**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 4 of 29 sampled residents, the facility did not provide a safe, clean, comfortable and homelike environment, which included housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, resident rooms were observed to have fly strips that were covered in flies that had been hung for an unknown amount of time. Resident identifiers: 8, 24, 34 and 47. Findings Include: On 4/22/24 at 11:23 AM, an observation was made in the 100 and 200 hall. Fly strips with dead flies were found in room [ROOM NUMBER] and room [ROOM NUMBER]. On 4/22/24 at 12:27 PM, an observation was made of room [ROOM NUMBER] with a fly strip present. Multiple dead flies were observed stuck to the paper. On 4/22/24 at 2:56 PM, an observation was made of room [ROOM NUMBER] with a fly strip hanging from the ceiling. The fly strip was visible from the resident hallway and had multiple dead flies. On 4/22/24 at 12:54 PM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated they were responsible for cleaning resident rooms. HK 1 stated they never touched the fly strips. HK 1 stated the fly strips drove them crazy. HK 1 stated they wondered how the flies were getting in the building and believed it was because of the open doors. HK 1 stated they knew the flies were inside since they were stuck on the fly strips. HK 1 stated they had accidentally touched one of the fly strips with their head recently and was immediately grossed out. HK 1 stated they did not have extra fly strips in their supply area and they were unaware of where to find more. On 4/23/24 at 8:46 AM, an interview was conducted with resident 8. Resident 8 stated that she does not know how long the fly strip had been in her room. Resident 8 stated that she was told that the fly strip needed to be up in her room to help with gnats. On 4/23/24 at 11:12 AM, an interview was conducted with resident 34. Resident 34 stated she was unsure how long the fly strip had been up in the corner of her room. Resident 34 stated that it had been there long enough to have dead flies attached to it. Resident 34 stated that no one had come to check on the fly strip or to remove it. On 4/23/24 at 11:19 AM, an interview was conducted with resident 47. Resident 47 stated that the fly strip was placed in his room last summer. Resident 47 stated that he did not remember asking for the fly strip to be placed in his room. Resident 47 stated that there were a lot of flies in the summer inside the facility. On 4/24/24 at 10:04 AM, an interview was conducted with resident 24. Resident 24 stated that she asked for the fly strip about one year ago and it has never been changed or removed. On 4/24/24 at 9:30 AM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that fly strips went up in spring or late fall. The Maintenance Director stated that some residents had a hard time keeping the food from getting flies. The Maintenance Director stated that residents had to ask for the fly strips. The Maintenance Director stated that there were some fly strips in common areas and ultraviolet (UV) plug in lights to help combat the flies in the facility. The Maintenance Director stated that fly strips were changed monthly or more often if a lot of flies started to accumulate. The Maintenance Director stated that residents asked to have the fly strips taken down. On 4/25/24 at 10:27 AM, an interview was conducted with the Administrator (ADM). The ADM stated that a pest company sprayed the facility monthly. The ADM stated that UV lights had been added to areas in the facility to help cut down on insects. The ADM stated that fly strips were hung up in resident rooms if residents complain about flies. The ADM stated that the Maintenance Director kept a log of what rooms had the fly strips in them. The ADM stated that he knew that the strips were hung up in the spring and fall and that was when the flies were the worst in the building. On 4/25/24 at 11:35 AM, the log of the fly strips was reviewed. Rooms 101 (Resident 24) and room [ROOM NUMBER] (Resident 8) were not included on the log as having fly strips in their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility did not provide sufficient support personnel to safely and effectively carry out the function of the food and nutrition services. Specifically, meals were served later than the posted meal time, there were contradicting meal times provided to surveyors verses posted in the dining room and residents complained of late meals. Resident identifiers: 17, 30, and 68. Findings include: On 4/22/24 at 10:38 AM, an interview was conducted with [NAME] 1. [NAME] 1 stated the 200 hall cart was served, then 100 and 300 hallway, then the other 300 hallway cart, the independent residents in the main dining room and then residents who required assistance. [NAME] 1 stated she started serving at 11:45 AM. On 4/22/24 at 12:01 PM, the meal times were posted in the main dining room. The meal times for lunch were the hallways were 12:00 PM, the assisted dining was served at 12:15 PM and independent was served at 12:30 PM. The meal times provided by the Administrator (ADM) upon entrance to the facility revealed the first hall cart for the lunch meal was to be delivered at 12:00 PM and the last cart was delivered at 12:30 PM. The dining room was to be served at 12:30 PM. On 4/22/24 at 12:12 PM, an announcement through the facility was observed. The staff member announced the hall cart was ready. The hall meal cart was observed at the end of the 100 hallway outside the dining room. On 4/22/24 at 12:13 PM, the meal cart was observed to be taken to the 200 hallway at 12:13 PM. The first tray was delivered to room [ROOM NUMBER]. On 4/22/24 at 12:32 PM, an observation was made of a meal cart in the 100 hallway. An observation was made of the meal cart transported to the 300 hallway. An observation was made of the hall trays to be delivered. On 4/22/24 at 12:35 PM, an observation was made of the facility dining room. 2 residents were observed in the dining room. On 4/22/24 at 12:43 PM, an observation was made of the 300 hallway meal cart being delivered. On 4/22/24 at 12:54 PM, an observation was made of the 400 hallway meal cart. The meals from the cart were done being serving at 12:59 PM. On 4/22/24 at 1:02 PM, an observation was made of the main dining room. Meals were observed to be served in the dining room. On 4/24/24 at 12:07 PM, an observation was made of lunch tray service in hall 200. The first tray was served. On 4/24/24 at 12:22 PM, an observation was made of lunch tray service in hall 100. The first tray was served. On 4/24/24 at 12:24 PM, the ADM stated to resident 68 that his lunch would be served to him within 5-10 minutes in hall 400. On 4/24/24 at 12:25 PM, an observation was made of lunch tray service in hall 300. The first tray was served. On 4/24/24 at 12:46 PM, an observation was made of lunch tray service in hall 400. On 4/24/24 at 12:22 PM, an observation was made of the 100 hallway meal cart delivered. On 4/24/24 at 12:26 PM, an observation was made of the 300 hallway meal cart delivered. On 4/24/24 at 12:44 PM, an observation was made of the 400 hallway cart out of the kitchen. At 12:46 PM, the first meal tray was delivered to the 400 hallway. On 4/24/24 at 12:35 PM, an observation of the main dining room was made. Residents were offered refreshments. On 4/24/24 at 12:49 PM, the first meal tray was served and at 12:58 the last meal was served. On 4/24/24 at 12:58 PM, the last 2 meals were plated for the dining room. On 4/24/24 at 8:00 AM, an interview was conducted with resident 17. Resident 17 stated the meals were always late and they had to wait a long time in the dining room to get served food. Resident 17 stated she would like to have a clock in the dining room to know what time she was served meals. On 4/22/24 at 2:37 PM, an interview was conducted with resident 30. Resident 30 stated that he doesn't know when meals are being served. Resident 30 stated that he has almost missed meals because they were constantly being served at different times. On 4/25/24 at 10:06 AM, an interview was conducted with the ADM. The ADM stated dietary staff delivered hall trays, then the main dining room and then the residents in the main dining room that required assistance. On 4/25/24 at 12:46 PM, an interview was conducted with the Dietary Manager (DM). The DM stated stated they recently changed the meal times and the one posted in the dining room was incorrect and usually meals were delivered on time. The DM stated the hallways were to be served about 12:00 PM and the main dining room at 12:30 PM.