin prep and cover with sock. Record review of clinical physician's order on 03/07/23 dated 03/07/23 at 1:12pm by APRN, stated Left great toe DTI: Apply skin prep and cover with sock. The treatment order on 02/22/23 at 1:07pm for Resident#5's wound on his left heel was as per the treatment plan dated 02/22/23, however, the treatment order on 03/07/23 at 1:12pm for Resident #5's left great toe was ordered 13 days after the completion of wound evaluation and treatment plan dated 02/22/23. Record review of February,2023 TAR on 03/07/23 at 01:18pm stated: Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400. Record review of March,2023 TAR on 03/7/23 at 1.28 pm stated: 1.Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400 2.Left great toe DTI: Apply skin prep and cover with sock. Every evening shifts. -Start Date-03/07/2023 1400. Record review on 03/07/2023 at 11.30am of the TAR reflected that as on 03/07/2023, 11.30am there were no evidence of any treatment provided as per the order to Resident#5's wounds starting from 02/24/2023, as per the order. Observation of Resident #5's wound dressing on 03/07/23 at 11:30 AM revealed Resident #5's left heel wound had redness without any secretion and the left toe wound was visible as a red spot without any secretion. An interview with LVN B on 03/07/23 at 11:30 am, LVN B stated she was not aware of the pressure ulcer treatment for Resident #5. LVN B said she was aware of the order for Witch Hazel Liquid (medicinal ointment) that was applied on 3/7/23 to Resident#5's face, neck, behind ears topically. This was provided every day as per the order. When asked about the adherence to TAR orders, LVN B stated it was mandatory that the treatments had to be provided by nurses as per the directions in the treatment order in the TAR. During an interview on 03/07/23 at 2.00pm the ADON stated that LVN B reported to her about the issue of the omission of wound treatment. ADON stated both orders for treatment were placed only on 03/07/23 by the APRN. She added that the facility had a new APRN who started few weeks ago and getting used to the system. When the investigator asked about the treatment order by APRN on 02/22/23 for the wound treatment for the left heel that was transcribed into the TAR clearly stating to commence from 02/24/23, ADON said most likely there was a software glitch in the EMR and transcribed the commencement date wrongly. When asked about the compliance by the nurses to the treatment order, ADON stated the nurses should strictly follow the treatment order in the TAR. During the interview on 03/08/23 at 2:30 pm the DON stated the nurses and MAs must follow the MAR and TAR while providing treatments and administering medications. DON stated the APRN did not place the orders for the treatments and that was the reason for not providing the treatment. When the investigator showed the treatment order for left heel wound on TAR scheduled to start from 02/24/23, DON stated that the commencement date on the TAR was wrong and most likely there was some issue with the EMR software. When asked about the risk of such software issues, she stated there was high risk of not getting very important medications and treatments to the residents on time if the EMR was malfunctioning. DON stated this was the first time happening like this. During the interview on 03/08/23 at 2pm the APRN stated she was new to the facility and settling in with the system at the facility. When asked about the treatment orders for the pressure ulcers of Resident#5, she stated on 02/22/23 after her wound evaluation she made a treatment plan, and not a treatment order. When the investigator asked when there was a treatment order for the wound on the heel, based on the treatment plan on 02/22/23, why there was not an order for the wound on the toe on 02/22/23 itself but only 13 days after on 03/07/23, though both of them had treatment plan on 02/22/23, APRN said she was not familiar with the EMR and might not have entered properly. During the interview on 03/08/23 at 3.30pm, the ADM stated the clinical aspects were taken care by DON and he was in charge of the administration. When the investigator asked about the accuracy and reliability of the EMR system, he stated it was a very reliable software and never heard of any complaints. He said, in case if any issues there, that could be immediately resolved with the support of the readily available EMR software technicians. He added, the facility never had any concerns about the reliability and accuracy of the system. The ADM stated there was no specific policy and procedure for medication administration and the nurses supposed to follow the standard clinical rules for medication administration and treatment.

