**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 4 (Resident #10) residents reviewed for abuse. The facility failed to ensure the housekeeping supervisor, per the facility's policy, immediately reported witnessed suspected roughness towards Resident #10 by CNA C on 09/07/24 to the Administrator, DON, or ADON. The housekeeper supervisor reported the allegation until 09/10/24. The housekeeper supervisor believed CNA C was rough with Resident #10 and wanted to see the video of the incident to see if CNA C was indeed abusive to the resident as she was not sure the incident occurred. Theses failures could place residents at risk for unsafe environment and further abuse. Findings included: Record review of the facility's policy and procedure, titled Abuse, neglect and exploitation policy dated 07/19/24 indicated in Part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by: prohibiting and preventing abuse, neglect, exploitation and misappropriation of resident property, investigating any such allegations. Training new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures and dementia management and resident abuse prevention. Reporting/Response - Report all alleged violations to the Administrator, state agency and to all other required agencies (e.g. law enforcement, adult protective services, etc. when applicable) within specified timeframes: Immediately but not later than 2 hours after the allegation is made. Record review of Resident #10's admission record dated 09/12/2024 indicated she was admitted to the facility on [DATE] with diagnoses of weakness, stroke, and depression. She was [AGE] years of age. Record review of Resident #10's care plan dated 07/17/2024 indicated in part: Focus: Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to vascular dementia. Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions: Resident needs assistance/escort to activity functions. Record review of Resident #10's MDS dated [DATE] indicated in part: BIMS = 12 indicating resident was moderately impaired. During an observation and interview on 09/11/2024 at 01:15 PM, Resident #10 was in her room sitting down in recliner awake and alert. Resident #10 was asked if she has had any issues with staff being rude or ugly to her and she said no that staff were very nice to her and she meant all staff and had no complaints about any of the staff. Resident #10 was asked if she had-had any problems with the staff being rude to her in the dining room some days ago, resident said no, resident then was asked specifically if she recalled an aide being rude or rough to her in the dining room due to her falling asleep at the dining room table. Resident #10 said that if she had fallen asleep then it was possible that staff had to really shake her up to get her to wake up as she was hard to arouse when asleep. Resident #10 said she did not feel like she had been mistreated by the aide and still had no complaints about the staff. During this interview Resident #10 did not appear to be in any distress and appeared to be at peace and comfortable at the facility. During a telephone interview on 09/11/2024 at 03:34 PM the housekeeping supervisor said she had witnessed the incident on Saturday September the 7th 2024 and waited until Monday September the 9th 2024 to report it in person to the Administrator. The housekeeping supervisor said unfortunately the Administrator was off on Monday, so she ended up not reporting it until Tuesday which was yesterday 09/10/2024. The housekeeping supervisor said she had not reported it right away because she first wanted to see the video of the incident to see if CNA C had indeed been abusive to Resident #10. The housekeeping supervisor said when she witnessed the incident on Sunday September the 7th it seemed that the CNA had been kind of rough with Resident #10 but that the resident had not cried out in pain or anything like that. The housekeeping supervisor said she was not sure if CNA C was indeed rough and the reason, she did not report it right away, she said the resident's family member was also present during the incident, but he had not said anything. The housekeeping supervisor said she had been trained to report abuse right away and she probably should have done that instead of waiting until Tuesday. The housekeeping supervisor said she had never seen CNA C being rude or rough to other residents and she had never heard of CNA C being abusive to residents. The housekeeping supervisor said if she did not report any type of abuse right away then the abuse could continue as the perpetrator would continue to have access to the residents. During a telephone interview on 09/12/2024 at 02:50 PM CNA C said on Saturday 09/07/2024 the residents were done with lunch, and the nursing staff were in the process of assisting the residents from the dining room back to their rooms. CNA C said Resident #10 would fall asleep in her wheelchair and could be hard to arouse at times. CNA C said she woke Resident #10 up and then wheeled her to her room. CNA C said at no time did she shake or talk ugly to the resident. CNA C said she would never mistreat any resident and that she loved her job and was very upset because she got suspended. CNA C said she had worked that Saturday 09/07/2024 and no one had said anything to her about being rude or rough with Resident #10. CNA C said she had also worked Sunday 09/08/2024 and was scheduled off for Monday and Tuesday 09/09/2024 through 09/10/2024 but that on Tuesday 09/10/24 the Administrator called her to come in and write a statement about what occurred and was then suspended and that currently she was still suspended. During an interview on 09/12/2024 at 04:10 PM the Administrator said she was aware that housekeeper supervisor should have not waited until Tuesday 09/10/24 to report a suspected allegation of abuse that she believed she witnessed on Saturday 09/07/24. The Administrator said the housekeeper supervisor had just recently been re-trained on reporting abuse immediately and did not understand why the supervisor had waited until Tuesday to report the allegation. The Administrator said the housekeeper supervisor failing to report the abuse immediately could lead to the perpetrator still working at the facility. The Administrator said she had viewed the video of the alleged abuse was could not verify if the abuse had indeed occurred by CNA C but had still suspended the CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made, or if the events that caused the allegation did not involve abuse or result in bodily injury not later than 24 hours, to Administrator for 1 of 4 residents (Resident #10 )reviewed for abuse in that: The housekeeper supervisor did not report that she thought she witnessed CNA C be rough with Resident #10 to the Administrator within 2 hours of the incident. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner. Findings included: Record review of Resident #10's admission record dated 09/12/2024 indicated she was admitted to the facility on [DATE] with diagnoses of weakness, stroke, and depression. She was [AGE] years of age. Record review of Resident #10's care plan dated 07/17/2024 indicated in part: Focus: Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to vascular dementia. Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions: Resident needs assistance/escort to activity functions. Record review of Resident #10's MDS dated [DATE] indicated in part: BIMS = 12 indicating resident was moderately impaired. During an observation and interview on 09/11/2024 at 01:15 PM, Resident #10 was in her room sitting down in recliner awake and alert. Resident #10 was asked if she has had any issues with staff being rude or ugly to her and she said no that staff were very nice to her and she meant all staff and had no complaints about any of the staff. Resident #10 was asked if she had-had any problems with the staff being rude to her in the dining room some days ago, resident said no, resident then was asked specifically if she recalled an aide being rude or rough to her in the dining room due to her falling asleep at the dining room table. Resident #10 said that if she had fallen asleep then it was possible that staff had to really shake her up to get her to wake up as she was hard to arouse when asleep. Resident #10 said she did not feel like she had been mistreated by the aide and still had no complaints about the staff. During this interview Resident #10 did not appear to be in any distress and appeared to be at peace and comfortable at the facility. During a telephone interview on 09/11/2024 at 03:34 PM the housekeeping supervisor said she had witnessed the incident on Saturday September the 7th 2024 and waited until Monday September the 9th 2024 to report it in person to the Administrator. The housekeeping supervisor said unfortunately the Administrator was off on Monday, so she ended up not reporting it until Tuesday which was yesterday 09/10/2024. The housekeeping supervisor said she had not reported it right away because she first wanted to see the video of the incident to see if CNA C had indeed been abusive to Resident #10. The housekeeping supervisor said when she witnessed the incident on Sunday September the 7th it seemed that the CNA had been kind of rough with Resident #10 but that the resident had not cried out in pain or anything like that. The housekeeping supervisor said she was not sure if CNA C was indeed rough and the reason, she did not report it right away, she said the resident's family member was also present during the incident, but he had not said anything. The housekeeping supervisor said she had been trained to report abuse right away and she probably should have done that instead of waiting until Tuesday. The housekeeping supervisor said she had never seen CNA C being rude or rough to other residents and she had never heard of CNA C being abusive to residents. The housekeeping supervisor said if she did not report any type of abuse right away then the abuse could continue as the perpetrator would continue to have access to the residents. During a telephone interview on 09/12/2024 at 02:50 PM CNA C said on Saturday 09/07/2024 the residents were done with lunch, and the nursing staff were in the process of assisting the residents from the dining room back to their rooms. CNA C said Resident #10 would fall asleep in her wheelchair and could be hard to arouse at times. CNA C said she woke Resident #10 up and then wheeled her to her room. CNA C said at no time did she shake or talk ugly to the resident. CNA C said she would never mistreat any resident and that she loved her job and was very upset because she got suspended. CNA C said she had worked that Saturday 09/07/2024 and no one had said anything to her about being rude or rough with Resident #10. CNA C said she had also worked Sunday 09/08/2024 and was scheduled off for Monday and Tuesday 09/09/2024 through 09/10/2024 but that on Tuesday 09/10/24 the Administrator called her to come in and write a statement about what occurred and was then suspended and that currently she was still suspended. During an interview on 09/12/2024 at 04:10 PM the Administrator said she was aware that housekeeper supervisor should have not waited until Tuesday 09/10/24 to report an allegation of abuse that she believed she witnessed on Saturday 09/07/24. The Administrator said the housekeeper supervisor had just recently been re-trained on reporting abuse immediately and did not understand why the supervisor had waited until Tuesday to report the allegation. The Administrator said the housekeeper supervisor failing to report the abuse immediately could lead to the perpetrator still working at the facility. The Administrator said she had viewed the video of the alleged abuse was could not verify if the abuse had indeed occurred by CNA C but had still suspended the CNA. Record review of the facility's policy and procedure, titled Abuse, neglect and exploitation policy dated 07/19/24 indicated in Part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by: prohibiting and preventing abuse, neglect, exploitation and misappropriation of resident property, investigating any such allegations. Training new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures and dementia management and resident abuse prevention. Reporting/Response - Report all alleged violations to the Administrator, state agency and to all other required agencies (e.g. law enforcement, adult protective services, etc. when applicable) within specified timeframes: Immediately but not later than 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one Resident (Resident #32) of one reviewed for Percutaneous Endoscopic Gastrostomy - PEG (a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent complications and aspiration. LVN B failed to check PEG tube residual prior to administering Resident #32's medication as ordered by the physician. This failure could place residents receiving tube feedings at risk for aspiration pneumonia, dehydration, and metabolic abnormalities which could result in additional medical treatment and a decline in the resident's health. Findings include. Record review of Resident #32's admission record dated 09/10/2024 indicated he was admitted to the facility on [DATE]. Diagnoses included dysphagia (difficulty swallowing), dementia and stroke. He was [AGE] years of age. Record review of Resident #32's order summary report dated 09/11/2024 indicated in part: Check PEG placement with stethoscope prior to feedings. Check residual before each feeding, if greater than 60ml, hold feeding and re-check in one hour. If less than 60ml may resume feeding. Record review of Resident #32's care plan dated 07/16/2024 indicated in part: Focus: Resident requires tube feeding (PEG) r/t Dysphagia. Goal: Resident will maintain adequate nutritional and hydration status and weight will stabilize, with no signs and symptoms of malnutrition or dehydration through review date. Interventions: Check for tube placement with stethoscope and gastric contents/residual volume per facility protocol and record. Hold feed if greater than (60) cc aspirate., hold feeding for 1 hour, recheck and if less than 60cc may resume. Record review of Resident #32's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. During an observation on 09/11/24 at 10:16 AM LVN B administered Resident #32's medication and feeding formula through the resident's PEG tube. LVN B placed the syringe without the plunger into Resident #32's PEG