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature did not reach the required temperature, cups were observed to have a white substance inside of them and a staff member was observed to touch dirty surfaces with gloves and then touched clean dishes. Resident identifier: 84. Findings include: 1. On 4/22/24 at 10:38 AM, an initial tour of the kitchen was conducted. The following observations were made: a. On 4/22/24 at 10:41 AM, an observation was made of Dietary Aide (DA) 2. DA 2 was observed to touch dirty dishes and loaded them into a dish machine basket. DA 2 was observed to push the basket into the dish machine with gloved hands. DA 2 was observed to grab the handle on the dish machine with soiled gloves and pull it down. DA 1 was observed to have gloves on and touched the handle that DA 2 had touched with soiled gloves. DA 1 was observed to touch clean dishes and put them away without changing gloves or performing hand hygiene. At 10:43 AM, DA 2 was observed to touch the dish machine handle after touching dirty dishes. DA 1 was observed to touch the same handle with a gloved hand and then was observed to touch the inside of the plate domes and plate bases when putting them away. DA 1 was observed to remove gloves and perform hand hygiene at 10:44 AM. b, At 10:46 AM, an observation of the facility dish machine was made. [Note: All temperatures were in degrees Fahrenheit.]: i. The washing temperature was 110 for wash and the rinse temperature. ii. The washing temperature was 115 and rinse temperature was 122. iii. DA 2 was observed to check the sanitizer solution and stated it was at 100 parts per million of chlorine. DA 2 was interviewed and stated the dish machine temperatures were to be 120 to 160 for the washing cycle and the rinse cycle. DA 2 stated the temperatures were checked before starting dishes after each meal. 2. On 4/22/24 at 12:54 PM, an observation was made of a meal cart in the 400 hallway. The vents on the back of the meal cart were observed to have a dried white substance dripping out of them and down the back of the meal cart. 3. On 4/24/24 at 3:04 PM, a follow-up kitchen tour was conducted. The following was observed: a. There was a white substance on the back of a meal cart after it had been cleaned by DA 2. b. There was a white substance inside cups that were stored in the clean area. c. The dish machine temperatures were the following: [All temperatures were in degrees Fahrenheit.] i. At 3:19 PM, an observation was made of DA 2 touching the handle of the dish machine. DA 1 was observed to touch the same handle with a gloved hand and then touch clean dishes and replace them with clean dishes. ii. At 3:20 PM, the washing cycle was 110 and the rinsing cycle was 120. iii. At 3:21 PM, an observation was made of DA 1 documenting temperatures from the dish machine. The temperatures documented were 139 for the washing cycle and 137 for the rinsing cycle. iv. At 3:23 PM, the washing cycle was 110 and rinsing cycle was 120. DA 1 was observed to place mugs and bowls from the dish machine to the shelves with clean dishes. v. At 3:26 PM, the washing cycle was 111 and the rinsing cycle was 125. An interview was immediately conducted with the Dietary Manger (DM). The DM stated the dish machine needed to run a few times for the temperatures to be above 120 for the washing cycle and the rinsing cycle. The DM stated he was unable to see the thermometer because it was to low, so he drew a line above the thermometer so staff could see the temperatures. The DM stated there was a water booster that was set to 150 so the temperatures were not able to be below 120. vi. At 3:30 PM, an observation was made of DA 2 touching the dish machine handle after DA 1 had touched the same handle with soiled gloves. DA 2 was observed to touch the inside of the domes and replace the domes with clean dishes without removing gloves or performing hand hygiene. vii. At 3:31 PM, the washing cycle was 116 and the rinsing cycle was over 125. An interview was conducted with DA 2. DA 2 stated if the dish machine sat unused for a few minutes, then it had to be run a few times to get the temperature above 120 for the washing and rinsing cycles. On 4/22/24 at 11:05 AM, an interview was conducted with resident 84. Resident 84 stated that the cups are dirty with a white film. Resident 84 stated that he asked the staff what the white stuff was and was told that it was hard water buildup. Resident 84 stated that he was able to wipe the white residue out of the cup with his finger. Resident 84 stated that he doesn't think the cups are being washed at a high enough temperature. Resident 84 stated that he refuses to use the cups and requested only to use Styrofoam cups. On 4/25/24 at 12:46 PM, an interview was conducted with the DM. The DM stated the white substance in the glasses was from hard water. The DM stated that the facility was looking into a water softener. The DM stated that until the facility installs a water softener, the glasses were soaked in lime-away weekly and then re-washed. The DM stated that he was aware of the white substance and tried to buy new glasses but it continues to build up quickly. The DM stated that he was not aware that DA 1 was putting clean dishes away after touching the same handle as DA 2 had touched with soiled gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not provide 1 of 28 sampled residents with supportive treatment and services to maintain or improve his or her ability to carry out the activities of daily living which included bathing or showering. Specifically, a resident was not showered according to his shower schedule and had gone 10 days without a shower. Resident identifiers: 35. Findings included: Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epilepsy, gastroesophageal reflux disease, essential, hypertension, phantom limb syndrome with pain, peripheral vascular disease, absence of left and right legs above the knee, pulmonary embolism, and muscle weakness. On 7/31/22 at 1:14 PM, an interview was conducted with resident 35. Resident 35 stated that sometimes staff forgot his shower days. Resident 35 stated he was supposed to shower 3 times a week on Tuesdays, Thursdays and Sundays between 2:00 PM and 5:00 PM, but this did not always happen. On 8/1/22 the medical record of resident 35 was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed that resident 35 required physical help in part of bathing activity with a 1 person physical assist. A review of the bathing section in the medical record revealed that resident 35 was scheduled to shower Tuesdays, Thursdays and Sundays on the afternoon shift. Further review of the bathing section in the medical record revealed resident 35 received a shower on 7/5, 7/10, 7/12, 7/14, 7/17, 7/28, and 7/31. Resident 35 did not receive a shower for 5 days from 7/5 - 7/10 and for 10 days from 7/17 - 7/28. No shower refusal forms were located in the medical record or provided by the facility. On 8/2/22 at 11:25 AM, an interview was conducted with Certified Nurses Assistant (CNA) 1. CNA 1 stated that each time a resident had a shower it was charted in the medical record. CNA 1 stated if the resident refused the shower it was noted on a refusal shower form, a nurse had to sign it and it was put in the bin for filing. CNA 1 stated the staff worked hard to get all of the showers completed when the residents would like them done. On 8/2/22 at 12:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there were no refusal forms found for resident 35, so the showers charted in the medical record were the showers that the resident had received from 7/5 through 7/31. The DON stated it was the expectation of the staff to ensure the residents got a shower when they were scheduled and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteomyelitis, end-stage renal disease, dialysis treatments, a right below-the-knee amputation, hypertension, anemia, congestive heart failure, and respiratory failure. On [DATE] at 1:11 PM, resident 31 was interviewed. Resident 31 stated that he chipped his front tooth when he tipped in the Hoyer lift. Resident 31 stated that he had not had his tooth repaired. On [DATE], resident 31's medical record review was completed. An Incident Report created on [DATE] at 8:57 PM, revealed that CNA (certified nursing assistant) reported to nurse that resident [31] suffered a