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 one of one kitchen reviewed for sanitation. 1. The DSM failed to ensure all items in the kitchen were labeled, dated, and discarded prior to their expiration date. 2. The DSM failed to ensure all personnel food items were stored separate from resident food items. 3. The DM failed to properly sanitize the thermometer probe when taking the temperature of food items. Findings included: Observations of the reach-in refrigerator on 3/06/2023 from 9:13 a.m. - 9:24 a.m. revealed the following: At 9:13 a.m., the reach-in refrigerator contained 12 bags of yellow unidentifiable substance unlabeled and undated. At 9:15 a.m., the reach-in refrigerator contained five foam containers of unidentifiable substance unlabeled and undated. At 9:16 a.m., the reach-in refrigerator contained three small foam containers of unidentifiable substance unlabeled and undated. At 9:17 a.m., the reach-in refrigerator contained a foam container, undated and labeled with the DSM's name. At 9:23 a.m., the reach-in refrigerator contained a bag of shredded carrots with a best-if-used-by date of 1/30/2023. The carrots appeared browned and had a foul odor. At 9:24 a.m., the reach-in refrigerator contained three sandwiches labeled PBH dated 2/26/2023. During an interview on 3/06/2023 at 9:30 a.m., the DM stated all items in the refrigerator should be labeled and dated. The DM stated the yellow substance was egg and usually they put it in a container with a label. The DM stated the items in the foam containers were parfait and whipped topping. The DM stated all items in the refrigerator needed to be labeled and dated. The DM stated all leftovers were discarded after seven days, the sandwiches were eight days old, and she would discard them. The DM stated the facility followed best-if-used-by dates and stated she would not serve the shredded carrots. The DM stated the foam container labeled with the DSM's name was the DSM's meal from the day prior. The DM stated the kitchen had a separate cooler for employee food items. An observation on 3/07/2023 at 10:46 a.m. revealed six bulk bins labeled sugar, rice, thickener powder, powdered milk, flour, and jasmine rice. These bins were labeled but not dated. Observations on 3/07/2023 from 11:10 a.m. - 11:20 a.m. revealed the DM took the temperatures of seven food items on the steam table and used a white rag to wipe the thermometer probe between each food item. During an interview on 3/07/2023 at 11:20 a.m., the DM stated no she had not sanitized the thermometer probe in between temping the food items because she had dipped the towel in sanitizer solution prior to temping the food items. The DM stated the kitchen did not have disposable sanitizer wipes. During an interview on 3/07/2023 at 3:17 p.m., the RDN stated the kitchen's policy on labeling and dating refrigerated items included the use of FIFO and stated staff labeled everything when it came in. The RDN stated it was not necessary to date bulk bin items as long as the container did not appear old and crusted. The RDN stated she would question it if it looked that way but stated the kitchen's stuff always looked fresh. The RDN then stated all food items needed a label and a date. The RDN stated she instructed kitchen staff to get rid of old produce if it looked wilted or was spotting and stated yes she would have expected staff to discard a bag of shredded carrots with a foul odor and a best-if-used-by date of over one month ago. The RDN stated the DM and the DSM inventoried the kitchen once or twice a week to identify and discard old food items. The RDN stated leftover food items such as sandwiches needed to be discarded after seven days. The RDN stated staff should use alcohol sanitizer wipes to sanitize the thermometer probe between temping different food items. The RDN stated that was how she trained staff to take food temperatures. The RDN stated the kitchen had sanitizer wipes and she expected them to use them. The RDN stated personal food items could be kept in the personal fridge or in the DSM's office. The RDN stated no that personal food items should not be kept in the reach-in refrigerator. The RDN stated all kitchen staff had been trained on food storage and sanitation through obtaining their Texas food handlers license upon hire. The RDN stated herself as well as the DM and DSM completed in-service trainings with staff on food storage and sanitation. The RDN stated she monitored the kitchen by completing monthly sanitation audits. The RDN stated she was in the kitchen a couple times a month and she would do a walk-through and make observations of tray line and the dining room. The RDN stated the kitchen was monitored daily by either the DM or DSM. The RDN stated they monitored the kitchen by going through to make sure items were labeled, dated, and covered. The RDN stated if policies on food storage and sanitation were not followed, there could be potential for foodborne illness. During an interview on 3/08/2023 at 4:01 p.m., the ADM stated the kitchen's policy on food storage included covering, labeling and dating food items. The ADM stated leftovers should be tossed. The ADM stated old produce with a best-if-used-by date of over a month ago should have been thrown away already. The ADM stated there was a personal refrigerator where employee's personal food items should be stored. The ADM stated yes that all items removed from their original package should have a label and a date. The ADM stated he did not know what the facility's policy was on sanitizing thermometer probes when temping food but stated it should be sanitized appropriately in between. The ADM stated all kitchen staff were trained on food storage and sanitation through obtaining their certification and through in-service trainings. The ADM stated the DSM, the RDN and himself monitored the kitchen by making frequent rounds. The ADM stated the RDN monitored the kitchen via visits at least once a month, by completing a report, and through communication with the ADM about how things were going in the kitchen. The ADM stated he was in the kitchen twice a week to make sure there was not anything out of hand. The ADM stated if food storage policies were not followed, someone could get sick and if sanitation policies were not followed, infections could spread. A record review of the facility's policy titled Taking Accurate Temperatures using Metal Stem Thermometers dated 2021 reflected the following: Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (use a new swab for each sanitizing.) A record review of the facility's policy titled Food Storage dated 2021 reflected the following: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contamination or cross contamination. Procedure: 8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. 