tube and did not check for residual by aspirating the stomach contents. LVN B then proceeded to administer the medications and the formula feeding through the resident's PEG tube. During an interview on 09/12/24 at 09:15 AM LVN B said that prior to administering Resident #32's medication she had checked for residual by placing the syringe in the resident's PEG tube and lowering the tube to see if any residual came up into the syringe. LVN B said she did not like to pull on the syringe plunger to check for residual because that would freak her out. LVN B said she thought that lowering the PEG tube to check for residual was a proper way to check for residual. LVN B said she was not aware of the facility's policy on how to check for PEG residual. LVN B said that it was her fault for not checking the residual correctly and should have aspirated for stomach contents. During an interview on 09/12/24 at 03:42 PM the DON was made aware of the observation of LVN B performing the PEG residual check for Resident #32. The DON said she had never heard of someone checking for PEG residual by lowering the PEG tube. The DON said the correct way was to place the syringe in the PEG tube and pull on the plunger to retrieve the stomach contents. The DON said the failure occurred because LVN B did not check for residual the correct way. The DON said she did rounds to monitor the nurses doing their job on a daily basis. During an interview on 09/12/24 at 04:12 PM the Administrator said LVN B was expected to follow the doctor's order and check for stomach contents before administering medications or feedings. The Administrator said she did not know why the LVN had not followed the orders. Record review of the facility's policy Gastrostomy tube procedure dated 05/28/98 indicated in part: Check tube placement and patency by aspirating stomach contents or by injecting 10 ml air into tube while listening with a stethoscope for a whooshing sound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 of 4 (Resident #2) residents reviewed for bed rails. The facility failed to ensure Resident #2's ½ side rail was installed correctly. The facility failed to correctly care plan Resident #2's side rails. These failures could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Review of Resident #2's admission Record, dated 9/11/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, paralysis affecting the right dominant side, and difficulty swallowing. Review of Resident #2's quarterly MDS Assessment, dated 8/15/24 revealed: Her mental status score was 9 of 15 (indicating moderate cognitive impairment). She needed substantial to maximum assistance with rolling to theft and right. She was incontinent of bowel and bladder. She was on an antidepressant, an antibiotic, an opiate, and a diuretic. Restraints were not identified as in use, including the use of side rails. Review of Resident #2's Care Plan updated 7/26/23 revealed: Resident #2 had an ADL self-care performance deficit related to Muscle Weakness (generalized), other lack of coordination, and need for assistance with personal care due to diagnosis of hemiplegia (paralysis), unspecified affecting right dominant side, Cerebrovascular Disease (stroke) and Major Depressive Disorder. The identified goal was Resident #2 will maintain current level of function in (ADLs) through the review date. Identified interventions included: Bed Mobility: Resident #2 required (substantial/maximum assistance) by (1-2) staff to turn and reposition and to move from lying to sitting on the side of the bed and sitting to lying, turn and reposition in bed every 2 hours, ensure proper padding and body alignment, keep heels off of the mattress. Bed Mobility: Resident #2 uses (1/4 rails) to maximize independence with turning and repositioning in bed. Review of Resident #2's Mobility Assessment, dated 8/15/24, revealed Resident #2's Ability to maintain normal head and trunk alignment was poor. Right side shoulder movement was poor. Left side shoulder movement was moderate. Right side elbow movement was poor. Left side elbow movement was moderate Right side wrist and elbow movement was poor. Left side wrist and elbow movement was moderate. Hip movement on the left and right side was poor. Knee movement of the left and right side were poor. Mobility and balance in all aspects was considered poor. Review of Resident #2's quarterly Restraint Evaluation, dated 8/8/24, revealed: contributing factors to the restraint were poor balance, confusion, short-term memory loss, and diagnosis contributing to increased risk of falls. The type of restraint in use was ½ side rails. The devices were indicated as an enabler and to promote greater functional independence. Review of the Restraint Consent, dated 7/28/22, revealed Resident #2's responsible party initialed for ½ bed rails as an enabler. Observation and interview on 9/10/24 at 12:30 p.m. revealed Resident #2 sitting in her doorway watching the traffic. Resident #2 gave permission for surveyor to look in her room. Resident #2 had a ½ side rail that was positioned at the halfway point of her bed which would restrict Resident #2's movement. Resident #2 stated the side rail did not bother her and it did not keep her in the bed if she did not want to be in it. In an interview on 9/12/24 at 11:31 a.m. the MDS Coordinator stated she also did the care plans for the facility. The MDS Coordinator stated she care planed Resident #2 as having ¼ side rails because that was what the staff told her (the MDS Coordinator) what Resident #2 had on her bed. The MDS Coordinator stated she updated Resident #2's care plan to reflect ¼ side rails the most recent care plan cycle and prior to that she (Resident #2) was care planned for ½ side rails. The MDS Coordinator stated Resident #2 had the old fashioned kind of side rails that screwed into the bottom of the bed. The MDS Coordinator admitted she did not go to look at Resident #2's room but got all of Resident #2's resident interviews after Resident #2's therapy exercises. The MDS Coordinator stated, it was my understanding everyone had new bed. Observation and interview on 9/12/24 at 12:11 p.m. the Maintenance Director stated the facility ordered 30 bed and he had so far put together 24 of them. He said he had to put them together and then inspect them. The Maintenance Director stated the old bed were operated by a crank or were a hospice provided bed. The Maintenance Director was shown Resident #2's rails which were now 75% of the way up the bed. The Maintenance Director looked at the rails and said that is not alright! The Maintenance Director checked the rail, and it was very loose. The Surveyor explained on 9/10/24 the rail was at the half- way point of the bed. The Maintenance Director said that will be changed as soon as possible. Someone tried to make these into rails. No one told me they were moving a rail. In an interview on 9/12/24 at 1:43 p.m. the DON stated the facility did not have a side rail policy. The DON stated the facility practice was to get a consent for half rails so if the facility decided it was needed as an enabler, they had the family sign for it. The DON admitted she had not been keeping up with the assessments to prove ongoing need for the side rails since she started working at the facility. The DON said the Maintenance Director, MDS Coordinator and her were talking about how Resident #2's side rail could get to the middle of the bed and the only thing they could think of was if the head of the bed was raised it might move the rail. The DON said Resident #2 was able to use the rail on one side and was able to hold onto it during incontinent care. The DON said she never considered the side rail a restraint. In an interview on 9/12/24 at 3:20 p.m. the Administrator stated the Maintenance Director informed her about the half rail. The Administrator said she did not know how it happened unless it wiggled that way and it loosened and maybe a CNA or housekeeper tightened it. The Administrator stated the Maintenance Director was swapping out beds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #1 and Resident #2) reviewed for care plans. 