chipped tooth as result of hook from hoyer lift, swinging and striking his tooth. Resident [31] states he was just put in bed by CNA's via hoyer lift. After resident was laid down and sling was unhooked, CNA attempted to remove the hoyer lift. The lift was stuck under a bar under the bed, the CNA jerked on the lift, causing the sling hooks to swing, and hitting resident [31] in the tooth. Corrective action included educating the CNA about raising the bed before attempting to move the lift under the bed. An Alert Note created on [DATE] at 9:24 PM revealed that resident 31 was not in pain after being hit in the mouth and having his tooth chipped. Resident 31 was a little bit frazzled after the incident. An Event Note created on [DATE] at 3:30 PM, revealed that an Interdisciplinary Team (IDT) meeting was held. The IDT team determined that The CNA jerked on the lift to unstick the wheel causing the suspended sling anchor to swing and hit the resident in the front top left tooth, chipping it . Risk Factors and Root Cause Identification: Resident has a dx (diagnosis) of below the knee amputation to his right leg, muscle weakness, CKD (chronic kidney disease), and heart failure. Resident is dependent on staff for transfers and bed mobility requiring the use of a hoyer for transfers. On 6/1 the CNA did not raise the hoyer lift before attempting to remove it from the side of the bed after transferring the resident into bed. As a result, when the lift got stuck and was jerked loose the suspended sling anchor swung and hit resident in his tooth. Preventative Measures: There have been no prior incidents r/t (related to) use of the hoyer. Aides are trained and competent in it's use. Resident has been fitted for an appropriate sling and is safe to transfer via the hoyer. New Interventions: Resident was assessed by staff nurse. There was no bleeding or bruising. The lift hit square on his tooth causing it to be chipped. A referral was made out to a dentist to repair the chipped tooth. Resident sustained no other adverse outcomes, and was not complaining of pain. It happened unexpectedly and suddenly so surprised him but he had no injuries or complaints post incident. MD and emergency contact notified. CNA was educated to raise bed when attempting to remove the hoyer lift, so that it does not get stuck under bars below bed. CNA also educated to raise the lift prior to removing the hoyer so that the lift is not likely to impact the resident should the sling anchor start to swing during removal. On [DATE] at 2:07 PM, two CNAs were observed using the Hoyer lift to transfer a resident. One CNA operated the controls while the other CNA steadied the resident and spoke to him about the transfer, expressing what would be happening. There were no issues with the use of the lift. On [DATE] at 7:56 AM, an interview was conducted with CNA 1. CNA 1 stated that residents who were transferred in the lift had the sling put in the position they preferred, the brakes were put on while the resident was being lifted, then one CNA stood by the resident while the other operated the lift. CNA 1 stated that the lift legs did not rotate properly under the bed unless the bed was raised. CNA 1 stated that if there was a problem with the lift being stuck under the bed, she would ensure the safety of the resident while she raised the bed before moving the lift. On [DATE] at 8:08 AM, CNA 2 was interviewed. CNA 2 stated that she was trained how to use the Hoyer lift when she started working at the facility. CNA 2 stated how to position a resident in the sling and hoyer, and how to transfer the residents. CNA 2 stated that she had not experienced any problems running the Hoyer, except if it stopped working due to the battery needing to be charged. CNA 2 demonstrated that the Hoyer was plugged in and located in the 100 hallway. CNA 2 stated that if a hoyer leg was stuck under the bed, she would raise the bed higher. On [DATE] at 7:59 AM, an interview was conducted with CNA 3. CNA 3 stated that she learned how to use the Hoyer lift when she started at the facility. CNA 3 stated that she had experience in CNA classes with using lifts, but made sure she knew how to use the lift at the facility. CNA 3 stated that she learned from the other CNAs, not from a formal class at the facility. On [DATE] at 10:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that to put the Hoyer lift in the proper position, the bed needed to be raised so that the crossbars were not in the way. The DON stated that two aides worked together when transferring, and one would ensure the safety of the resident while the other CNA operated the lift. The DON stated that for resident 31's accident, the CNA should have lifted the bed instead of jerking on the Hoyer. The DON stated that if the Hoyer had been positioned properly, it would not have been wedged under the bed frame. The DON stated that the CNA did not understand why the lift was not moving, and after the accident, when the CNA was being educated, she had a better understanding of the issue. The DON stated that when the hoyer was stuck, the CNA pulled harder, and when it struck resident 31's mouth, it happened very fast. The DON stated that some CNAs believed that adjusting the bed was time consuming. Based on observation, interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not have adequate supervision to prevent accidents. Specifically, a resident was missing from the facility for over 5 hours without staff noticing. This will be cited at past non-compliance. In addition, another resident's mouth was hit by the hoyer lift during a transfer, resulting in a broken tooth. Resident identifiers: 31 and 67. Finding include: 1. Resident 67 was admitted to the facility on [DATE] with a d/c on [DATE] with diagnoses which included generalized anxiety disorder, type 1 diabetes mellitus, insomnia, hypothyroidism and paranoid schizophrenia. Resident 67's medical record was reviewed on [DATE]. A nursing progress note dated [DATE] at 11:00 PM, Resident's brother contacted Facility to notify staff that his sister had eloped and was at [name of city] Airport and that he was contacting law enforcement to apprehend resident to bring her back to the facility. Administrator, DON (Director of Nursing), and MD (Medical Doctor) notified of incident. Resident was brought back to facility by facility administrator. Resident was assessed and medication giving (sic). Law enforcement was then contacted to facilitate transfer to hospital for a psych (psychological) evaluation. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental status score of 15. The MDS further revealed resident 67 did not have memory problems. Resident 67 had a Wander/elopement Risk Evaluation dated [DATE] and [DATE] which revealed she was not an elopement risk. A care plan dated [DATE] revealed The resident is at risk for impaired cognitive function or impaired thought processes r/t (related to) schizoaffective disorder, bipolar type, paranoid schizophrenia, . Psychotropic drug use, confusion, wandering, mood, behavioral disturbances, hypothyroidism, and diabetes mellitus type 2. A goal revealed The resident will maintain current level of cognitive function through the review date. Interventions included Administer medications as ordered; monitor/document for side effects and effectiveness; ask yes/no questions in order to determine the resident's needs; keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion; and present just one thought, idea, question or command at a time. An additional intervention was Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues stop and return if agitated. On [DATE] at 2:22 PM, an interview was conducted with the Administrator. The Administrator stated resident 67 had not shown signs of exit seeking or wanting to leave the facility prior to [DATE]. The Administrator stated the day she left the facility she was hearing voices. The Administrator stated that she told staff she was to pretty to be in this facility and needed to go to California. The Administrator stated resident 67 left through the front door at 3:00 PM on [DATE] to bus, tracks, airport, and then realized she did not have a ticket so she called the brother and asked for money and a ticket. The Administrator stated resident 67 was gone from the facility for about 5 and a half hours before her brother called about 8:30 PM to inform staff of where she was. The Administrator stated he picked her up from the airport. The Administrator