13. Refrigerated food storage: f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. A record review of the facility's undated policy titled Policy for Personnel Food Items reflected that employee's personal food items were to be stored in a mini fridge located in the hallway near the kitchen or in the DSM's office. A record review of the RDN's monthly sanitation audit titled Food Safety and Sanitation Checklist dated 2/28/2023 reflected no that the facility did not identify food not stored in its original container by its proper name and out of date leftovers x 4-5. A record review of the FDA's 2017 Food Code reflected the following: Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 24 residents (Residents #55, 57, and 76) and one of four medication carts reviewed for infection control. 1. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff. 2. LVN A stored and locked her used scrub-top in the drawer of a medication cart that contains medications and treatment supplies. 3. LVN C assisted both Residents #57 and 76 with eating, using the same hand, and did not perform hand hygiene between them. These failures placed residents at risk of transmission of infectious diseases. Findings included: Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia. Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so. Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan. During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would. Review of facility policy dated August 2019 and titled Cleaning and Disinfection oc Environmental Surfaces reflected the following: Housekeeping surfaces (e.g. floors, table tops) will be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. Environmental services will be disinfected or clean on a regular basis (e.g. daily), three times per week, and when surfaces are visibly soiled. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated. 2. During an observation on 03/06/2023 at 10.30 AM revealed the storage of a green colored slightly faded scrub- top in the bottom drawer of a medication cart in the medication room situated at Hall A of the facility. There were wound care supplies, compound benzoin tincture swab sticks, oxygen tubing, sanitary pads, liquid medications in bottles and gastrotomy care supplies were in that drawer. LVN A was assisting the investigator by opening the drawers of the cart one by one for medication storage inspection. The scrub was found above the medications and treatment supplies in the bottom drawer, in plain without any package or wrap. LVN A removed the scrub immediately from the drawer and stated she regrets for storing it in the med cart. During an interview on 03/06/23 at 10.45 AM LVN A stated the scrub owned by her and should not have stored in the med cart after the use. When asked about the adverse result of storing used scrub with medications, LVN A stated the scrub could contaminate the medications and treatment supplies stored in the med cart and helps to spread diseases. During an interview on 03/07/23 at 3:00 PM ADON stated the med cart was exclusively for storing medications and treatment items and should not be used for storing any other materials like food or clothes. She stated this was necessary to minimize spreading diseases through cross contamination. During an interview on 03/08/23 at 2:00 PM DON stated no materials other than medications and treatment items should be there in the med cart. She stated used clothes stored in a med cart could contaminate the medications in the cart and this compromises infection control efforts. Review on 03/08/23 of the facility policy Storage of Medications dated November 2020 reflected: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . . 3.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 3. A record review of Resident #57's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of mild intellectual abilities, hypertension (high blood pressure), hyperlipidemia (high cholesterol), legal blindness, gastro-esophageal reflux disease (acid reflux), dysphagia (difficulty swallowing), schizoaffective disorder (mental condition causing delusions), major depressive disorder (depression), bipolar disorder (extreme mood swings), and repeated falls. A record review of Resident #57's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #57 required supervision and a one-person physical assist with eating. A record review of Resident #57's care plan last revised on 01/29/23 reflected she had ADL self-care deficit related to physical limitations and eyesight, and required meal set up, verbalized placement of food on table and verbal cueing as needed. A record review of Resident #76's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, unspecified convulsions, severe intellectual disabilities, irritable bowel syndrome, and epilepsy (nervous system disorder). A record review of Resident #76's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #76 was totally dependent on staff and required a one-person physical assist with eating. A record