1. The facility failed to have a care plan in place to accurately address Resident #1 diagnosis of diabetes. 2. The facility failed to ensure Resident #2's care plan accurately reflected her ½ side-rail use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #1 Record review of the admission record indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had medical diagnoses that included Burn of unspecified degree of lower back, burn of third degree to left thigh, burn of third degree of right thigh, acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, hypertension (high blood pressure), and type II diabetes. Record review of Resident #1's Annual MDS assessment dated [DATE] revealed his Cognitive Skills for Daily Decision Making to be Cognitively intact. He required maximum assistance with transfers and was independent for all ADL's except for bathing. He relied on electronic wheelchair for mobility. Under section I for Active diagnosis Diabetes was selected. Record review of Resident #1's order summary dated 9/12/24 included, Pioglitazone HCl Tablet 30 mg - give 1 tablet by mouth one time a day related to type 2 diabetes mellitus with unspecified complications. Record review of Resident #1's care plan dated 09/11/2024 revealed no care plan for Diabetes. Interview on 09/12/24 at 10:41 AM with the MDS coordinator stated anything out of the ordinary will be in a care plan like specific request or needs, anything triggered by MDS, diagnosis. For diabetes there would need to be care planned to monitor resident because the exposure to hot and colds, hypo/hyper glycemia side effects, clean feet daily, podiatrist, if they have any infection consult doctors, any wounds watch closely nail care by licensed nurses. The MDS coordinator stated that she does not believe there to be a negative outcome for this specific resident to not have diabetes care planned because he does not have any complications due to his diabetes. RESIDENT #2 Review of Resident #2's admission Record, dated 9/11/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, paralysis affecting the right dominant side, and difficulty swallowing. Review of Resident #2's quarterly MDS Assessment, dated 8/15/24 revealed: Her mental status score was 9 of 15 (indicating moderate cognitive impairment). She needed substantial to maximum assistance with rolling to theft and right. She was incontinent of bowel and bladder. She was on an antidepressant, an antibiotic, an opiate, and a diuretic. Restraints were not identified as in use, including the use of side rails. Review of Resident #2's Care Plan updated 7/26/23 revealed: Resident #2 had an ADL self-care performance deficit related to Muscle Weakness (generalized), other lack of coordination, and need for assistance with personal care due to diagnosis of hemiplegia (paralysis), unspecified affecting right dominant side, Cerebrovascular Disease (stroke) and Major Depressive Disorder. The identified goal was Resident #2 will maintain current level of function in (ADLs) through the review date. Identified interventions included: Bed Mobility: Resident #2 required (substantial/maximum assistance) by (1-2) staff to turn and reposition and to move from lying to sitting on the side of the bed and sitting to lying, turn and reposition in bed every 2 hours, ensure proper padding and body alignment, keep heels off of the mattress. Bed Mobility: Resident #2 uses (1/4 rails) to maximize independence with turning and repositioning in bed. Observation and interview on 9/10/24 at 12:30 p.m. revealed Resident #2 sitting in her doorway watching the traffic. Resident #2 gave permission for surveyor to look in her room. Resident #2 had a ½ side rail that was positioned at the halfway point of her bed which would restrict Resident #2's movement. Resident #2 stated the side rail did not bother her and it did not keep her in the bed if she did not want to be in it. In an interview on 9/12/24 at 11:31 a.m. the MDS Coordinator stated she also did the care plans for the facility. The MDS Coordinator stated she care planed Resident #2 as having ¼ side rails because that was what the staff told her (the MDS Coordinator) what Resident #2 had on her bed. The MDS Coordinator stated she updated Resident #2's care plan to reflect ¼ side rails the most recent care plan cycle and prior to that she (Resident #2) was care planned for ½ side rails. The MDS Coordinator stated Resident #2 had the old fashioned kind of side rails that screwed into the bottom of the bed. The MDS Coordinator admitted she did not go to look at Resident #2's room but got all of Resident #2's resident interviews after Resident #2's therapy exercises. The MDS Coordinator stated, it was my understanding everyone had new bed. Review of facility policy titled Comprehensive Care Plans undated revealed, in part: A comprehensive person-centered care plan is developed and implemented for each resident, consistent with the resident's rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 2 of 4 residents (Resident #2 and Resident #3) reviewed for dietary services in that: The residents with puree diet did not receive consistent portion sizes of the puree desert. The facility served zero sugar pudding cups in place of the fortified pudding for lunch for Resident #2 and Resident #3. These failures could place residents at risk for poor food intake, weight loss, and diminished quality of life. Findings included: Observation and interview of the noon meal on 9/11/24 at 11:25 a.m. revealed six 4 oz bowls of pureed dessert - three of the bowls were almost completely full, one approximately half full, and the last two were approximately 25% full. At 11:52 a.m. the first puree desert went out. The DM said the dessert bowls did not have the same portion sizes. The DM also saw the sugar free pudding left out for the fortified meal program and stated zero sugar pudding was not appropriate for a fortified program. The DM stated there was a weight loss problem in the building. In an interview on 9/11/24 at 1:38 p.m. the DM stated she thought the kitchen observation went well. She stated fortified meal not being served was completely on her since she did not notice the sugar free pudding was laid out. In an interview on 9/11/24 at 2:38 p.m. DM stated there were five residents on a fortified diet. In an interview on 9/11/24 at 2:48 pm. the Administrator