stated after the incident their process was reviewed and found missed opportunities to determine she was gone. The Administrator stated the Certified Nursing Assistant (CNA) was late to her shift and there was no shift to shift report completed. The Administrator stated that the nurse thought she was in the dining room when her insulin should have been administered and did not administer the insulin. The Administrator stated a CNA dropped off a dinner meal and the bathroom light was on and she thought resident 67 was in the bathroom. The Administrator stated the next day an elopement drill was completed and an in-service regarding shift to shift report and 2 hours checks was completed. The Administrator stated the system was tightened and elopement drills had been implemented. The Administrator provided an inservice for all staff that was completed on [DATE] regarding the elopement policy and procedure. The Administrator provided a staff sign in form. The incident was reviewed in their Quality Assessment meeting and elopement drill documentation was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not obtain routine dental services to meet the needs of the resident. Specifically, one resident who received a chipped tooth in the facility was not scheduled for routine dental care. Resident identifier: 31. Findings include: Resident 31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteomyelitis, end-stage renal disease, dialysis treatments, a right below-the-knee amputation, hypertension, anemia, congestive heart failure, and respiratory failure. On 7/31/22 at 1:11 PM, resident 31 was interviewed. Resident 31 stated that he chipped his front tooth when he tipped in the Hoyer lift. Resident 31 stated that he had not had his tooth examined or repaired. On 8/3/22, resident 31's medical record was reviewed. An Incident Report created on 6/1/22 at 8:57 PM, revealed that CNA (certified nursing assistant) reported to nurse that resident [31] suffered a chipped tooth as result of hook from Hoyer lift, swinging and striking his tooth. Resident [31] states he was just put in bed by CNA's via Hoyer lift. After resident was laid down and sling was unhooked, CNA attempted to remove the Hoyer lift. The lift was stuck under a bar under the bed, the CNA jerked on the lift, causing the sling hooks to swing, and hitting resident [31] in the tooth. Corrective action included educating the CNA about raising the bed before attempting to move the lift under the bed. An Alert Note created on 6/1/22 at 9:24 PM revealed that resident 31 was not in pain after being hit in the mouth and having his tooth chipped. Resident 31 was a little bit frazzled after the incident. An Event Note created on 6/6/22 at 3:30 PM, revealed that an Interdisciplinary Team (IDT) meeting was held. The IDT team determined that The CNA jerked on the lift to unstick the wheel causing the suspended sling anchor to swing and hit the resident in the front top left tooth, chipping it . New Interventions: Resident was assessed by staff nurse. There was no bleeding or bruising. The lift hit square on his tooth causing it to be chipped. A referral was made out to a dentist to repair the chipped tooth. There was no documentation located in resident 31's medical record that a referral had been made to the dentist. On 8/2/22 at 1:53 PM, the Resident Advocate (RA) was interviewed. The RA stated that the dentist had been scheduled to come to the facility on 8/11/22. The RA stated that there were two dentists that might treat the residents, one for general cleanings and the other for dentures or to pull teeth. The RA stated that there were 27 residents on the list to be seen by the dentist, which did not include resident 31. The RA confirmed that resident 31 was not scheduled to be examined by the dentist. The RA stated that when a resident requested a dental appointment, she would put it on the calendar and schedule the dentist. The RA stated that one resident was sent to a different dentist to be examined more quickly. The RA stated that the last dental visit was on 7/5/22, and resident 31 was not examined at that time. The RA stated that resident 31 went to the dentist on 5/24/22 for extractions, and could have also been examined by the dentist on 6/29/22, but was not. On 8/3/22 at 10:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the dentist was going to be at the facility on 8/11/22. The DON stated that the dentist usually made appointments on Wednesdays or Fridays, but since resident 31 had dialysis those days, the dentist was scheduled on the 11th. The DON stated that the RA had arranged that day specifically, but did not know why resident 31 did not have an appointment scheduled to see the dentist on that date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 4 out of 28 sampled residents, that the facility did not ensure that residents were free from abuse. Specifically, one resident was headbutted by another resident and two other resident experienced physical altercations on two different occasions and the facility did not identify it as abuse. Resident identifiers: 4, 5, 34, and 268. Findings include: 1. Resident 34 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included generalized anxiety, major depressive disorder, post-traumatic stress disorder, metabolic encephalopathy, and muscle weakness. On 8/2/22 at 10:31 AM, an interview was conducted with resident 34. Resident 34 stated that resident 4 had an attitude problem. Resident 34 stated that an incident had happened in May between the two of them was because of hair that was in the sink. Resident 34 stated that it was not a big issue and it got made out to be a bigger deal then what it was. Resident 34 stated that he believed resident 4 was intoxicated when the scuff went down between them. Resident 34 stated that resident 4 headbutted him in the head and he developed and bump and 3 scratches from the encounter. Resident 34 stated that he was angry when it first happened but things between him and resident 4 were better now that they were not roommates. On 8/1/22 resident 34's medical record was reviewed. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 34 had a brief interview for mental status (BIMS) score of 11 which indicated mild cognitive impairment. Progress notes revealed: a. A health status note dated 5/5/22 at 6:30 PM stated, This resident [resident 34] was sitting in his wheelchair outside of his room. After a brief verbal exchange between this resident and his neighbor [resident 4], the neighboring resident grabbed this resident's right shoulder in an aggressive manner from behind, squoze his shoulder [resident 34], causing acute pain. After the two residents had another short verbal exchange, the neighboring resident [resident 4] then head butted this resident [resident 34] to the left side of his head. Staff intervened and separated the residents. Physical assessment performed; no visual injuries noted. MD (Medical Doctor) notified. b. Resident 34 was placed on alert charting on 5/6 and 5/7 for receiving physical aggression from another resident. C. An event note dated 5/11/22 at 3:30 PM stated, On 05/05/2022 at 1800 (6:00 PM) resident was outside of his room in the hallway talking to some of his friends. His neighbor started to become verbally aggressive and make threats over an argument the two had earlier in the week about their shared bathroom. His neighbor was accusing him of being a snitch for telling his friends about the disagreement over the bathroom and he took a picture of him on his phone and was threatening to text it to a friend in prison boasting that his friend is going to rough him up if he has to go back. Resident stood up to his neighbor and told him to knock it off and leave him alone. His neighbor did not like that he was 'talking back' so (sic) got more upset and began to threaten to fight him. Resident tried to wheel himself away from the argument. As he did so his neighbor grabbed onto his right shoulder from behind, coming down hard when he did so. Resident told his neighbor to get off of him and leave him alone, turning around in his wheelchair as he did so. His neighbor took a couple of steps away and came in close to him, lowering his head as he did so. He then headbutted the resident's left forehead with the top of his head. Nursing staff arrived at the scene immediately after the head-butt and separated the two residents, bringing resident to the nurses station and redirecting his neighbor to his room. Risk factors and root causes identified were that On 5/4 resident's neighbor got mad at him because he washed his hair in the sink and left some of his black hairs. Upon observing the black hairs in the sink, his neighbor went into his room and chastised him for leaving the hairs there and then berated him until he went in and cleaned up the hairs. Resident told him he was being a jerk but ignored his aggressive gestures as he cleaned up the sink. Resident did not notify staff of the incident or express concerns, but he did complain about the interaction to some of his friends that live in the facility and it got back to his neighbor. This triggered an argument on 5/5 which escalated to the neighbor becoming physically aggressive and grab onto [resident 34's] shoulder, later head-butting him with the top of his head. He had developed redness and minor swelling on his left forehead. On 5/11/22 an investigation was done and the facility unsubstantiated that the altercation between the two residents constituted as abuse but that a physical altercation did occur between the two residents. 