review of Resident #76's care plan last revised on 01/28/23 reflected she had ADL self-care deficit related to altered cognitive status, cerebral palsy, and autistic disorder. Resident #76's care plan reflected she needed to be spoon fed all meals. An observation on 03/06/23 at 11:58 AM revealed LVN C was sitting between Resident #76 and Resident #57 in the dining room. LVN C was observed feeding Resident #76. Resident #57 was observed to be having trouble feeding herself, LVN C began feeding her with the same hand she used to feed Resident #76. LVN C went back and forth three times between feeding Resident #76 and Resident #57 without using hand hygiene in between. During an interview on 03/06/23 at 12:04 PM, LVN C stated she did not use hand hygiene in between feeding Resident #76 and Resident #57 because she did not believe it was cross-contamination since she did not touch the resident themselves. LVN C stated Resident #57 usually ate on her own but that day she needed help. LVN C then stated she should have used hand hygiene in between. During an interview on 03/07/23 at 02:31 PM the ADON stated she expected staff to sanitize their hands in between feeding different residents. The ADON stated all staff were trained on proper hand hygiene upon hire. When asked what potential negative resident impact there could be if staff did not practice proper hand hygiene when feeding residents, the ADON stated, they are exchanging different bacteria when changing from one resident to another. During an interview on 03/08/23 at 3:20 PM, the DON stated the facility's policy on hand hygiene during meal assistance included that staff were to perform hand hygiene between each resident. The DON stated yes that hands should be sanitized between feeding one resident and another. The DON stated staff were trained during orientation on proper hand hygiene during meal service. The DON stated herself, the ADON, and other management personnel monitored for compliance of proper hand hygiene by completing audits with staff. The DON stated if the facility's policy on hand hygiene during meal service were not followed, it would be an infection control issue. During an interview on 03/08/23 at 04:01 PM, the ADM stated staff should perform hand hygiene between feeding multiple residents. The ADM stated all staff were trained on this upon hire. The ADM stated typically the nurse managers monitored staff to ensure they used proper hand hygiene. When asked what potential negative resident impact there could be if the facility's policy on hand hygiene in the dining room were not followed, the ADM stated, it is not best practice, it is not the right thing to do, and there was not an infection that came out of it. A record review of the facility's orientation checklist titled Employee Onboarding Checklist reflected LVN C was trained on the facility's policy on hand hygiene in the dining room on 02/08/23. LVN C signed a statement reflecting she understood the policy for hand hygiene in the dining room. A record review of the facility's undated policy titled Hand Hygiene in the Dining Room reflected the following: It is the policy of (facility name) to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting residents with eating. Policy Interpretation and Implementation: 6. If you are assisting a resident to eat, hand hygiene must be done prior to the beginning of the actual feeding or assistance. 7. You may feed two residents at the same time as long as you maintain a clean hand that is dedicated to touching only the silverware, plate or glassware of each resident. If you touch either resident with your dedicated hand, you must perform hand hygiene before you resume feeding or assisting the resident. 8. If you move from a resident at one table to a resident at another table to begin feeding or assisting, you must perform hand hygiene before assisting the new resident. 9. Hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 12 of 14 resident rooms (rooms for Residents ##3, 6, 12, 14, 15, 19, 35, 40, 42, 43, 50, 51, 52, 55, 64, 65, 66. 67, 72, 74, 75, and 81) reviewed for physical environment. The air conditioning units in rooms for Residents #3, 6, 12, 14, 15, 19, 35, 40, 42, 43, 50, 51, 52, 55, 64, 65, 74, 75, and 81 were covered with a black and grey substance, and the units in rooms for Residents #52, 64, 65, 66, and 67 were broken and/or not securely fastened to the wall. This failure placed residents at risk of respiratory illness, infection, and injury by accident. Findings included: Review of the undated face sheet for Resident #66 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #67 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. During observation and interview on 03/06/23 beginning at 09:42 AM, Resident #67 was sitting in his wheelchair in the doorway of his room. He stated his air conditioner was broken and pointed to a unit under the window and near his roommate's bed. He roommate, Resident #66, sat in his wheelchair approximately three feet from the AC, with a peg tube attached and operating, and did not respond to efforts to communicate with him. The AC unit was coming away from the wall, the filters were jammed and would not slide back into the unit. The unit's air output grill was covered with a thick grey and black substance. Review of the undated face sheet for Resident #15 reflected an [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of chronic respiratory failure, chronic bronchitis, intellectual disabilities, and allergic rhinitis. Observation