stated she expected to see fortified foods to have recipes. The Administrator said generally there was hot cereal for breakfast and pudding for lunch. The Administrator said there was usually something in the food to add calories or protein like butter, powdered milk. The Administrator stated zero sugar pudding cups would not be fortified. The Administrator said she had told the dietary department they could not just give residents a pudding cup and have it be considered a fortified diet. RESIDENT #2 Review of Resident #2 admission Record, dated 9/11/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, paralysis affecting the right dominant side, and difficulty swallowing. Review of Resident #2's quarterly MDS Assessment, dated 8/15/24 revealed: Her mental status score was 9 of 15 (indicating moderate cognitive impairment). She ate with set-up from staff. She weighed 150 pounds and had a weight loss of 5% or more in the last month or 10% or more in the last 6 months was no or unknown. Review of Resident #2's Care Plan, revised on 5/23/24 revealed Resident #2 had a nutritional problem or potential nutritional problem as evidenced by signs or symptoms or dehydration and history of skin break down, weight loss, and therapeutic diet of Regular with large egg portion with breakfast and fortified meal program. The goal was Resident #2 would maintain adequate nutritional status as evidenced by maintaining weight within (x)% of 130 pounds, no signs or symptoms of malnutrition and consuming at least 75% of at least 2 meals daily though the review date. Identified interventions included: provide and serve diet as ordered. Monitor and record each meal. Review of Resident #2's Order Summary revealed orders large egg portions with breakfast, fortified meal plan dated 1/9/23. Review of Resident #2's Nutrition/ Dietary Note, dated 6/11/24 revealed her weight had increased 12 pounds in the last three months. RESIDENT #3 Review of Resident #3's admission Record, dated 9/12/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, protein-calorie malnutrition, and stroke. Review of Resident #3's Annual MDS Assessment, dated 8/29/24, revealed: She had a mental status score of 15 of 15 (indicating she was cognitively intact). She needed set-up assistance from the staff to eat. She weighed 126 points and had significant weight loss not on physician-prescribed weight loss program. Review of Resident #3's Care Plan revised on 6/5/24 revealed Resident #3 had a nutritional problem or potential nutritional problem as evidenced by need for mechanically altered diet (pureed texture) and need for therapeutic diet of large egg portions with breakfast, and fortified meal plan due to weight loss and a stage II pressure ulcer (bed sore) to right gluteus (butt cheek). The identified goal was Resident #3 would maintain adequate nutritional status as evidenced by maintaining weight within 10% of 129 pounds, no signs or symptoms of malnutrition, and consuming at least 75% of at least two meals daily through the review date. Identified interventions included Resident #3 currently was eating tomato soup or soft/pureed soup with no texture related to pain in gums/mouth. Snacks with protein twice a day, chocolate milk twice a day. Review of Resident #3's Order Summary Report, dated 9/11/24, revealed diet orders of regular diet pureed texture, large egg portions with breakfast and fortified meal plan, start date 6/21/24. Review of Resident #3's Nutrition Dietary Note dated 9/6/24 revealed she had gained 5 pounds in the last 30 days and the dietician felt her weight fluctations were likely due to medications. Review of portion sizes for the 9/11/24 menu revealed residents were to receive a #20 scoop (approximately 3 Tablespoons, or slight less than half the 4 oz bowl). Review of the Fortified Diet Program, undated, revealed: Foods/Snacks suggested to added calories and/or protein: cake, cheese/cottage cheese, chocolate/flavored milk, cookies, dry cereal, ice cream/ice cream bars, pies, pudding, snack crackers, yogurt. Food items/Ingredients to add additional calories: some individuals primary need to increase calories in the diet but have difficulty consuming additional volume. This may be the case for persons with decreased appetite, under nutrition, unintentional weight loss or other conditions. The following are suggestions of ways to increase calories by adding ingredients to foods already offered at the meal. Margarine or butter; mayonnaise; cream/ half or half, sour cream, honey, corn syrup, jam and jelly, cheese, non-fat dried milk, brown sugar and sugar, whipped cream. Recipe for fortified pudding: Portion sized ½ cup. Ingredients: Milk, whole, milk non-fat dry, pudding mix instant, any flavor; whipped topping dry, prepare according to package directions. Recipe for fortified soup. Portion size: 6 oz Ingredients: condensed soup, condensed cream, whole milk, shredded cheddar cheese.

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 in the facility's only kitchen. The facility failed to ensure: Staff did not re-glove using the same single use glove. Staff did not cross contaminated the kitchen after touching the trash can lid and the did not immediately wash their hands. Staff did not handle food with their bare hands. Staff did not put food on cooking surfaces without ensuring they were covered. The walk-in refrigerator was maintained in a sanitary manner. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Observation on 9/10/24 at 10:24 a.m. of the dry storage revealed a container of bullion on the floor underneath the shelves. The cook picked it up and put it on the shelf with the rest of the containers of bullion without wiping it down. Observation on 9/10/24 at 10:30 a.m. of the walk-in refrigerator revealed: the eggs used were not pasteurized. There was a dried puddle of dripped food on the floor. There was food debris shoved to the back of the corners of the wall and corners underneath the shelves. Observation of the noon meal preparation on 9/11/24 beginning at 9:53 a.m. revealed: At 10:04 a.m. [NAME] D took her glove off, pulled a spoon out of the drawer and pulled the same glove back on. At 10:50 a.m. [NAME] E lifted the lid of the trash can with her gloved hand, threw something out, went to the refrigerator opened it, put in a cup of fluid, picked up some unused cups off the table, returned them to the shelf placed them with the other clean, unused cups and then took off her gloves and washed her hands. At 11:30 [NAME] G cut open a bag of lettuce for the evening meal with his bare hands, emptied the lettuce into a large bowl and then evened the lettuce in the bowl by pushing it with his bare hands. At 11:52 a.m. [NAME] E opened the oven drawer to show surveyor that [NAME] G put potatoes on the rack in the oven with no foil and not on a pan. In an interview and observation on 9/11/24 at 1:38 the DM stated she thought the kitchen task went well until [NAME] G came in. The DM said usually when she told [NAME] G to correct something he did. The DM looked at the walk-in refrigerator and stated under the wire shelves were not clean and had food debris just pushed to the back. Surveyor reviewed other observations made through the cooking preparation. The DM stated when [NAME] E did not wash her hand after touching the trash can lid and then touched other surfaces was cross-contamination. The DM asked why someone would take off a single use glove and put it back on. The DM said it was not acceptable to handle food with a bare hand at any time because of the risk of contamination. In an interview on 9/11/24 at 2:48 p.m. the Administrator was informed of the kitchen observations. The Administrator asked for clarification that food was handled with bare hands and not by the packaging. The Administrator stated no one re-gloves when informed of the staff re-gloving to prepare food. The Administrator said she brought the foot pedal trash cans because the kitchen had so many problems with cross contamination prior to this survey. Review of the cleaning schedule for the kitchen revealed the evening dietary aide was responsible for cleaning refrigerators out inside and out daily and the last time this was done was 9/5/24. Review of in-service dated 7/10/24 revealed: Bare Hand Contact with Food and use of Plastic Gloves. Policy: single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Staff will use clean barrier such as single-use gloves, tongs, deli paper, and spatulas when handling food. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: after handling garbage or garbage cans. (Cook D attended the in-service)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #32 and Resident #1) of 5 residents reviewed for infection control. CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #32. CNA's I & J failed to use enhanced barrier precautions (EBP) during transferring Resident #1 from his bed to his wheelchair. (EBP - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). These failures could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #32's admission record dated 09/10/2024 indicated he was admitted to the facility on [DATE]. Diagnoses included dementia and stroke. He was [AGE] years of age. Record review of Resident #32's care plan dated 07/16/2024 indicated in part: Focus: Resident has incontinence r/t DX. Dementia, Cerebral infarction (stroke). Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Resident uses (large) disposable briefs. Clean peri-area with each incontinence episode. Record review of Resident #32's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Urinary continence = Always incontinent. Bowel continence = Always incontinent. During an observation on 09/10/24 at 10:54 AM CNA A performed incontinent care for Resident #32. CNA A put gloves on and undid Resident #32's brief from the back and wiped his rectal area with some wet wipes. It was noted that the resident had some bowel movement. CNA A continued to wipe the resident's rectal area and then removed the soiled brief. While still wearing the same gloves, CNA A took a clean brief and placed it under the resident's buttocks. While still wearing the same gloves, CNA A then wiped Resident #32's penis with some wet wipes. During an interview on 09/10/24 at 01:50 PM CNA A said she should have changed gloves after she wiped Resident #32's rectal which had some bowel movement. CNA A said she should have changed gloves before she wiped the resident's penis area as she was still wearing the same gloves, she used to wipe the bowel movement. CNA A said she normally changed her gloves before going from dirty to clean. CNA A said if she did not change her gloves that could lead to cross contamination. CNA A said she had gotten nervous and forgot to change her gloves before applying the new brief and cleaning Resident #32's penis area. During an interview on 09/11/24 at 05:45 PM the DON was made aware of the observation of incontinent care performed by CNA A. The DON said CNA A should have changed her gloves and washed her hands before touching the new brief and performed incontinent care to Resident #32's penis area. The DON said they monitored staff for incontinent care by performing competency checks. The DON said if the CNA did not change her gloves at the appropriate time that could lead to the spread of germs and infections. The DON said the failure probably occurred because the CNA got nervous. During an interview on 09/12/24 at 04:15 PM the Administrator said CNA A should have changed her gloves before going from dirty to clean. The Administrator said the CNA probably got nervous and did not change her gloves as indicated. The Administrator said the CNA not changing her gloves could lead to cross contamination. Resident #1 Record review of the admission record indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had medical diagnoses that included Burn of unspecified degree of lower back, burn of third degree to left thigh, burn of third degree of right thigh, acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, hypertension (high blood pressure), and type II diabetes. Record review of Resident #1's Annual MDS assessment dated [DATE] revealed his Cognitive Skills for Daily Decision Making to be Cognitively intact. He required maximum assistance with transfers and was independent for all ADL's except for bathing. He relied on electronic wheelchair for mobility. Under section H for Bowel and Bladder indwelling catheter was selected. Under section M - Skin conditions resident has a stage 1 or greater, a scar over a bony prominence, or a non-removable dressing or device. was selected. Record review of Resident #1's order summary dated 9/12/24 included, Enhanced Barrier Precautions every shift related to wounds/Foley catheter Observation of a Hoyer lift transfer on 09/11/24 at 04:00 PM with CNA I and CNA J for Resident #1 revealed Neither CNA I or CNA J donned EBP for the transfer of the resident. Both did wash hands and donned gloves prior to direct care. During the transfer both CNAs touched the resident's bed, bedding, clothes, wheelchair, and foley catheter tubing and bag. An interview on 09/11/24 at 04:30 PM with both CNA I and CNA J both revealed they did not believe they needed to don full enhanced barrier precaution PPE due to not directly touching the foley catheter. Both stated it was their understanding that unless they were directly cleaning or maneuvering the foley they do not have to have on extra PPE. Record review of the facility policy titled perineal care/Incontinent care-male dated 09/20/2007 indicated in part: It is the policy of this facility to provide perineal/incontinent care on male residents as needed without contaminating the urethral area with germs from the rectal area. Properly clean hands before procedures. Wash rinse and dry the remaining area including the penis, scrotum and outward to the thighs. Turn resident on side. Wash, rinse and dry the remaining area including the rectum and buttocks without returning to the urethral area. Wash, rinse and dry from clean to dirty area leaving entire area clean and dry. Remove soiled linen and gloves and place in appropriate place. Wash hands or use hand sanitizer. Record review of the facility undated policy titled Handwashing policy and procedure indicated in part: Handwashing shall be regarded by this facility as the single most important means of preventing the spread of infections. All personnel shall follow our established handwashing procedure to prevent the spread of infection and disease to other personnel, residents and visitors. Employees must perform appropriate twenty (20) second handwashing procedure under the following conditions: After removing gloves. The use of gloves does not replace handwashing. Record review of the facility document titled Infection control guidelines for all nursing procedures dated 07/26/2016 indicated in part: Purpose - to provide guidelines for general infection control while caring for residents. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Employees must wash their hands for 10 to 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions - Before and after direct contact with residents; After removing gloves.