2. Resident 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dementia, irritability and anger, post-traumatic stress disorder, mild cognitive impairment, major depressive disorder and generalized anxiety disorder. Resident 4's medical record was reviewed on 8/2/22. An MDS dated [DATE] revealed resident 4 had a BIMS score of 7 which indicated cognitive impairment. Resident 4's care plan initiated on 11/03/21 and revised on 5/6/22 revealed that resident 4 was at potential complications related to dementia with behavioral disturbances and resident 4 could become agitated quickly and have verbal and physical outbursts. Interventions developed on 5/12/22 included avoid areas with less staff supervision that put him in contact with residents that triggered him, remove himself from conflict and return to his room to be by himself. Progress notes revealed: A. A health status note dated 5/5/22 at 6:30 PM, stated This resident [resident 4] had a negative verbal exchange with his neighboring resident [resident 34] in the hallway, regarding cleanliness of their shared bathroom. This resident [resident 4] was standing behind his neighboring resident [resident 34], who was seated in a wheelchair. This resident [resident 4] grabbed the other residents [resident 34] right shoulder from behind, and squoze it tightly. They continue to yell at each other, then this resident [resident 4] headbutted the other resident [resident 34] to the left side of his face. Staff quickly intervened and separated the two residents. MD, administrator, and emergency contact notified. B. Resident 4 was placed on alert charting on 5/6/22 and 5/7/22 for initiating physical aggression towards another resident. C. An event note dated 5/11/22 at 15:30 (3:30 PM) stated, On 05/05/2022 at 1800 (6:00 PM) resident become verbally aggressive with his neighbor out in the hallway outside his room over an argument the two had earlier in the week about their shared bathroom. He was upset with his neighbor for 'being a snitch' because he told his friends about the disagreement over the bathroom. He took a picture of his neighbor on his phone and was threatening to text it to a friend in prison boasting that his friend is going to rough him up if he has to go back. Resident's neighbor told him to knock it off and leave him alone, which this resident interpreted as 'talking back' and 'being mouthy,' so he got more angry and began to threaten to fight him. The neighbor tried to wheel himself away but as he did so this resident grabbed onto his right shoulder from behind, coming down hard when he did so. The other resident told him to get off leave him alone, turning around in his wheelchair as he did so. At this point this resident took a couple of steps away and came in close to his neighbor, lowering his head as he did so. He then head-butted his left forehead with the top of his head. Nursing staff had been notified of the argument by other resident's who were observing the argument and arrived at the scene immediately after the head-butt and separated the two residents, bringing the neighbor to the nurses station and redirecting this resident to his room. Risk factors and root cause identified were resident 4 had a diagnosis of dementia with behavior disturbances, irritability and anger and amnesia. It was identified that resident 4 had intermittent confusion and had difficulty coping due to his mental health and medical problems, which at times manifested in angry outbursts and threatening gestures. D. A psychosocial note dated 5/12/22 at 2:30 PM revealed that resident 4 had a behavioral plan of care discussion to address their recent display of physical aggression towards resident 34. The purpose of the discussion was to help staff identify resident's triggers and how to deescalate from any verbal or physical aggression. Resident 4 triggers were identified as uncleanliness and disrespect for his space and disrespect towards himself when other residents get mouthy. On 5/11/22 an investigation was done and the facility unsubstantiated that the altercation between the two residents constituted as abuse but that a physical altercation did occur between the two residents. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia, asthma and insomnia. Resident 5's medical record was reviewed on 8/1/22 An MDS dated [DATE] revealed a BIMS score of 5 which indicated resident had mild cognitive impairment. Resident 5's care plan initiated on 12/27/17 revealed an identifiable problem as impaired cognitive function/dementia or impaired thought process related to Dementia. The goals developed on 12/27/17 with a target date of 5/17/22 included resident 5 was able to communicate basic needs on a daily basis through the review date. Interventions developed included: 1. Resident educated to avoid confrontation with other residents and ask for staff assistance if a resident was agitating them. [Note: This approach was developed on 2/24/22 after resident 5 had their first of two altercations with resident 268.] 2. Educated staff to intervene when resident was heard or observed being verbally loud towards other residents. This approach was developed on 5/6/22. A Monthly Summary Forms for the months of February - April 2022 revealed resident 5's mental status was alert and orient and her emotional status as friendly, noisy, cooperative, expresses according to situation and easily upsets. Progress notes revealed: A. An event note dated 2/28/22 stated, On 2/22/2022 at 1130 (11:30 AM) resident was walking to her room from the 400 hallway and near the RA [resident advocate] office another resident tapped her on her left shoulder as she passed and said something loud to her. This physical gesture upset her who interpreted it as the other resident had hit her and was being aggressive with her. RA overheard resident [resident 5] yell 'Hey, don't hit me.' As the other resident [resident 268] began to walk away this resident followed and hit her in the left shoulder with her right hand. Residents were separated and resident was redirected to her room. There was no adverse outcomes from the incident. [State Survey Agency], APS, and family were notified. Investigation conducted. Resident was educated to avoid confrontation with other residents and ask for staff assistance if a resident is agitating them. Risk factors and root causes identified were that resident 5 had confusion related to her dementia and had a BIMS of 7. Resident 5 thought that she had been hit by another resident and responded impulsively by retaliating and hitting her back. Resident 5 was upset about the incident for several hours after it occurred. B. Resident 5 was placed on alert charting on 2/23/22 and 2/24/22 due to received physical aggression. C. Medical doctor progress note dated 2/28/22 revealed that resident 5 has not had behavioral changes. D. A nurse practitioner note dated /28/22 stated that resident 5 behaviors were stable and that she can be forgetful. E. A health status note dated 5/6/22 stated, This resident was standing in the assisted dining area. The other resident walked up to this resident and had a short verbal exchange. The other resident hit this resident on her left shoulder unprovoked. This resident hit back at the other resident to her left face. Residents were separated. F. Resident 5 was placed on alert charting from 5/6/22 to 5/9/22 due to received physical