on 03/07/23 at 11:43 AM revealed the AC unit's air output grill in #6 and 15's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #81 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #75 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and history of infections of the central nervous system. Observation on 03/07/23 at 11:45 AM revealed the AC unit's air output grill in #75 and 81's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #42 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis due to pollen and intellectual disabilities. Review of the undated face sheet for Resident #64 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of seasonal allergic rhinitis. Observation on 03/07/23 at 11:46 AM revealed the AC unit's air output grill in #52 and 64's room was covered with a thick grey and black substance. It was also cracked and pulling away from the wall. Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnosis of intellectual disabilities. Observation on 03/07/23 at 11:47 AM revealed the AC unit's air output grill in #55's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #12 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #51 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and allergic rhinitis. Observation on 03/07/23 at 11:48 AM revealed the AC unit's air output grill in #12 and 51's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #43 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic and intellectual disabilities. Review of the undated face sheet for Resident #50 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis. Observation on 03/07/23 at 11:49 AM revealed the AC unit's air output grill in #43 and 50's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #72 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Observation on 03/07/23 at 11:52 AM revealed the AC unit's air output grill in #74's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of obstructive sleep apnea and allergic rhinitis. Review of the undated face sheet for Resident #14 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of obstructive sleep apnea. Observation on 03/07/23 at 11:53 AM revealed the AC unit's air output grill in #3 and 14's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #40 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis due to pollen and intellectual disabilities. Review of the undated face sheet for Resident #42 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of seasonal allergic rhinitis and intellectual disabilities. Observation on 03/07/23 at 11:54 AM revealed the AC unit's air output grill in #40 and 42's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #35 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis due to pollen, seasonal allergic rhinitis, and intellectual disabilities. Review of the undated face sheet for Resident #19 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of snoring and intellectual disabilities. Observation on 03/07/23 at 11:55 AM revealed the AC unit's air output grill in #19 and 35's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #65 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis and intellectual disabilities. Observation on 03/07/23 at 11:56 AM revealed the AC unit's air output grill in #65's room was covered with a thick grey and black substance. The Ac unit was pulling away from the wall and left a gap in the drywall behind it. During an interview on 03/07/23 at 11:52 AM, HK G stated the maintenance department was responsible for cleaning the AC units. HK G stated she had noticed the grey and black substance on the AC units, but she did not know who to tell. HK G stated she thought someone from the maintenance department cleaned the units sometimes but did not know of any schedule. During an interview on 03/07/23 at 01:53 PM, the MAINT stated he was the director for the entire campus, which included two assisted living facilities and an independent living facility. He stated the position of maintenance director for this facility was vacant, but someone was scheduled to start the following day (03/08/23). He stated he also employed a dedicated HVAC specialist for the whole campus, but that position was also vacant. his team cleaned the AC filters monthly, but he was not aware how long it had been since the unit's air output grills had been cleaned. The MAINT stated the ideal service times for the AC units when they would be fully inspected was quarterly, but he had not had a had a full time HVAC service person since June 2022, and a new one would finally start on 03/14/23. After walking through the rooms and viewing the AC units, the MAINT stated the ACs pulling away from the wall were a safety hazard, and the grey black substance was probably a form of mildew and was not healthy for anyone to be breathing in. During an interview on 03/07/23 at 2:51 PM, the ADM stated he knew there was a general schedule they maintained of cleaning out the AC unit filters. The ADM stated they were without a permanent maintenance person just for their facility, but when they had one, he had cleaned the filters at least twice a month. When asked if he expected the staff who cleaned the filters to also notice if there was debris or grime in the air output grate, he stated it would depend on what it looked like, but he hoped that staff would take care of it. He stated he had not done any specific training or given guidance on this issue, but it was common sense that if there was mold, mildew, or other mess it should be cleaned. During an