Based on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage (January 2023, February 2023, and March 2023). The facility did not have the required 8 consecutive hours of RN coverage during the months of January 2023 (4 days), February 2023 (3 days), and March 2023 (1 days). This failure could place residents at risk for not having their nursing care and medical needs met. Findings included: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 08/04/2023 revealed No RN Hours was triggered for the fiscal year Quarter 2 2023 (January 1 - March 31). The infraction dates were 01/08 (SU); 01/15 (SU); 01/21 (SA); 01/22 (SU); 02/04 (SA); 02/05 (SU); 02/12 (SU); 03/11 (SA); 03/18 (SA). Record review of the January 2023 time sheets indicated no RN worked on Sunday 01/08/23, Sunday 01/15/2023, Saturday 01/21/2023, and Sunday 01/22/2023. Record review of the February 2023 time sheets indicated no RN worked on Saturday 02/04/2023, Sunday 02/05/2023, and Sunday 02/12/2023. Record review of the March 2023 time sheets indicated no RN worked on Saturday 03/11/2023. In an interview on 8/10/23 at 1:50 PM, the ADON stated that the facility had requested agency RN coverage for all the days listed on the PBJ report. She stated that the days listed on the report were all due to last minute call ins and because they were such a rural facility, getting someone to cover the shifts was very difficult. The ADON stated that the facility used multiple staffing agencies from surrounding cities, and they were not able to get anyone last minute for those shifts. She stated the facility did not have a policy to address the time frame for calling in, and that employees were instructed to call in in a timely manner so that management could try to cover the shift. The ADON stated that the facility had four RNs on staff and was using agency RNs for weekend coverage to avoid having any gaps in coverage like what they experienced in January, February, and March. She stated there have been no staffing issues since March 2023. In an interview on 8/10/23 at 2:15 PM, the DON stated that on the dates listed on the PBJ report for no RN coverage, the facility was unable to get coverage from any of their contracted staffing agencies. She stated that the facility used 4 staffing agencies routinely, but they had contracts with 11. She stated that some of the agency contracts were only for long-term staffing, so they were not contacted. She stated the agencies that were for short-term contracts did not have anyone available to send to fill the shifts. The DON stated all shifts listed on the PBJ report for no RN coverage were last minute call-ins. She stated the call-ins in January were due to family deaths and were unavoidable. She stated the facility only had 2 RNs on staff in January 2023, and 1 full time RN and 1 PRN RN in February 2023 and March 2023. At the time of survey, there were 4 staff RNs (including the DON) and the rest are agency. The DON stated the facility had been advertising for RN positions but because of the rural location of the facility there were a limited number of applicants. The DON stated the facility had a staff satisfaction PIP in place to help with RN retention and that she had petitioned the facility's board of directors for salary increases to help bring in more applicants. She stated there had been no staffing issues since March. In an interview on 8/10/23 at 3:20 PM, the Administrator stated that the two RNs scheduled to work in January were aunt and niece and they had deaths in the family so the call-ins were related. The facility tried to have all shifts covered but, on those occasions, they were not able to find anyone through the agencies they contracted with. She stated that from January 2023 through March 2023, they did not have any other RNs employed at the facility. She stated the facility had a long stretch where they were advertising for RN positions with no applicants. The Administrator stated that due to the rural location of the facility it was difficult for them to find staff. She stated that currently, they had several RNs on staff and agency RNs available and the DON and ADON were aware of the need to have RN coverage every day. She stated RN coverage had not been an issue since March 2023.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents, 1 of 1 Medication Carts and 1 of 1 Medication Storage Rooms reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include two expired cards of Morphine Sulfate 15mg tablets. - The facility failed to ensure the Medication Storage Room did not contain one expired card of Baclofen 10 mg and one expired box of Albuterol Sulfate Inhalation Solution 1.25mg/3ml. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Included: Medication Storage Room In an observation on 08/09/23 at 10:00 AM, inventory of the Medication Room with CMA A revealed: - one card (83 tablets) of Baclofen 10mg, expired 08/02/23 - one box (24 packages) of Albuterol Sulfate Inhalation Solution 1.25mg/3ml, expired 07/23 Medication Cart In an observation 08/09/23 at 10:45AM, inventory of the Medication Cart with CMA A revealed: - one card (8 tablets) of Morphine Sulfate 15mg, expired 08/02/23 - one card (5 tablets) of Morphine 15mg, expired 08/02/23 In an interview on 08/10/23 at 9:00 AM, the DON stated the night shift nurse checks the expired meds on the 25th of each month and the Pharmacist comes out each month and hand picks meds to review for expiration dates. The DON stated there was a policy regarding checking and handling of expired meds. In an interview on 08/10/23 at 2:15 PM, CMA A stated the night nurse checks for expired meds when she orders meds. The MA stated she also checks for expired dates on the medications before she administers the medication. In an interview on 08/10/23 at 3:20 PM, the Administrator stated she wrote the policy on Drugs and Biologicals Distribution and would implement retraining and monitoring of the staff to ensure the policy was followed. Record review of the facility policy titled Drugs and Biologicals Distribution updated on 10/11/2018 reads in part: The facility will do a monthly inventory of all drugs and biologicals to check expiration dates and ensure expired drugs do not remain stored in areas where they are available for continued use. This monthly inventory of expiration dates will be done in all med storage areas, including med storage refrigerator and all medication and treatment carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for one (Resident #1) of one resident reviewed for discharge assessments. The facility failed to complete and transmit Resident #1's and discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records. Findings include: Record review of Resident #1's admission record dated 06/28/22 indicated she was admitted to the facility on [DATE] with diagnoses of COVID-19 and muscle weakness. Also indicated discharged date of 03/16/22, she was [AGE] years of age. Record review of Resident #1's electronic MDS assessments revealed Resident #1 did not have a discharge MDS completed and transmitted. The discharge MDS was in progress on 06/28/22 and was greater than 120 days late . During an interview on 06/28/22 at 04:30 PM, the MDS Coordinator said she had just noticed she had not transmitted Resident #1's MDS. She said she just missed it but would get that done right now, she also said it would probably not get accepted now since it was late. During an interview on 06/29/22 at 11:10 AM, the Administrator said the MDS coordinator had forgotten to complete Resident #1's MDS timely. Said the DON would monitor the MDS coordinator to make sure they were done timely. Said the MDS just got missed and it was an isolated incident. Record review of facility's undated policy, resident assessment policy and procedure indicated in part: Facility will electronically transmit to CMS resident entry and death in facility tracking records required by the RAI and OBRA assessments, including admission, annual, quarterly, significant change, significant correction and discharge assessments. Automated data processing requirement: The facility will complete an MDS for a resident by entering MDS data into the facility's assessment software within 7 days after completing the MDS and electronically transmit the MDS data to CMS within 14 days after completing the MDS.

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 in the facility's only kitchen in that the facility: - failed to label and date food items. - failed to maintain cleanliness in the kitchen. - kitchen staff did not practice proper sanitization. - failed to store plates/bowls inverted. - failed to maintain clean equipment (refrigerator and food prep table). These failures could place residents who received meals prepared in the kitchen at risk for food borne illness and cross-contamination. The findings include: Observation of kitchen on 06/27/2022 between 11:35 AM - 12:10PM revealed the following: - 3 shelf rolling cart placed in between steam table and clean side of dishwasher table being used for storage of plates, divided plates, bowls, and serving trays, uncovered and all bowls, plates and trays stored resident/food contact surface side up - Large stand mixer on raw wood cart that was approximately 6-8 inches off the floor next to stove observed with no protective cover - Refrigerator doors visibly dirty with dry, flaky white substance noted at door handles - Cabinet doors above industrial coffee machine have exposed wood which could not be sanitized - Freezer noted with tray holding 2 plastic wrapped cuts of meat with no label or date - Stack of disposable food trays with fold over lids stored on shelf not inverted - 2 approximately 6-by-6-inch floor tiles completely detached from floor at floor drain in front of dishwasher - 3 approximately 6-by-6-inch floor tiles completely detached from floor in front of sink - Tape around storage shelf under food prep table holding pots and pans, visibly dirty and peeling off in large pieces at 2 of 4 corners; this tape was curling upwards toward the pots and pans on the shelf - [NAME] observed using thermometer that was sitting uncovered on dirty counter to check food temperatures without cleaning probe with alcohol prior to inserting into food for 3 separate containers, using a rag to wipe food off in between uses before getting alcohol pads to clean probe - Food prep table visibly dirty with food particles for 45 minutes after meal prep completed During observation and interview on 06/28/22 at 02:30 PM, [NAME] A observed placing clean cutting board with lettuce and tomatoes on prep table without sanitizing prep surface, he began chopping lettuce and tomatoes for dinner salad. When asked if he had cleaned the table first, he said no. [NAME] A removed everything from prep table, changed his gloves and sanitized the surface. He then resumed chopping vegetables. In an interview on 06/28/22 02:40 PM, the Food Service Director stated her expectation was all surfaces are to be sanitized immediately before and after use. She stated [NAME] A should have wiped the prep table down before he began chopping food on it. Observation on 06/28/22 at 02:45 PM, revealed rolling cart used for storage of plates, bowls and remained uncovered with plates, bowls, and trays resident/food contact surface side up. Observed a fly walking across one plate on the cart. In an interview on 06/28/22 03:00 PM, [NAME] A stated the cart holding the plates, bowls and trays has been kept in the same spot with everything face up since he started working in the facility around 5 months ago. He stated that he believed it has always been stored that way. He stated that he understood the reason for the pots and pans to be kept inverted when not in use but had never thought about the need for plates and bowls to be stored the same way. In an interview on 06/28/22 at 3:05 PM, the Food Service Director stated that pots and pans are to be stored inverted. She stated that she was unsure why they have not been storing plates, bowls, and trays in the same way. She stated that they have never stored plates, bowls and trays inverted, nor have they ever placed a cover over they cart that they are stored on. In an interview on 06/29/22 at 12:35 PM, the Administrator stated that she was unsure what the policy was for sanitizing prep surfaces in the kitchen. She stated that she assumed it was to be done when the kitchen staff first arrived in the morning and before they let at night, but that she would have to check with the Food Service Director to find out what the facility policy indicated. She stated she was unaware of what the policy was for storing resident food service equipment and dinnerware. Review of facility's policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated December 2008 on 06/29/22 revealed, in part, All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Review of facility's policy, Preventing Foodborne Illness - Food Handling dated November 2010 an 06/29/22 revealed, in part, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. Review of facility's policy, Refrigerators and Freezers dated December 2008 on 06/29/22 revealed, in part, All food shall be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Expiration dates on unopened foods will be observed and 'use by' dates indicated once food is opened. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of facility's policy, Sanitization dated October 2008 on 06/29/22 revealed, in part, The food service area shall be maintained in a clean and sanitary manor. All kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. All utensils, counters, shelves, and equipment shall be kept clean, maintained and in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solution. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.