aggression from another resident. G. An event note dated 5/12/22 stated, On 5/6/2022 at around 0740 (7:40 AM)resident was walking from the nurses station to her room. As she was walking past the assisted dining area a resident who was there stood up from her chair and started talking to her. This resident began telling her to sit backdown, but the other resident continued walking towards her until she was standing next to her. The other resident then slapped this resident in the left shoulder with her right hand. This resident retaliated by slapping the left side of the other resident's face with her right hand. CNA staff member who was near the nurses station at the time observed the incident and separated the two resident's as soon as he was able to get to them. The note further revealed risk factors and root causes identified were resident 5 did not have the capacity to understand resident 268's cognitive functioning or mental confusion and that was why she got frustrated with resident 268. On 05/06/2022 she became frustrated with the other resident because she was trying to talk to her and started to boss her around telling her to sit back down. This further attracted the other resident's attention causing her to come up next to her and impulsively hit her. No physical injuries were noted to resident 5's shoulder and resident 5 did not show any signs of mental distress after the incident occurred. On 2/25/22 an abuse investigation was done between the altercation between resident 5 and resident 268 and it was unsubstantiated that any abuse had occurred. Administration concluded that a physical altercation had occur. It was also documented that even though both residents had dementia and each exhibited a varying level of confusion; they each recognized they did not like each other. On 5/12/22 an abuse investigation was done on altercation between resident 5 and resident 268 and it was unsubstantiated that any abuse had occurred. Administration concluded that a physical altercation had occurred and that resident 268 had not intentionally attempted to cause resident 5 harm as well as resident 268 was not aware of the impact of her behaviors and was not able to identify what she had done was inappropriate. 4. Resident 268 was admitted to the facility on [DATE] with diagnoses which included vascular dementia with behavioral disturbances, major depressive disorder, generalized anxiety disorder, metabolic encephalopathy, and altered mental status. A MDS dated [DATE] revealed a BIMS score of 1 which indicated severe cognitive impairment. Resident 268's care plan revealed the following: A. A problem identified on 9/6/21 with a revision date of 3/24/22 stated that resident 268 had potential for complications related to dementia with behavioral disturbances and can be physically aggressive towards other. Interventions developed on 3/20/22 and 3/23/22 included: 1. Educated staff to monitor for increased anxiety and intervene with other activities to help reduce anxiety. 2. Educated staff to intervene and keep other resident's from going to resident 268's room. B. A problem identified on 2/24/22 with the same revision dated stated that resident 268 was at risk for pain, mental anguish related to an allegation of physical abuse. Interventions developed on 2/24/22 included: 1. Educated staff to monitor resident in common areas to ensure she was safe. 2. Abuse reporting and investigating protocol initiated. 3. Alert charting initiated to monitor for adverse outcomes such as pain, injury or mental anguish. Staff shall intervene as indicated for any adverse outcomes that occur, including notifying MD as applicable. 4. Immediate actions taken at the time of the allegation: Staff separated resident from the perpetrator and ensure resident's safety; Nurse performed an assessment to check for pain, injury, mental anguish; Abuse coordinator notified of the allegation. Monthly Summary Forms from February, April and May 2022 revealed that resident 268's mental status was alert, confused, and a poor memory. Her emotional status was documented as friendly, anxious, noisy and easily upset. Progress notes revealed: A. Resident placed on alert charting from 2/22/22 through 2/24/22 due to resident altercation. B. An event note dated 2/28/22 stated, On 2/22/2022 at 1130 (11:30 AM) resident was walking another resident near the 400 hallway next to the RA's office. As she passed the other resident, she tapped her on her left shoulder with her left hand and said something loud, but not antagonistic. This physical gesture upset the other resident who thought that she had hit her and was being aggressive with her. RA overheard the other resident yell 'Hey, don't hit me.' This resident then began to walk away towards her room. The other resident followed her and hit her with her right hand on her left shoulder. The RA, after hearing the other resident shout what she did, came out of her office to investigate and separated the two residents, bringing this resident into her office while other staff redirected the other resident. Risk factors and root causes identified were that resident 268 had a severely impaired cognition and a diagnosis of dementia with behavioral disturbances along with a BIMS of 2. On 2/22/2022 as she was passing another resident in the hallway she tapped that resident as she passed her to get her attention and said something to her in her normal loud voice. This gesture upset the other resident who became aggressive and retaliated by punching her in the arm. Resident 268 had no signs of emotional or physical injuries. C. Resident placed on alert charting from 3/20/22 through 3/26/22 due to physical aggression initiated. D. Event note dated 3/21/22 revealed that resident 268 had another resident to resident altercation. Resident 268 was unprovoked and slapped the other resident on his left shoulder. Note stated that resident 268 was impulsive and her ability to understand and exhibit normal social behavior was impaired by her dementia. E. An alert note on 3/24/22 stated, [Resident 268] has been very anxious and unsettling. She has been going around hitting people. F. A medical doctor progress noted dated 3/28/22 stated, [Resident 268] continues to have anxious and aggressive behaviors. G. Event note dated 3/29/22 revealed that resident 268 had impulsively kicked another resident on 3/23/22. H. A health status note dated 4/27/22 revealed that resident 268 had slapped another resident in the arm. I. Resident placed on alert charting from 4/27/22 through 4/30/22 due to initiating aggression towards another resident. J. An alert note dated 5/5/22 revealed that resident 268 had been very aggressive. The note documented that resident 268 had hit multiple staff members, administration, and residents. K. Health status note dated 5/6/22 at 8:30 AM stated, This resident walked up to another resident in the assisted dining area. After a short verbal exchange, this resident hit the other resident on the left shoulder. The other resident hit this resident in return to her left side of face. Resident were separated by staff. Emergency contact and MD notified. L. Health status note dated 5/6/22 at 3:30 PM, revealed that resident 268 had hit another resident twice in the back of the shoulder unprovoked. [Note: This did not include the altercation between resident 268 and resident 5 that happened earlier that day.] M. Resident placed on alert charting from 5/6/22 through 5/12/22 due to initiating aggression towards another resident. N. A health status note dated 5/9/22 revealed that resident 268 was witnessed slapping another resident in the face. O. A health status note dated 5/11/22 stated, Resident suffers from dementia, and continues to have trouble appropriately expressing her anxiety. Resident continues to hit at staff, although it is obvious that the 'hits' are not intended in a malicious manner, but rather an anxious behavior that she can't seem to control. P. An event note dated 5/12/22 stated, On 5/6/2022 at around 0740 (7:40 AM)resident was brought to the assisted dining area by staff to wait for the breakfast cart to come out. Sometime afterwards another resident was walking from the nurses station to her room. As she was walking past the assisted dining area this resident stood up from her chair and started talking to her. The other resident began telling her to sit back down, but this resident continued walking towards her until she was standing next to her. She then slapped her in