interview on 03/08/23 at 03:21 PM, the DON stated mildew in the air output grate could cause harm or discomfort to a resident. She stated the main concern would be respiratory issues in a room where that was the condition. Review of facility policy dated February 2021 and titled Homelike Environment reflected the following: Policy Statement- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation- 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility, they reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. Review of facility policy dated December 2009 and titled Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1.The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2.Functions of maintenance personnel include, but are not limited to: d. Maintaining the heat/cooling system, plumbing, fixtures, wiring, etc., in good working order i. Providing routinely scheduled maintenance service to all areas j. Others that may become necessary or appropriate.

Based on interview and record review the facility failed to make prompt efforts to resolve grievances for five (CR #1, CR #2, CR #3, CR #4, and CR #5) of twenty confidential residents reviewed for grievances, in that: The facility failed to resolve grievances for CR #1, CR #2, CR #3, CR #4, and CR #5 and establish a policy to ensure a system was in place to provide residents with a written decision or response regarding grievances. This failure placed the residents at risk for unresolved grievances and a decreased quality of life. The findings included: During a confidential interview on 1/5/22 at 10:15 AM with twenty Confidential Residents, CR #1, CR #2, CR #3, CR #4, and CR #5 expressed the following grievances: CR #1 - Items are taken out of her closet such as clothes, bedspread, and her pillow CR#2 - Missing clothes CR#3 - Down comforter is missing CR#4 - Half of his DVD collection is missing CR#5 - Several missing blouses The residents stated they had expressed their missing items to staff members, but they never hear back. None of these residents knew what a grievance form was, or if there was a grievance process. They all stated they had their names written on their items. During an interview on 1/5/22 at 1:20 PM with the SW, she stated she had only worked at the facility for a week, so she was not sure how they had been doing their grievance process before her. She stated that in her experience, any complaints made by a resident or family member would be written on a grievance form and given to the appropriate manager. She stated the family member or resident that reported the complaint should always receive a written response. She stated if a resident alleged, she was missing a blouse and it was unable to be located, a grievance form should be completed to start the process of an investigation. During an interview on 1/6/22 at 9:43 AM with LVN C, she stated if a resident notified her of an item of theirs that was missing, she stated she would look in their room for the item and would also notify the laundry department. She stated she would also write a note on the dashboard (resident EMR system) but was not sure if that would create a grievance form. During an interview on 1/6/22 at 9:46 AM with CNA B, she stated if a resident is missing clothing, she would notify the laundry department. She stated she assumed they would complete a grievance form. During an interview on 1/6/22 at 9:50 AM with a LA F, she stated if it was clothing that was reported missing, she would first check the resident's closet to see if it was misplaced. She stated she would also inform the Housekeeping Supervisor. During an interview on 1/6/22 at 9:55 AM with the HSKS, she stated if there was a piece of clothing that a resident was missing and she could not locate it, she would notify the Social Worker. She stated she did not know where a grievance form would be located. During an interview on 1/6/22 at 10:00 AM with AD G, she stated she takes the resident council meeting notes, types them up, and sends them to the managers. She stated she does not get a verbal or written response from the managers. She stated if she does not receive the same complaint again, she figured it was resolved. During an interview on 1/6/22 at 12:23 PM with the ADM, he stated his expectations on grievances was that they use the grievance process when something could not be immediately resolved. He stated as for a missing piece of laundry, they could be found pretty easily. He stated if it went for a couple of days without being found, then that was a different story. When asked what could be a potential negative outcome for the residents if they felt their grievances or concerns were not being responded to, he stated he had never been told the residents felt like they were not getting responses. Review of the facility's grievance form log reflected two grievances documented from the past year, 1/21 - 1/22, neither of which were regarding missing items. Review of the facility's Resident Council Minutes, dated 10/28/21 reflected the following grievances made by residents: - Still missing shirt with beadwork on shoulders - Missing brown shirt with vertical stripes - Missing black socks that stretch all the way to the knee - Missing pair of black jeans Review of the facility's Resident Council Minutes, dated 11/24/21, reflected the following grievances made by residents: - Still missing dark gray blouse with beadwork on the shoulders - Missing blue blazer Review of the facility's Grievances/Complaints Policy, revised April 2017, reflected the following: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff . The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. . 