the left shoulder with her right hand. The other resident retaliated by slapping the left side of her face with her right hand. CNA staff who was near the nurses station at the time observed the incident and separated the two resident's as soon as he was able to get to them. Risk factors and root causes identified were resident 268 had a diagnosis of dementia with behavioral disturbances, a short attention span and a BIMS of 2. On 5/6/2022 she was brought down to the assisted dining area before food was ready to be served and as a result became restless, stood up from her chair, and began engaging with another resident when staff were not nearby to redirect her. The other resident agitated her by the way she was ordering her around which prompted this resident to walk up to her and impulsively slap her in the shoulder triggering an altercation. No injuries or adverse outcomes such as mental anguish or distress were noted on resident 268. On 2/25/22 an abuse investigation was done between the altercation between resident 5 and resident 268 and it was unsubstantiated that any abuse had occurred. Administration concluded that a physical altercation had occur. It was also documented that even though both residents had dementia and each exhibited a varying level of confusion; they each recognized they did not like each other. On 5/12/22 an abuse investigation was done on altercation between resident 5 and resident 268 and it was unsubstantiated that any abuse had occurred. Administration concluded that a physical altercation had occurred and that resident 268 had not intentionally attempted to cause resident 5 harm as well as resident 268 was not aware of the impact of her behaviors and was not able to identify what she had done was inappropriate. On 8/2/22 at 10:49 AM, an interview was conducted with the MDS Coordinator. The MDS stated that when residents were upset they redirect them and that it was possible for two confused residents to be abusive towards each other and not realize it or remember what they did. The MDS coordinator stated willful was defined as the intention to cause harm in terms of, the resident understands what their actions caused and still chose to do it. The MDS defined accidental as an action that was not premedicated and not done on purpose. The MDS stated that it depended on a resident's situation and cognitive abilities to determine if something was done willfully or accidentally. The MDS stated that all resident to resident interactions were reported to the administrator and the administrator was the one to report it further as needed. On 8/2/22 at 11:12 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that abuse was anything that could cause harm or hurt someone physically, emotionally, and verbally. LPN 1 stated they determined if abuse took place based on the situation. LPN 1 stated a lot of demented residents did not do things willfully only accidentally. LPN 1 stated demented residents did not understand the why behind their actions or how the incidents happened but at the moment of the incident they know they did something bad. LPN 1 stated that demented residents could not help their actions because the disease took over and they were not in their right mind. LPN 1 stated that in the instance an altercation, it was considered abuse since harm was being inflicted on someone. LPN 1 stated in regard to the altercation between resident 34 and resident 4, it was considered abuse. In regards to the situation between resident 268 and resident 5, LPN 1 stated that resident 5 was not capable of abusing anyone and even if she were to hit somebody it would not be considered abuse because she did not mean to hit. On 8/2/22 at 11:45 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON defined abuse as mistreatment of anyone in anyway shape or form which included mentally, physically and neglect. The ADON defined willfully as the ability to recognize your actions and the consequences they caused. The ADON defined accidentally as no intentions to cause harm of any type. The ADON stated that they had a couple of resident-to-resident altercations between dementia residents. The ADON stated that in those cases, they looked at the situation to determine if abuse occurred. The ADON stated in regard to the altercation between resident 5 and resident 268, it was considered more of a fight and not abuse since neither resident had the intention of fighting or hitting. The ADON stated in regard to the altercation between resident 4 and 34, it was physical abuse because of the way resident 4 reacted and intentionally hit resident 34. On 8/2/22 at 1:14 PM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 defined willfully as a resident that mentally knew what they did while accidentally would be a resident did not consciously mean to do something. CNA 4 stated if both residents were in their right state of mind, then their actions were considered willful. CNA 4 stated when asked how to categorize two demented residents who had an altercation, CNA 4 stated that the altercation would not be considered willful since both residents were not in their right state of mind and not aware of what they were consciously doing. CNA 4 stated in regards to resident 268, that she was not in her right state of mind and if resident 268 were to hit another resident it would not be considered willful. CNA 4 stated that if resident 5 were to hit, it would be considered willful since she understands her actions. On 8/2/22 at 1:59 PM, an interview was conducted with the Administrator (ADM). The ADM stated that whenever abuse was suspected, it was reported within 2 hours. The ADM stated that during an abuse investigation, they interviewed staff and residents and looked at camera footage to determine what happened. The ADM stated there were two parts to abuse. The ADM stated the first part was the intent to cause harm and the second was the infliction of harm. The ADM stated based on those two parts, they determined if abuse had occurred or not. The ADM stated that something that was done incidentally meant there was no intention behind the action, while intentional meant you thought what your actions and you meant to do it. The ADM stated when asked about the altercation that occurred between resident 4 and 34, the ADM stated that the abuse investigation was unsubstantiated due to not being able to determine if resident 4's intention was to harm resident 34 and there were no physical injuries noted on both resident's. The ADM stated that resident 4 acted in an inappropriate way but his intention was not to cause harm. The ADM stated that after the altercation both residents went back to their normal routine and no harm had occurred such as emotional anguish and pain.

Based on observation and interview it was determined, for 9 of 28 sampled resident, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of the food quality and a test tray was not palatable. Resident identifiers: 4, 8, 18, 27, 35, 39, 41, 52 and 62. Findings include: 1. On 7/31/22 at 1:18 PM, an interview was conducted with resident 35. Resident 35 stated he was served chicken salad for the last 3 days and it was getting kind of old. Resident 35 stated the food was too spicy. 2. On 7/31/22 at 11:33 AM, an interview was conducted with resident 52. Resident 52 stated I'm not going to lie, the food is not good. Resident 52 stated the food on the weekend was not good. Resident 52 stated her partner was not going to be able to bring her food anymore. Resident 52 stated usually her partner brought her frozen dinners. Resident 52 stated they served chicken salad, egg salad, and tuna salad on the weekends that did not have any flavor. Resident 52 stated the food looked terrible and was served cold. Resident 52 stated that she received big blobs of food. 3. On 7/31/22 at 1:38 PM, an interview was conducted with resident 8. Resident 8 stated that the food was nasty. Resident 8 stated that the alternative menu was just as Shitty as the main menu. Resident 8 stated that the food was served cold. 4. On 7/31/22 at 11:21 AM, an interview was conducted with resident 18. Resident 18 stated that the food was cold and did not taste very good. Resident 18 stated there were only two food choices. 5. On 7/31/22 at 12:03 PM, an interview was conducted with resident 39. Resident 39 stated the food was so, so. 6. On 7/31/22 at 12:13 PM, an interview was conducted with resident 62. Resident 62 stated the food sometimes tasted good and sometimes bad. Resident 62 stated he should be receiving 2 yogurts, toast and fruit for breakfast but had not received any for the last 4 days. 7. On 7/31/22 at 12:43 PM, an interview was conducted with resident 4. Resident 4 stated that one week food was served hot and the next week cold and not good. Resident 4 stated an example was when fish was served the other day, tarter sauce was not served with it. Resident 4 stated if a quesadilla was ordered, then the kitchen would say they were out of cheese or tortillas. 8. On 7/31/22 at 12:54 PM, an interview was conducted with resident 27. Resident 27 stated the food was so, so. 9. On 7/31/22 at 12:57 PM, an interview was conducted with resident 41. Resident 41 stated the food was not served hot and most of the time it was barely lukewarm. Resident 41 stated that the meat cuts were not prime cuts. Resident 41 stated the meat was hard for her to deal with. On 8/2/22 at 11:50 AM, an observation was made of the facility tray line. [NAME] 1 was interviewed. [NAME] 1 stated there was BBQ chicken, baked beans, coleslaw, cheese biscuit and cake for lunch. [NAME] 1 stated the alternative meal was Teriyaki Beef and rice. A test tray was requested at 12:39 PM. The test tray was placed in the assisted dining room cart. The last tray was served at 12:48 PM. Temperatures were obtained. [All temperatures were in degrees Fahrenheit.] a. BBQ chicken was 98.0. b. Coleslaw temp was 82.0. c. Baked beans were 95.0. d. Teriyaki Beef and rice were 104.5. e. Milk was 46.0. The tray was observed to be brown and tan colored items. The BBQ chicken was palatable. The baked beans had a burnt flavor and were mushy to the taste. Coleslaw was warm to the taste. The Teriyaki Beef had a grisly texture, hard to cut, dry to the taste and did not have a Teriyaki flavor. The biscuit was very dry. The cake was dry to the taste. On 8/3/22 at 9:43 AM, an interview was conducted with [NAME] 1. [NAME] 1 stated that she tasted the chicken but did not taste the other foods. [NAME] 1 stated she did not add extra seasons or anything fancy like that.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, areas in the kitchen were unclean and staff used purell hand sanitizer on a thermometer. Findings include: 1. On 8/1/22 at 9:10 AM, an initial tour was conducted of the facility kitchen. The following was observed: a. The walk in refrigerator had a white substance running down the glass doors and on the floor. b. The menu book was soiled with brown substance on the plastic sheets the menu and recipes were inside of. c. The stove/oven had food soiled on the front of it. d. The table next to the oven had food debris on the legs of it. e. The side of double oven had food splatter on the side of it. f. The steam table had debris and substance on the side of it. g. There was an electrical box between the steam table and preparation table that had food and debris on it. h. There was a brown substance around the dials on the steam stable. i. There was food debris on the bottom of the tray where bases were stored. j. There was debris and plastic behind the double ovens. k. The storage rack for the domes and bases were soiled with dust. l. There were clean cups that had a white film inside of them. m. The dry storage room had water stains on ceiling and wall. n. There was black substance on the door into the dry storage around the handle on both sides. 2. On 8/2/22 at 12:25 PM, an observation was made of the kitchen. Dietary Aide (DA) 1 was observed to use a Purell hand sanitizer wipe on a thermometer and then placed it in coffee. The wipe packaging revealed for external use only. 3. On 8/3/22 at 9:43 AM, a follow-up observation was made of the facility kitchen. The following was observed: a. There was a white substance on side of steam table. b. There were 2 knobs with brown substance around them on the steam table. c. There was an electrical box between the prep table and steam table with food debris on it. d. There was food splatter on the sides of the tray line. e. There was debris inside the plate and hot plate warmer. f. The storage rack for the domes and bases were soiled with dust. g. There was a black substance in the bottom of double ovens. h. The handles to the ovens had substance on them. i. There was food splatter on the side of the double ovens. j. The front and side of stove/oven had dried food splatter. k. There was food splatter on the ceiling. l. Behind the stove/oven, microwave/toaster table and double oven there were brown and black substances on the walls and debris on the floor. m. A pipe outside the walk in refrigerator had a dried white substance from the top to the bottom running down the wall. n. There were clean cups that had a white film inside of them. o. The door into the kitchen from the dining room had black substance and dust on it. p. The dish room had black substance around the edges and on the walls and on the door frame. q. There was a black substance on the wall under the spray sink in the dish room. r. The door to the back hallway had black substance on the bottom of the door and by the door knob. s. There was a plate underneath the double oven. t. There were holes in the door to the dry storage with black substance on both sides of the door. u. The floor in the dry storage was sticky and had black substance on it. v. The walk in refrigerator's handle was sticky. w. There was a white substance on glass door and on the floor in the walk in refrigerator. An interview was conducted with [NAME] 1. [NAME] 1 stated that the white substance in the cups was hard water from the dish machine. [NAME] 1 stated the tray line was deep cleaned weekly on Friday's. [NAME] 1 stated it was deep cleaned by pulling all items out and all of the shelving was wiped down. [NAME] 1 stated the electrical box needed to be cleaned when the tray line was deep cleaned. [NAME] 1 stated that ovens were cleaned monthly. [NAME] 1 stated the griddle was cleaned when it was used, burners were cleaned weekly, take them off and scrubbed in the sink. [NAME] 1 stated the outside of the oven was wiped down weekly and at the end of each shift. [NAME] 1 stated she did not know what the white substance was on the wall outside the walk in but noticed it a few weeks ago. [NAME] 1 stated that under the stoves and ovens were cleaned weekly. [NAME] 1 stated We probably need a new binder for the menus.

Based on interview and record review, it was determined that the facility did not inform residents, resident families and representatives of a confirmed COVID-19 infection in a timely manner. Specifically, the facility did not send a notification to resident families and representatives by 5:00 p.m. the next calendar day following the occurrence of a confirmed COVID-19 infection. Findings included: On 7/31/22 at 10:30 AM, during entrance conference the Administrator (ADM) reported there were no active COVID-19 cases in the building and the last positive COVID-19 case occurred on 7/4/22. A review of the entrance documents revealed the last positive COVID-19 case in the facility involved a staff member and occurred on 7/4/22. On 8/2/22 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the Resident Advocate (RA) let the families and residents know the same day there was a positive COVID-19 case and that this information was charted in the progress notes. On 8/3/22 at 9:40 AM, an interview was conducted with the RA. The RA stated she informed the families and residents of those who have been tested for COVID-19 or who had COVID-19. The RA reported she put the information in the progress notes section of the medical record. The RA stated she was unsure who's responsibility it was to let the entire facility know when there was a positive COVID-19 result. On 8/3/22 at 9:45 AM, an interview was conducted with the ADM. The ADM stated the RA was in charge of informing the families and residents when there was a positive COVID-19 case in the building. The ADM stated the RA was over that process. The ADM stated the facility did not make have an area on the facility website where this information was posted. No documentation was found during record review or was provided by the facility that the residents, residents families or representatives were notified of the positive COVID case by 5pm the following day. The Centers for Medicare & Medicaid Services Center for Quality, Safety & Oversight Group, QSO-20-29-NH stated, The facility must inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.