7. The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is the Facility Social Worker. 8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 Hydration Resident #16 Nutrition On 09/13/2021, the resident weighed 169.4 lbs. On 12/04/2021, the resident weighed 151.8 pounds which is a -10.39 % Loss. Sept had aspiration that lead to URI treated with abx. palliative care care Based on interview and record review the facility failed to review and revise quarterly a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for three (Resident #15, Resident #16, Resident #42) of ten residents reviewed for care plans, in that: The facility failed to: A.) update Resident #42's care plan to indicate his excessive thirst or that he was on a behavioral monitoring program in an attempt to redirect his desire for fluids. B.) update Resident #15's care plan to reflect current weight monitoring and current dining status. C.) update Resident #16's care plan to identify weight loss and interventions to address weight loss and change of diet. These failures placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental and/or psychosocial well-being. Findings included: A.) Review of Resident #42's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including moderate intellectual disabilities, Alzheimer's disease, down syndrome, delusional disorders, and major depressive disorder. Review of Resident #42's most recent MDS, dated [DATE], reflected a BIMS of 2, indicating a severe cognitive impairment. During an observation and interview on 1/4/22 at 12:40 PM revealed Resident #42 ambulating from his room utilizing his walker. His water jug was in the front basket on the walker, and he indicated he wanted it to be filled. LVN D stated he could not have any more water, and that he had already drank enough water. She stated that he drank so much water that he urinated on himself and was always sitting in a pool of urine. She stated he is urinating out all of his sodium. During an observation on 1/5/22 at 10:45 AM revealed Resident #42 in the hall attempting to get an aide to fill his water pitcher. LVN E told the aide that he could have ice, but no water. During an interview on 1/5/22 at 10:55 AM with the NP, she stated Resident #42's excessive thirst was a new issue for him. She stated he was now drinking so much water that his last lab results showed his sodium was low. She stated that Resident #42 tends to have stages where he perseverated on different things. She stated it was now liquids, but it used to be constantly picking at his skin. She stated he was now on a behavioral monitoring program in an attempt to redirect him when he requested water. During an interview on 1/5/21 at 1:25 PM with the DON, she stated if a resident was on a behavior monitoring program, a nurse would complete a behavior monitoring note when a resident had an episode or behavior. She stated Resident #42 tended to perseverate on different things, for example, he used to constantly want to shave and would carry around a razor. She stated the excessive thirst is new for him and a new plan was in development. She stated once a pattern of behaviors was recognized, the psychologist and SW would create a behavioral monitoring plan. She stated all behaviors should be documented in Resident #42's care plan. She was unable to locate any behavior monitoring notes in Resident #42's EMR. During an interview on 1/5/21 at 1:32 PM with the Psychiatrist, she stated she got involved when a resident had behaviors that were acute. She stated she did not see Resident #42 regularly anymore but was aware he was on a behavior monitoring plan for his excessive thirst. She stated the plan entailed limiting his water consumption. During an interview on 1/6/21 at 9:47 AM with the MDS Nurse, she stated she was responsible for care plans, but mostly focused on the nursing aspect. She stated other departments can update care plans. She stated they should be updated quarterly, annually, or on a daily basis depending on what was going on. She stated if a resident was on a behavioral monitoring program, it should be in their care plan because care plans served as a function as a way to show what was going on with each resident. Review of Resident #42's care plan, dated 12/20/21, reflected no documented evidence of his excessive thirst or him being on a behavioral monitoring program. B.) Review of Resident #15's face sheet printed 1/6/22 reflected a [AGE] year-old male admitted to the facility 11/2/18 with diagnoses including anoxic brain damage, dysphagia, gastrostomy, multiple contractures, anorexia, aphasia, MDD, hemiplegia, and multiple contractures. Review of Resident #15's MDS dated [DATE] reflected a BIMS assessment was not completed but staff assessed the resident's short- and long-term memory as OK indicating no memory problem. The MDS indicated no behaviors and no rejecting care during the reporting period. He required extensive assistance of one staff for all ADLs except he was totally dependent on staff for eating. The MDS also reflected that he received 51% or more of his calories through a tube feeding. Further review of Resident #15's MDS assessments reflected he had 5 assessments since his oral diet was discontinued. Annual assessments were completed 10/14/21 and 10/16/20, and quarterly assessments completed 7/15/21, 4/16/21, and 1/15/21. Review of Resident #15's physician order dated 4/24/19 reflected regular diet mechanical soft, thin liquids was discontinued 2/5/20. His most recent diet order was dated 10/6/20 and reflected, One can Two CAL HN (237cc) via g-tube five times per day. Review of Resident #15's care plan last reviewed on 10/18/21 reflected, Resident at risk for decreased oral intake/dehydration/weight loss r/t COVID-19 Pandemic, Assist resident to the dining room, set up meals and provide verbal cueing as needed, and monitor resident weight weekly per facility protocol for residents with g-tube. Review of Resident #15's weight record revealed his weight was documented 16 times, not weekly, from 1/21 through 12/21. Further review of the weight records revealed weekly weights have not been documented since his admission. Observation on 1/4/22 at 9:50 AM revealed resident sitting up in a wheelchair in his room. During an interview on 1/4/22 at 9:50 AM, Resident #15 answered questions by nodding or shaking his head. Resident shook his head indicating No when asked if he goes to the dining room for meals. During an interview on 1/4/21 at 9:53 AM with CNA A, she stated resident does talk sometimes, doesn't eat, and gets tube feeds. During an interview on 1/6/22 at 9:05 AM LVN E stated resident #15 received all of his medications and nutrition through his g-tube. During an interview on 1/6/22 at 10:30 AM, the MDS Nurse care plans should be revised with each assessment such as admission, quarterly and annual. She stated in general she was responsible for updating most of the care plan areas although dietary, activities and social services also updated the care plans. When asked if a diet was changed should the care plan be updated to reflect the change and she responded, yes. When asked what a reasonable time frame was to update the diet change she responded, Soon, because the care plan is like directions so you should be able to read the care plan and know what to do even if you didn't know what was going on. She stated most floor nurses probably would not update care plans. Asked if waiting two months to update a diet change was acceptable, she stated, No, it should be done sooner than that. During an interview on 1/6/21 at 10:48 AM, the DON stated care plans should be updated with changes and with the MDS assessments. She stated a diet change should be updated sooner than quarterly. C.) Review of Resident #16's face sheet printed 1/6/22 reflected an [AGE] year-old male admitted to the facility 8/29/16 with diagnoses including dysphagia pharyngoesophageal and oropharyngeal phases, GERD, hemiplegia and hemiparesis following cerebral infarction affecting dominate side, mild intellectual disabilities, disturbances of salivary secretion and vascular dementia. Review of Resident #16's MDS dated [DATE] reflected a BIMS score of 2 indicating severe cognitive impairment. He required extensive assistance with most ADLs but only supervision for eating. The MDS indicated a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months, no coughing or choking during meals, and complaints of difficulty or pain when swallowing. Review of Resident #16's physician order dated 9/10/21 reflected the diet was downgraded to, Regular diet, puree texture, nectar consistency. Review of Resident #16's care plan, last reviewed 12/6/21 reflected Resident has the potential for nutrition problem. Provide and serve diet as ordered. Serve regular diet, mechanical soft with nectar thick liquids. Resident is at nutritional risk . potential for decreased oral intake/dehydration/weight loss .r/t Covid-19 Pandemic . provide snacks and extra hydration as needed The care plan does not reflect dietary interventions, current diet, or actual weight loss. Review of Resident #16's weight records reflected the following: 6/14/21 174.4lbs, 7/5/21 172.8lbs, 8/6/21 169.4lbs, 9/13 169.4lbs, 10/12/21 160.4lbs, 11/5/21 155lbs, 12/4/21 151.8lbs. From 9/13/21 to 12/4/21 (3 months) Resident #16 had a 10.39% weight loss. From 6/14/21 to 12/4/21 (6months) Resident #16 had a 12.96% weight loss. During an interview on 1/6/22 at 10:30 AM, the MDS Nurse stated care plans should be revised with each assessment such as admission, quarterly and annual. She stated in general she was responsible for updating most of the care plan areas although dietary, activities and social services also updated the care plans. When asked if a diet was changed should the care plan be updated to reflect the change and she responded, yes. When asked what a reasonable time frame was to update the diet change, she responded, Soon, because the care plan is like directions so you should be able to read the care plan and know what to do even if you didn't know what was going on. She stated most floor nurses probably would not update care plans. Asked if waiting two months to update a diet change was acceptable, she stated, No, it should be done sooner than that. During an interview on 1/6/21 at 10:48 AM, the DON stated care plans should be updated with changes and with the MDS assessments. She stated time frames for updating a care plan could sometimes depend on the situation. Review of the facility's Care Plan Policy, revised April 2009, reflected the following: Policy Statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Policy Interpretation and Implementation: 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. 3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: a. Are resident oriented; b. Are behaviorally stated; . 5. Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved;