**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R97) of 26 sampled residents. The third floor day room, dining room, and hallway contained several missing and broken floor tiles. Staff indicated the missing and broken floor tiles were a potential safety hazard. R97 indicated the tiles were unsightly and should be fixed. Findings include: The facility's admission Agreement document, dated 2/2025, indicates: Rights of Nursing Home Members: The Home must protect and promote the rights of each Member, including each of the following rights: .I. Right to a dignified existence, self-determination .II. Right to be treated with respect and dignity and to be cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the Member's individuality. The facility did not provide a policy related to a home-like environment or safety of the environment. On 3/17/25, Surveyor reviewed R97's medical record. R97 was admitted to the facility on [DATE] and had diagnoses including dementia, femur fracture, anxiety, depression, and insomnia. R97 had a history of falls with major injury. R97's Minimum Data Set (MDS) assessment, dated 2/26/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R97 had intact cognition. On 3/18/25 at 1:10 PM, Surveyor observed the third floor dining area/day room and the A and C hallways. Surveyor noted more than twenty floor tiles exhibited varying degrees of damage. Some tiles had missing corners, some tiles were half missing, and other tiles were completely missing. The missing and broken tiles were in highly visible areas frequently walked on by residents, staff, and visitors. On 3/18/25 at 1:38 PM, Certified Nursing Assistant (CNA)-R approached Surveyor while Surveyor walked down the C wing hallway and asked if Surveyor had noticed the floors. CNA-R indicated the floors were unsightly and a safety hazard and had been that way for years. CNA-R was not aware of any residents who had tripped on the damaged areas. On 3/19/25 at 12:29 PM, Surveyor interviewed CNA-Q who indicated the floors had been that way for years. CNA-Q indicated the floors don't look good and are not a nice aesthetic for the residents' home. CNA-Q indicated the missing tiles could be a trip or fall hazard. CNA-Q indicated CNA-Q slipped on a missing tile in the past. CNA-Q was not aware of any residents who had tripped on the missing tiles. On 3/19/25 at 12:41 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who indicated the floor tiles have been that way for a long time. LPN-L indicated the floors do not look good and are broken and old. LPN-L indicated the floors could be a trip hazard, however, LPN-L was not aware of any residents who had tripped or fallen on them. LPN-L indicated the floors were reported as a concern in the past. On 3/19/25 at 1:01 PM, Surveyor interviewed R97 who indicated the missing floor tiles in R97's hallway are off to the side so R97 doesn't worry about tripping on the tiles. R97 indicated R97 watches R97's self closely while ambulating because R97 had recently fallen in R97's room and and broken a bone. R97 indicated the tiles in the hallways and dining area are unsightly, don't look nice, and should be fixed. On 3/19/25 at 1:54 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who verified the broken and missing tiles on the third floor and confirmed the floor has been that way for a while. ADON-C indicated the facility plans to address the floor but needs to figure out where to move the third floor residents while the work is completed. ADON-C indicated ADON-C is aware the broken and missing tiles don't look home-like and could be a potential safety hazard. On 3/19/25 at 2:23 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility has a responsibility to identify and fix issues and potential safety concerns for residents' safety and happiness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R22 was transferred to the hospital on 9/23/24 and 11/28/24. R22 was not provided with a written transfer notice on 9/23/24 or 11/28/24. In addition, the Ombudsman was not notified of R22's 9/23/24 hospital transfer. Findings include: The facility's Notice of Transfer policy, revised 1/31/23, indicates: .The Notice of Transfer document must include the following: date/time of the transfer, destination of the transfer, reason for the transfer, who was notified of the transfer, transfer appeal rights, and the facility's bed hold policy. The notice shall be issued to members/representatives at the time of any emergent transfer and prior to any planned/non-emergent transfer or admission to another health care facility. Following the transfer, a written notice shall be issued to the notified representative within a reasonable time frame .3. The unit Registered Nurse (RN) documents the Notice of Transfer within the member's electronic health record, completes all fields, and indicates how the bed hold was issued . On 3/17/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, open wound of the left leg, type two diabetes, and anxiety. R22's Minimum Data Set (MDS) assessment, dated 1/29/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R22 had severely impaired cognition. R22 had a Guardian who was responsible for R22's healthcare decisions. R22's medical record indicated R22 was transferred to the hospital on 9/23/24 for a planned procedure and hospital stay. R22 was transferred to the emergency room (ER) on 11/28/24 and admitted to the hospital related to heart failure. R22's medical record did not indicated R22 or R22's Guardian were provided with a written transfer notice for either transfer. R22's medical record also did not indicate the Ombudsman was notified of the transfers. On 3/19/25, Surveyor requested a copy of R22's written transfer notices and Ombudsman notification for the 9/23/24 and 11/28/24 hospital transfers. On 3/19/25, Surveyor received some of the requested information. The facility did not provide a transfer notice or Ombudsman notification for R22's 9/23/24 hospital transfer. The facility also did not provide a transfer notice for R22's 11/28/24 hospital transfer. On 3/19/25 at 11:10 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R22's 9/23/24 hospital transfer was not documented correctly. DON-B indicated the planned hospital admission was not coded for a discharge but should have been. DON-B confirmed a written transfer notice and Ombudsman notification were not completed for the 9/23/24 hospital transfer. DON-B indicated DON-B could not locate a written transfer notice for R22's 11/28/24 hospital transfer. DON-B confirmed all hospital transfers should be provided with a discharge/transfer notice and Ombudsman notification per the facility's policy. DON-B indicated staff have been trained and should follow the transfer/discharge policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 sampled residents received written information of the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility. R22 was transferred to the hospital on 9/23/24 and 11/28/24. Neither R22 or R22's Guardian were provided with a written bed hold notice for either transfer. Findings include: The facility's Notice of Transfer policy, revised 1/31/23, indicates: .The Notice of Transfer document must include the following: date/time of the transfer, destination of the transfer, reason for the transfer, who was notified of the transfer, appeal rights, and the facility's bed hold policy. The notice shall be issued to members/representatives at the time of any emergent transfer and prior to any planned/non-emergent transfer or admission to another health care facility. Following the transfer, a written notice shall be issued to the notified representative within a reasonable time frame .3. The unit Registered Nurse (RN) documents the Notice of Transfer within the member's electronic medical record, completes all fields, and indicates how the bed hold was issued . The facility's admission Agreement-Attachment B-Bed Hold policy states: Absence from the Veterans Home at midnight requires a bed hold to ensure the Member can return to the same bed and is secured by payment . On 3/17/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, open wound of the left leg, type two diabetes, and anxiety. R22's Minimum Data Set (MDS) assessment, dated 1/29/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R22 had severely impaired cognition. R22 had a Guardian who was responsible for R22's healthcare decisions. R22's medical record indicated R22 was transferred to the hospital for a planned procedure and hospital stay on 9/23/24. R22 was also transferred to the emergency room (ER) and admitted to the hospital related to heart failure on 11/28/24. R22's medical record did not contain a bed hold notice for either transfer. On 3/19/25, Surveyor requested a copy of bed hold notices for R22's 9/23/24 and 11/28/24 hospital transfers. On 3/19/25 at 11:10 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R22's 9/23/24 discharge was not documented correctly. DON-B indicated the planned hospital admission was not coded as a discharge but should have been. As a result, a bed hold notice was not provided to R22. DON-B was unable to locate a bed hold for R22's 11/28/24 hospital transfer. DON-B confirmed all hospital transfers should be provided with a bed hold notice. DON-B indicated staff have been trained and should follow the transfer/discharge policy which includes providing bed hold notices.

Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 3 residents (R) (R30, R49, and R1) of 26 sampled residents. R30's MDS assessment, dated 2/26/25, contained diagnoses of long term (current) use of anticoagulant medication and long term (current) use of aspirin; however, R30 was not prescribed anticoagulant medication or aspirin. The MDS assessment also indicated R30 received hypnotic medication; however, R30 was not prescribed hypnotic medication. In addition, MDS assessments, dated 6/5/24, 6/21/23, 4/13/23, and 4/20/22, indicated R30 did not have a Preadmission Screening and Resident Review (PASRR) Level II Screen; however, a PASRR Level II Screen was completed and indicated R30 had a mental illness. R49's MDS assessment, dated 3/5/25, contained a diagnosis of long term (current) use of anticoagulant medication and indicated R49 received anticoagulant medication and insulin; however, R49 was not prescribed anticoagulant medication or insulin. R1's MDS assessment, dated 2/12/25, indicated R1 received anticoagulant medication; however, R1 was not prescribed anticoagulant medication. Findings include: The Resident Assessment Instrument (RAI) 3.0 user's manual version 1.19.1, dated October 2024, indicates: Code medications in item N0415 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. Medline Plus, https://www.nlm.nih.gov/medlineplus/druginformation.html is a reference within the RAI to help determine classification of medications. Medline Plus indicates, Clopidogrel (or Plavix) is in a class of medications called antiplatelet medications.The RAI manual indicates to be coded as an active diagnosis on the MDS, it must be a physician-documented diagnosis in the last 60 days that has a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period .RAI manual indicates to code yes if the PASRR Level II screening determined that the resident has a serious mental illness and/or intellectual disability (ID)/developmental disability (DD) or related condition, and continue to A1510, Level II PASRR conditions. 1. From 3/17/25 to 3/19/25, Surveyor reviewed R30's medical record. An MDS assessment, dated 2/26/25, indicated R30 had a diagnoses of long term (current) use of aspirin and long term (current) use of anticoagulant medication (Section I); however, Surveyor noted R30 was not prescribed aspirin or anticoagulant medication. The MDS assessment also indicated R30 received anticoagulant but not antiplatelet medication (Section N). In addition, the MDS assessment indicated R30 received hypnotic medication (Section N). Surveyor reviewed R30's medication list which included clopidogrel bisulfate (an antiplatelet medication). Surveyor noted there were no anticoagulant or hypnotic medications on R30's medication list. R30's medical record contained a PASRR Level I Screen and an abbreviated Level II Screen, dated 10/8/15, that indicated R30 had a serious mental illness. MDS assessments, dated 6/5/24, 6/21/25, 4/13/23, and 4/20/22, indicated R30 was not evaluated by a Level II PASRR Screen and determined to have a serious mental illness (Section I). Surveyor noted R30's diagnosis list included post-traumatic stress disorder (PTSD). R30's care plan indicated R30 had a PASRR Level II Screen and did not require specialized services. On 3/18/25 at 1:00 PM, Surveyor interviewed MDS Nurse (MDSN)-F and asked which anticoagulant and hypnotic medications R30 was prescribed. MDSN-F indicated R30 was prescribed Plavix but was not prescribed a hypnotic medication. MDSN-F indicated MDSN-F would remove the hypnotic medication and change the anticoagulant medication to antiplatelet medication on R30's 2/26/25 MDS assessment. Surveyor mentioned to MDSN-F that R30 also had diagnoses of long term (current) use of anticoagulant medication and long term (current) use of aspirin. When Surveyor asked about the PASRR coding on R30's 2/26/25 MDS assessment, MDSN-F indicated the assessment was coded by a Social Worker (SW). On 3/18/25 at 1:23 PM, Surveyor interviewed SW-G who indicated R30's 3/5/25 MDS assessment did not indicate R30 had a PASRR Level II Screen. SW-G indicated R30 was referred for a new Level I Screen in 2023 and didn't require specialized services at that time. The facility did not provide a PASRR completed in 2023. R30's last PASRR, dated 10/8/15, indicated R30 had a serious mental illness. 2. From 3/17/25 to 3/19/25, Surveyor reviewed R49's medical record. An MDS assessment, dated 3/5/25, contained a diagnosis of long term (current) use of anticoagulant medication (Section I); however, R49 was not prescribed anticoagulant medication. In addition, the MDS assessment indicated R49 received anticoagulant but not antiplatelet medication (Section N). The MDS also indicated R49 received insulin seven days during the look back period (Section N). Surveyor reviewed R49's medication list which included clopidogrel bisulfate (an antiplatelet medication) but did not include anticoagulant medication or insulin. On 3/18/25 at 1:00 PM, Surveyor interviewed MDSN-F and asked if R49 received insulin. MDSN-F indicated R49 received Plavix (an antiplatelet medication) but did not receive insulin. Surveyor also noted R49 had a diagnosis of current anticoagulant use. MDSN-F indicated MDSN-F would investigate. MDSN-F indicated MDSN-F would remove the insulin and change Plavix from anticoagulant to antiplatelet on the MDS assessment. 3. From 3/17/25 to 3/19/25, Surveyor reviewed R1's medical record. R1's MDS assessment, dated 2/12/25, indicated R1 received anticoagulant medication (Section N) but not antiplatelet medication. Surveyor reviewed R1's medication list which included clopidogrel bisulfate. Surveyor noted there were no anticoagulant medications on R1's medication list.

Based on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R16) of 7 sampled residents. R16 had a mental illness (MI) diagnosis. R16's PASRR Level I Screen stated No to MI. R16 did not have a PASRR Level II Screen. Findings include: The facility's Preadmission Screening and Resident Review (PASRR) policy, dated 11/8/24, indicates: A Level I Screen is required for all applicants being admitted to the facility to assess for mental illness or intellectual disability. It is used to determine if the individual requires specialized services. Level I Screens that indicate mental illness or intellectual disability require additional assessment to confirm the intellectual disability or mental illness, this is a Level II Screen .Members admitting to the facility from another nursing facility will require a new Level I Screen effective January 2025 to associate the level screening with a new level of care request. The discharging facility is expected to provide the admitted facility with all PASRR records. From 3/17/25 to 3/19/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility from a sister facility on 9/15/22 and had diagnoses including dementia, anxiety disorder, and post-traumatic stress disorder (PTSD). R16's Minimum Data Set (MDS) assessment, dated 1/1/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 was not cognitively impaired. R16 was responsible for R16's healthcare decisions. R16's medical record contained a PASRR Level I Screen completed on 6/29/10 with a most recent review date of 7/17/24. Section A was marked No for current MI diagnosis. Surveyor reviewed R16's medical diagnoses which included anxiety disorder and PTSD. Surveyor reviewed R16's care plan (initiated 9/13/23) which indicated R16 was at risk for ineffective individual coping related to mental illness. R16's medical record did not contain a PASRR Level II Screen. On 3/19/25 at 8:47 AM, Surveyor interviewed Social Worker (SW)-E who confirmed PTSD and anxiety are mental illnesses. SW-E confirmed submission for a Level II Screen should be completed even if R16 was not on any medications. On 3/19/25 at 11:16 AM, Surveyor interviewed SW-G who confirmed SW-G was R16's social worker. SW-G confirmed PTSD and anxiety are mental illnesses. SW-G stated SW-G did not complete any PASRR screenings for R16 because R16 never had any symptoms. SW-G stated SW-G was not aware that a Level II Screen is required if the resident does not have symptoms and is not on any medications. On 3/19/25 at 2:52 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R16 had mental illnesses of anxiety and PTSD. DON-B was unsure if R16 required a Level II Screen.

Based on staff interview and record review, the facility did not ensure a comprehensive care plan to meet psychosocial needs was developed and implemented for 1 resident (R) (R30) of 26 sampled residents. R30 was identified as having a serious mental illness of post-traumatic stress disorder (PTSD). R30 did not have a a care plan or interventions in place to address the diagnoses. Findings include: From 3/17/25 to 3/19/25, Surveyor reviewed R30's medical record. R30 had a Preadmission Screening and Resident Review (PASRR) Level I Screen, dated 10/8/15, that indicated R30 had a serious mental illness. A Behavioral Consulting Services (BCS) determination, dated 10/8/15, indicated R30 had a serious mental illness but was appropriate for nursing home placement without specialized services. Surveyor reviewed a life events checklist (LEC-5 extended) assessment completed by Social Worker (SW)-G on 4/15/22 that indicated R30 witnessed a natural disaster, fire or explosion and sudden accidental death and suffered a transportation accident and life-threatening illness or injury. R30 described R30's worst event as an explosion in Vietnam. Minimum Data Set (MDS) assessments, dated 6/5/24, 6/1/25, 4/13/25, and 4/20/22 indicated R30 had PTSD (Section I). R30's diagnoses list included PTSD. R30's medical record did not contain a care plan or interventions related to PTSD. On 3/18/25 at 2:17 PM, Surveyor emailed BCS and asked if a diagnosis of PTSD indicates a mental illness on the Level I Screen and triggers a referral for a Level II Screen even if the resident doesn't currently take medications. BCS indicated yes. On 3/18/25 at 1:23 PM, Surveyor interviewed Social Worker (SW)-G who confirmed R30 had a diagnosis of PTSD. SW-G verified R30 did not have a care plan to address the diagnosis. SW-G indicated PTSD didn't trigger on R30's LEC-5 and SW-G doesn't do anything with the diagnosis on MDS assessments. Surveyor reviewed the LEC-5 assessment. Per the directions, there is no formal scoring protocol or interpretation. On 3/19/25 at 8:47 AM, Surveyor interviewed SW-E to identify the process of determining mental illness for a new admission. SW-E indicated the screening process for residents consists of different assessments, initial interviews, a discharge plan, a diagnoses list, Level Screens, medications, the discharge process, social history, and an LEC-5 trauma informed care screen. (LEC-5 is a Veterans Affairs (VA) form for trauma that may be experienced as an adult.) A referral can then be made to the facility's psych Advanced Practice Nurse Prescriber (APNP), licensed clinical social worker, the psychologist, or a contracted psych Nurse Practitioner (NP). Members are most likely to be referred to psych services. SW-E confirmed PTSD is a mental illness and it is important to review past records and develop a care plan for a resident with a history of trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R22 and R31) of 2 sampled residents. R22 and R31 were known smokers. Staff did not follow R22 and R31's assessments and care plans for safe smoking. Findings include: The Facility's Tobacco Use policy, dated 2/25/25, indicates: .Members who use tobacco must be able to do so independently. It shall be addressed in the member's plan of care. Supervised and assisted smoking is prohibited .6. After assessment and all observations, if no safety concerns were noted, the care team discusses the member's smoking. The team collaborates with the member to develop or revise a safety plan addressing their choice to use tobacco. 6.1 The plan must include an intervention identifying the member as a tobacco user and any items needed for safe, independent smoking (e.g., smoking apron) . The Facility's Member Smoking and Tobacco Use Rules, dated 1/2025, states: Smoking on grounds is permitted for grandfathered members. You must demonstrate the ability to: Smoke/vape safely, independently, including lighting and snuffing of the tobacco product or device; Call for assistance should an emergency occur; Store your tobacco products(s) and any materials safely and securely .If unsafe smoking is observed at any time, your privileges will be revoked until the interdisciplinary team (IDT) can review and discuss the incident. Depending on the severity of the offense, your privileges may not be reinstated. Examples of unsafe smoking are: .Not safely securing products and materials. Smoking or lighting of a tobacco product indoors . 1. On 3/17/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including vascular dementia with mood disturbance, dizziness and giddiness, myopia, contracture, and tobacco use. R22's Minimum Data Set (MDS) assessment, dated 1/29/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R22 was severely cognitively impaired. R22 had a Guardian who was responsible for R22's medical decisions. R22's plan of care indicated R22 was an independent smoker and staff should distribute smoking materials to R22. The care plan indicated R22 was at risk for injury related to cognitive losses which may contribute to unsafe smoking. The care plan indicated R22 should receive seven cigarettes per day from staff in the morning and should wear a smoking apron. R22's Kardex (an abbreviated care plan used by nursing staff) indicated R22 was an independent smoker who received seven cigarettes per day and had to sign them out. The Kardex also indicated R22 needed to wear a smoking apron. R22's most recent smoking assessment, dated 1/20/25, indicated: .2. Smoking materials: b. Smoking materials must be managed at the nurses' station .10. Member is able to return smoking supplies to approved storage. On 3/17/25 at 1:13 PM, Surveyor interviewed R22 who indicated R22 smoked and was wearing a smoking apron. R22 indicated R22 wore the smoking apron all the time. R22 indicated R22 receives eight to ten cigarettes in the morning. R22 stated when the cigarettes are gone, R22 is finished smoking for the day. R22 indicated R22 keeps cigarettes and a lighter on R22's person and does not need to return them to staff after smoking. Surveyor observed R22 in R22's room with cigarettes and a lighter. On 3/18/25 at 1:38 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-R regarding R22. CNA-R showed Surveyor R22's bedside drawer where R22 keeps extra lighters. CNA-R indicated R22 receives seven cigarettes in the morning and keeps smoking materials on R22's person all day. CNA-R stated R22 is forgetful at times and asks for a lighter. CNA-R reminds R22 that R22 has a lighter in R22's pocket. CNA-R indicated R22 is an independent smoker and wears a smoking apron. CNA-R showed Surveyor where R22's smoking materials should be kept behind a locked door in a sealed plastic tote at the nurses' station. The plastic tote contained a sign that indicated R22 should receive seven cigarettes per day and wear a smoking apron. Surveyor observed a sign out sheet for R22's cigarettes. On 3/18/25 at 1:44 PM, Surveyor observed R22 smoke outside and then return to the building. Surveyor noted R22 did not return R22's smoking materials to the nurses' station. Surveyor did not observe staff ask R22 for the smoking materials. On 3/19/25 at 12:29 PM, Surveyor interviewed CNA-Q who stated R22 is an independent smoker who wears a smoking apron. CNA-Q indicated R22 keeps smoking materials on R22's person. CNA-Q was unsure how to monitor for residents who are supposed to return their smoking materials and stated the resident's assigned CNA should watch and ask for the smoking items when the resident returns from smoking. CNA-Q indicated the items are stored in a basked behind the door of the nurses' station. On 3/19/25 at 1:54 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who indicated staff are educated on residents who smoke and the smoking policy. ADON-C indicated residents who smoke are assessed quarterly and with any smoking concerns or changes in condition. ADON-C indicated smoking assessments should be followed and be incorporated in the resident's care plan and Kardex. ADON-C indicated if a smoking assessment indicates a resident's smoking materials are maintained by nursing staff, the resident should turn in the smoking materials after smoking. ADON-C indicated there is an issue if a resident does not turn in smoking materials as designated and keeps them on their person or in their room with staffs' knowledge. On 3/19/25 at 2:23 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff and residents should be aware of and follow the facility's smoking policy which includes completing and following smoking assessments. 2. From 3/17/25 to 3/18/25, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, post-traumatic stress disorder (PTSD), and tobacco use. R31's MDS assessment, dated 1/16/25, had a BIMS score of 9 out of 15 which indicated R31 had moderate cognitive impairment. R31's medical record indicated R31 signed the facility's smoking rules on 12/9/24. R31's smoking care plan indicated R31 was at risk for injury related to R31's choice to smoke and by the recent findings by staff of burn holes in R31's jeans and scooter cushion. The care plan indicated R31 was an independent smoker and contained interventions to keep smoking materials at the Assistant Director of Nursing (ADON) nurses' station, distribute three cigarettes and a lighter, and ensure R31 is wearing a smoking apron prior to going out to smoke for R31's safety and the safety of others. A smoking assessment, dated 12/27/24, indicated the following: ~ R31 is an approved smoker with no safety concerns. ~ R31 uses a smoking apron related to a smoking incident where burn holes were discovered in R31's jeans and scooter cushion during the week of 12/23/24. A smoking apron was implemented. ~ R31's smoking materials must be maintained at the nurses' station due to safety per R31's Power of Attorney for Healthcare (POAHC). R31 can receive three cigarettes at a time. Staff should make sure R31 is wearing a smoking apron before R31 leaves the unit to the smoke. ~ A summary of a historical smoking incident indicated: Smoking assessment (12/27/24) Note: On 9/14/22, R31 stated R31 lit a cigarette in R31's room to see what would happen to the sprinkler head. As soon as the cigarette was lit, R31 put the cigarette out. R31 stated R31 would not smoke in R31's room and knew it was unsafe. On 3/17/25 at 10:47 AM, Surveyor observed R31 in a manual wheelchair with a smoking apron on. R31 was alert and oriented to person and place and stated R31 was going outside to smoke. Surveyor observed R31 go outside, take a cigarette out of a box, light the cigarette with a lighter, and smoke the cigarette unsupervised. R31 disposed of the cigarette appropriately, reentered the facility, and went to R31's room. On 3/18/25 at 10:02 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated R31's cigarettes are kept at the nurses' station and R31 has to request cigarettes from staff. LPN-I stated R31 can have two cigarettes each time R31 goes out to smoke. LPN-I stated R31 is able to smoke independently per R31's smoking assessment. On 3/19/25 at 11:09 AM, Surveyor interviewed CNA-J who indicated R31 wears a smoking apron while smoking. CNA-J stated R31 must ask staff for cigarettes and a lighter. On 3/19/25 at 11:29 AM, Surveyor interviewed Registered Nurse (RN)-H who stated R31 is able to smoke unsupervised but must wear a smoking apron. RN-H stated R31 is given two cigarettes at a time by staff and is able to keep a lighter in R31's room. RN-H stated staff verify R31 does not have cigarettes in R31's possession by looking in R31's cigarette box when R31 re-enters the facility. On 3/19/25 at 11:33 AM, Surveyor observed a box of cigarettes and two lighters in R31's room on a side table. R31 was in the room and opened the cigarette box. Surveyor observed five cigarettes in the box. On 3/19/25 at 1:12 PM, Surveyor interviewed ADON-C who indicated R31 has to go to the nurses' station with a smoking apron on and request cigarettes. ADON-C stated R31's POAHC prefers staff give R31 two cigarettes each time R31 goes out to smoke. ADON-C stated R31 is able to keep a lighter in R31's possession. ADON-C indicated staff are able to observe R31 smoking outside via the camera in the smoke shack. When Surveyor mentioned Surveyor observed five cigarettes in R31's room earlier that day, ADON-C stated R31's cigarettes should be at the nursing station and not in R31's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure monitoring interventions for adverse reactions to antipsychotic medication were in place for 1 resident (R) (R104) of 6 sampled residents. R104 was prescribed quetiapine (an antipsychotic medication) 50 milligrams (mg) once daily with a start date of 11/22/24. The facility did not ensure an Abnormal Involuntary Movement Scale (AIMS) assessment was completed when R104 started the medication. Findings include: The facility's Tardive Dyskinesia Monitoring policy, revised 7/24/24, indicates: Members taking antipsychotic, tricyclic antidepressants, and/or metoclopramide shall be screened: on admission or new order, every 6 months, at discontinuation, and monthly every 3 months following discontinuation. On 3/18/25, Surveyor reviewed R104's medical record. R104 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease with dyskinesia (involuntary movements), unspecified dementia, and specified forms of tremors. R104's Minimum Data Set (MDS) assessment, dated 1/15/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R104 had intact cognition. R104's medical record indicated R104 had an order for quetiapine 50 mg once daily in the AM as noted on R104's medication administration record (MAR). R104's medical record did not indicate an AIMS assessment was completed when R104 started quetiapine. On 3/19/25, Surveyor requested a copy of R104's AIMS assessment. On 3/19/25 at 12:47 PM and 2:49 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who indicated the facility did not have an AIMS assessment for R104 and confirmed an AIMS assessment should have been completed per the facility's policy.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 105 residents residing in the facility. Food items for resident consumption were not appropriately labeled and/or were beyond the discard date. Equipment in the main kitchen and unit 2 kitchenette was not in clean condition and/or covered. Findings include: On 3/17/25 at 9:20 AM, Surveyor interviewed Dietary Manager (DM)-K who stated the facility follows the Federal Food Code. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .(B) Except as specified in (E)-(G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. During an initial tour of the kitchen that began at 9:20 AM on 3/17/25, Surveyor noted an item in the cooler labeled tater tot casserole with a prepped date of 12/12/23, a pulled date of 12/13/23, and no use-by date. Surveyor noted an item in the freezer labeled gluten free (GF) hot dog bun (single) dated 2/12 with no year or use-by date. Surveyor also noted an open box of turkey breasts dated 9/25/22 with no use-by date. On 3/17/25 at 9:20 AM, Surveyor interviewed DM-K who confirmed the tater tot casserole, hot dog bun, and turkey breasts were past the expiration date and should have been discarded. Cleanliness: The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. The 2022 FDA Food Code documents at 4-903.11 Equipment, utensils, linens, and single-service and single-use articles: (a) Except as specified in (d) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) in a clean, dry location; (2) where they are not exposed to splash, dust, or other contamination; and (3) at least 15 centimeters (cm) (6 inches) above the floor. (b) Clean equipment and utensils shall be stored as specified under (a) of this section and shall be stored: (1) in a self-draining position that allows air drying; and (2) covered or inverted. During an initial tour of the kitchen that began at 9:20 AM on 3/17/25, Surveyor observed a coffee dispensing machine and noted dried coffee ground-like debris on the interior compartment. Surveyor also noted a cleaning sign off log posted on the exterior of the machine. The cleaning log indicated the coffee dispenser should be cleaned weekly on Fridays. The log indicated the machine was last cleaned on 1/10/25. On 3/17/25 at 9:20 AM, Surveyor interviewed DM-K who confirmed the coffee dispenser should be cleaned weekly on Fridays. DM-K acknowledged the dried debris on the interior of dispenser and verified the log indicated the machine was last cleaned on 1/10/25. During a follow-up tour of the kitchen that began at 12:01 PM on 3/18/25, Surveyor noted the coffee dispenser appeared to have been cleaned and the log contained a date of 3/17/25. On 3/17/25 at 9:20 AM, Surveyor observed three standing mixers in the main kitchen. The mixers were not in use and were not covered. Surveyor also observed a vertical cutter mixer (VCM) and 5+ VCM disc blades that were hung on the wall. The VCM and disc blades were not covered. On 3/17/25 at 9:20 AM, Surveyor interviewed DM-K who stated the three stand mixers, the VCM, and the blades are not covered when not in use. On 3/17/25 at 12:31 PM, Surveyor toured the unit 2 kitchenette and observed food debris on the countertop and the top of the microwave. Surveyor also observed a toaster with food debris on the exterior and a layer of food debris on the bottom of the interior. On 3/19/25 at 9:15 AM, Surveyor completed a follow-up tour of the unit 2 kitchenette and again observed food debris on the top of the microwave and interior and exterior of the toaster. Surveyor also noted a banana labeled for resident (R65) on the countertop. Surveyor noted food debris covered the countertop. On 3/19/25 at 12:55 PM, Surveyor interviewed DM-K and discussed the unit 2 kitchen observations. DM-K acknowledged the concerns and stated nursing staff are responsible for unit kitchenettes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 105 residents residing in the facility. During two care observations, staff did not adhere to enhanced barrier precautions (EBP) for R8. Hand hygiene was not offered or completed for multiple residents prior to or after dining. Findings include: The facility's Transmission-Based Precautions (TBP) policy, dated 4/11/24, states: Enhanced Barrier Precautions (EBP): For members with novel or targeted multidrug-resistant organism (MDRO) infections, indwelling medical devices and wounds, including as part of a public health containment response. This type of precaution falls between standard and contact precautions and requires gown and glove use for certain members during specific high-contact member care activities that have been found to be at increased risk for MDRO transmission. When a member is colonized, or has completed treatment for infection with a novel or targeted MDRO, direct care staff don gown and gloves prior to high-contact activities including: 1.1 Dressing; 1.2 Bathing/showering; 1.3 Transferring; 1.4 Providing hygiene; 1.5 Changing linens; 1.6 Changing briefs or assisting with toileting . The facility's Member Meals and Snacks Policy. dated 1/10/25, states: .Hand Hygiene shall be offered to all members prior to and following a meal .Staff shall assist members who are unable to complete hand hygiene independently . 1. From 3/17/25 to 3/19/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including history of methicillin-resistant staphylococcus aureus (MRSA), neuromuscular dysfunction of bladder, hydronephrosis, disorders of the urethra, disorders of the bladder, urinary tract infection, and presence of urogenital implants. R8 had an indwelling urinary catheter. R8's Minimum Data Set (MDS) assessment, dated 3/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R8 was not cognitively impaired. R8 had a physician order for EBP related to R8's Foley catheter and history of MRSA. R8's care plan indicated staff should use EBP (including donning gloves, a gown, and completing hand hygiene) when completing high-contact cares for R8 related to R8's Foley catheter and history of MRSA. R8's [NAME] (an abbreviated care plan used by nursing staff) indicated R8 had a catheter and staff should use EBP during R8's cares. On 3/17/25 at 1:26 PM, Surveyor observed an EBP sign on the wall near the entrance to R8's room. The sign read: Enhanced Barrier Precautions Everyone Must: Clean hands, including before entering the room and when leaving the room. Provider and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Surveyor also observed a personal protective equipment (PPE) cart outside R8's room that contained gloves, gowns, and hand sanitizer. On 3/17/25 at 1:32 PM, Surveyor observed Certified Nursing Assistant (CNA)-M knock on R8's door and enter R8's room. When CNA-M asked if R8 wanted to get up, R8 stated yes. CNA-M stated CNA-M would get R8 up and closed the door. CNA-M did not apply PPE prior to entering the room and shutting the door. On 3/17/25 at 1:39 PM, Surveyor observed CNA-M exit R8's room. CNA-M did not complete hand hygiene upon exit and was not wearing PPE. CNA-M then entered a room across the hall. At 1:40 PM, Surveyor observed CNA-M re-enter R8's room. CNA-M did not complete hand hygiene and did not don gloves or a gown. At 1:42 PM, Surveyor observed CNA-M exit R8's room. CNA-M did not complete hand hygiene. Surveyor observed R8 in a wheelchair. On 3/17/25 at 1:43 PM, Surveyor interviewed CNA-M who verified CNA-M got R8 out of bed. CNA-M confirmed CNA-M did not don PPE or follow EBP precautions while assisting R8. CNA-M confirmed R8 had a catheter and indicated CNA-M was aware R8 was on EBP. CNA-M indicated CNA-M didn't feel a gown was necessary for R8's cares and indicated CNA-M just needed to disinfect the catheter tubing after emptying it. CNA-M indicated EBP are for when body fluids could be splashed on staff. CNA-M indicated EBP isn't needed for R8 because CNA-M places the catheter drain tube far into the collection basin and isn't worried about splashing urine. CNA-M was aware R8's urine is colonized with an MDRO. On 3/17/25 at 1:51 PM, Surveyor observed CNA-M enter R8's room and leave the door open. CNA-M donned gloves without washing or sanitizing hands but did not don a gown. CNA-M then made R8's bed. On 3/19/25 at 1:54 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who indicated a resident with a catheter and history of MRSA should be on EBP. ADON-C indicated staff are aware of EBP and should follow the facility's EBP policy which includes gowns, gloves, and hand hygiene for high-contact cares. On 3/19/25 at 2:23 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff are trained in infection control practices including EBP and should follow residents' EBP orders and the facility's EBP policies. 2. On 3/17/25 at 12:02 PM, Surveyor observed the 100 wing east dining room which contained seventeen residents and five staff. Surveyor observed staff assist residents into the dining room and observed residents enter the dining room independently. Surveyor did not observe staff offer residents hand hygiene before the meal was served. On 3/17/25 at 12:31 PM, Surveyor noted multiple residents were finished eating and began to leave the area. On 3/17/25 at 12:32 PM, Surveyor interviewed CNA-N who was unsure if residents were offered hand hygiene before lunch. When asked the process for offering hand hygiene to residents, CNA-N looked in four cupboards and found a container of hand sanitizing wipes. CNA-N put the wipes on the counter across from the sink. On 3/17/25 at 12:35 PM, Surveyor interviewed CNA-O who indicated CNA-O uses a washcloth to wash residents' faces or lets residents wash their own faces after meals. CNA-O initially indicated CNA-O does not wash residents' hands before meals but later indicated staff toilet residents before meals and provide hand hygiene at that time. When Surveyor asked how residents who go to the dining room independently receive hand hygiene before meals, CNA-O indicated CNA-O wasn't sure. On 3/17/25 at 12:40 PM, Surveyor observed CNA-O remove the pump/lid from a container of hand sanitizer and pour an unmeasured amount of hand sanitizer into a basin of water. CNA-O then put several washcloths in the basin. CNA-O washed a resident's face and hands with a washcloth. CNA-O put the soiled washcloth on the counter and washed the hands and face of another resident with another washcloth. CNA-O continued the process with other residents and offered a washcloth to a resident to wash their own hands and face. On 3/17/25 at 12:41 PM, Surveyor observed CNA-P take the container of hand sanitizing hand wipes off the counter and put them back under the cupboard. On 3/17/25 at 12:49 PM, Surveyor interviewed CNA-O who verified CNA-O poured hand sanitizer into a basin of water to offer hygiene to residents which was CNA-O's regular practice. On 3/17/25 at 12:54 PM, Surveyor interviewed CNA-P who indicated residents' faces and hands are typically washed after meals by using a bowl of water with hand sanitizer On 3/17/25 at 12:56 PM, Surveyor observed the bottle of hand sanitizer used in the basin of water for resident hygiene. The bottle stated: Health Guard. Foaming 70% alcohol hand sanitizer with aloe and vitamin E. On 3/19/25 at 1:54 PM, Surveyor interviewed ADON-C who indicated it is not acceptable for staff to use hand sanitizer in water to wash residents' faces and hands after meals. ADON-C indicated resident hand hygiene is expected before meals. ADON-C indicated staff have been trained and should follow the facility's hand hygiene protocol. On 3/19/25 at 2:23 PM, Surveyor interviewed DON-B who indicated resident hand hygiene should be completed before meals. DON-B indicated staff have been trained should follow the facility's hand hygiene protocol.

Based on observation, staff interview and record review, the facility did not ensure kitchen equipment was monitored appropriately to ensure food safety. This practice had the potential to affect all 164 residents residing in the facility. Mechanical warewashing wash, sanitization, and internal surface temperature logs were not consistently completed. Cooking and cooling temperature logs for food cooked in the oven were not consistently completed. Logs that documented parts per million (PPM) of the sanitizing solution in sanitizer buckets and sanitization levels in the 3 compartment sink were not consistently completed. Findings include: On 1/29/24 at 8:40 AM, Surveyor began an initial kitchen tour with Dietary Administrator (DA)-F and Food Service Manager (FSM)-H. DA-F indicated the facility followed the US Food and Drug Administration (FDA) Food Code. The FDA Food Code 2022 at 3-402.12 Records, Creation and Retention indicates: Records must be maintained to verify that the critical limits required for food safety are being met. Records provide a check for both the operator and the regulator in determining that monitoring and corrective actions have taken place. 1. The FDA Food Code 2022 at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature indicates: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (4) For a multi-tank, conveyor, multi-temperature machine, 150 degrees Fahrenheit (F). The FDA Food Code 2022 at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures indicates: (A) .in a mechanical operation, the temperature of the fresh hot water sanitizing rinse .(2) For all other machines, 180 degrees F. During the initial kitchen tour on 1/29/24, Surveyor requested to review the January 2024 dishwasher temperature log. FSM-H provided the log and Surveyor noted there were missing dates. On 1/30/24 at 11:08 AM, DA-F provided additional requested logs. DA-F stated the log should be filled out by the kitchen supervisor prior to the morning dish cycle and again during the afternoon dish cycle. Surveyor noted: ~The November 2023 dishwasher temperature log indicated temperatures were documented at least once daily for 10 out of 30 days and 20 days contained no documentation. ~The December 2023 dishwasher temperature log indicated temperatures were documented at least once daily for 11 out of 31 days and 20 days contained no documentation. ~The January 2024 dishwasher temperature log indicated temperatures were documented at least once daily for 14 out of 28 days and 14 days contained no documentation. Surveyor noted on the dates the temperatures were recorded, the warewashing machine external and internal sani-disk temperatures were within the appropriate wash and sanitization ranges. On 1/30/24 at 11:08 AM, DA-F indicated the logs should be completed twice daily by the kitchen supervisors. 2. The FDA Food Code 2022 at 3-501.14 Cooling indicates: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135º Fahrenheit (F) to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. (B) Time/Temperature Control for Safety Food (TCS) shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. During the initial kitchen tour on 1/29/24, Surveyor requested to review cook temperature logs to ensure food was cooked to the appropriate temperature and cooled within the regulatory timeframe. On 1/30/24 at 11:08 AM, DA-F provided 4 logs for January 2024. The logs indicated at the top: Record product name along (include all versions) and final cooking temperature. Record cooling temperatures every hour during the cooling cycle. Record corrective action, if applicable. The food service manager will verify that the production staff is cooking and cooling food properly by visually monitoring production employees during the shift and reviewing, initialing, and dating this log daily. DA-F stated the facility uses a cook chill system in which some items are cooked in bulk in large kettles. The kettles are digitally monitored for time and temperature through the cooking and cooling process by a computerized line graph on a paper wheel. The facility uses a paper log for food items cooked in the oven and then cooled for the cook chill system. The paper log contains cook temperatures and cooling temperatures. For the month of January, DA-F provided a log for 1/8/24, 1/10/24, 1/15/24, and 1/29/24. On 1/30/24 at 11:22 AM, Surveyor interviewed [NAME] (CK)-G who confirmed paper logs are filled out for food cooked and cooled in the oven. CK-G and DA-F indicated the oven is not used every day, but was used more than the 4 days that were documented. DA-F indicated when food is cooked in the oven, staff should be document the cooking and cooling temperatures. Surveyor also noted the log was not completely filled out per the instructions at the top that indicated the food service manager would review, initial, and date the log daily. 3. The FDA Food Code 2022 at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness indicates: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions. The FDA Food Code 2022 at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration indicates: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The facility's PPM Monitoring for 3 Compartment Sanitation Sink and Sanitation Buckets policy, dated 11/6/15, indicates: The PPM of the sanitizing sink or bucket must be checked every 2 hours to ensure appropriate sanitizing levels. Procedure: At the indicated times on the recording sheet . The facility's Sanitizing Solution Concentration/Wiping Cloth Use policy, with a review date of April 2011, indicates: A PPM monitoring record shall be maintained with the daily mixing of sanitizing solution for spray bottles and sanitizing buckets. Completed monitoring records shall be filed along with the Bureau of Dietary Services for a period of at least 6 months. During the initial kitchen tour on 1/29/24, Surveyor requested to review the 3 compartment sink and sanitization bucket test logs. FSM-H provided logs for January 2024 that were incomplete. On 1/30/24, DA-F provided the November and December 2023 logs which contained the following information: Sanitization Bucket: ~The December 2023 log was completed for 3 out of 31 days. ~The January 2024 log was completed for 7 out of 28 days. 3 Compartment Sink: ~The November 2023 log was completed for 16 out of 30 days. ~The December 2023 log was completed for 17 out of 31 days. ~The January 2024 log was completed for 17 out of 29 days. On 1/30/23 at 11:08 AM, DA-F indicated sanitization bucket and 3 compartment sink testing should be completed per policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 Resident (R) (R1) of 3 sampled residents. R1 reported R1 was missing money. The allegation of misappropriation was not thoroughly investigated. Findings include: On 7/20/23, Surveyor reviewed R1's medical record. R1 was admitted to [NAME] Hall from another building on the same campus on 3/24/22. R1 had diagnoses to include Multiple Sclerosis (a chronic illness that affects the central nervous system, which includes the brain, spinal cord, and optic nerves), dementia unspecified severity with mood disturbance, and dementia unspecified severity with anxiety. R1 had an activated Power of Attorney for Healthcare (POAHC) and Finance (POAF). On 7/20/23, Surveyor reviewed a facility-reported incident, dated 6/1/23, that contained the following information: R1 reported R1 had $140 last week, and this week R1 only had $69 (missing $71). R1 allowed staff to search R1's room twice. The amount of money found in R1's wallet was as follows: three $10 bills, six $5 bills, three $1 bills (total $63) along with a $50 U.S. Savings Bond, and various coins scattered around R1's room. R1 stated R1 withdraws $200 each month from R1's account. R1 confirmed the last withdrawal was 5/1/23; however, R1's POAF only approves for R1 to receive $25 each week ($100 per month). An email was sent to the laundry department, but they replied on 6/2/23 that they did not find any money in R1's clothing. Staff witness statements were initiated and the Nursing Home Administrator (NHA) was notified at the time R1 reported the missing money. The local sheriff's department was notified. R1 has a diagnosis of dementia and has numerous behavior care plans, including a paranoia behavior care plan that states I often feel that others are entering my room and stealing my items that are locked up. Intervention: please notify the RN (Registered Nurse) and SW (Social Worker) if I have reports of missing money as my POAF limits me to $25 a week of cash to be withdrawn .Surveyor noted the investigation did not include interviews with other residents to determine if there were other concerns in the facility regarding missing valuables or money. On 7/20/23 at 9:14 AM, Surveyor interviewed Social Worker (SW)-C who stated R1 often changes the amount of money that R1 says is missing. SW-C also stated R1 says someone picks the master (key) lock to R1's closet where R1 keeps R1's money locked at night, even though R1 keeps the key to the lock with R1 all of the time. SW-C stated previously R1 had a finger print safe, but did not want to use that safe, and also had a locked drawer which R1 thought someone was getting into as well. SW-C verified R1's POAHC/POAF put a $25 per week limit on withdrawals from R1's resident account, but went on to say that R1 also had an account at the credit union on campus. SW-C stated R1 had R1's electric scooter privileges reinstated and R1 was able to go to the credit union on campus and withdraw $200 from R1's account on 4/19/23 (which was verified by SW-C). SW-C stated the credit union employees were not aware of the $25 per week withdrawal limit, but they are aware now. SW-C verified additional resident interviews were not completed for the investigation because the social workers wait for the supervisors to tell the social workers if they (social workers) need to complete additional resident interviews, and SW-C was not told to complete any. On 7/20/23 at 9:40 AM, Surveyor interviewed R1 regarding the allegation of missing money. R1 stated R1 locks R1's money in the closet and keeps the key at night, but thinks someone knows how to pick the lock. R1 stated R1 did not know how much money R1 had left, but that at one time, R1 had $200. R1 verified R1 purchases coffee and other snacks from the facility's vending machine, but does not borrow money to anyone. On 7/20/23 at 12:25 PM, Surveyor interviewed RN-D who completed the initial investigation. RN-D stated R1 did not report the missing money until approximately 10:00 PM. RN-D did not interview additional residents because they were in bed at that time. RN-D indicated the SW helps the next day and would do the interviews. On 7/20/23 at 9:07 AM during a conversation with NHA-A regarding the allegation of missing money, NHA-A stated staff did not believe the money was missing based on the date of the last withdrawal and R1's spend rate, and that's why no any other resident interviews were completed. NHA-A stated R1 had paranoia about missing things which was care planned.

Based on observation, staff interview, and record review, the facility did not ensure a safe and sanitary environment for staff. Kitchen floor disrepair caused tripping or injury to at least 4 (Dietary [NAME] (DC)-H, Dietary Aide (DA)-F, Dietary Supervisor (DS)-E, and DC-I) dietary staff and had the potential to be unsafe for 48 dining services staff. DC-H and former DA-F submitted injury reports related to the unsafe state of the kitchen floor. DS-E and DC-I both verbalized tripping on the unsafe kitchen floor. Findings include: On 12/5/22, during an initial tour of the kitchen beginning at 9:08 AM, Surveyor observed and Dietary Manager (DM)-D verified the kitchen floor was in a state of disrepair. Surveyor observed food residue in areas of the floor that were no longer smooth. Surveyor stepped over divots in the floor where food residue and other debris settled. Floor leading into a walk-in cooler and blast chiller had layers pulled away with powdery material visible, white mesh material visible, and black unknown material visible in areas where the blue top coat was worn away. Surveyor observed the dishwasher area floor and noted parts of the floor stood up irregularly at the floor seams. The tray line area had a large area of blue top layer missing with tile and unsealed concrete patches visible. An area under a kettle cooker had purple material visible, which DM-D identified as a waterproofing membrane. Disconnected ends of the purple material floated in liquid at the bottom of the divot. On 12/6/22 at 12:07 PM, DM-D and Maintenance Worker (MW)-K took rough measurements of the largest areas of floor disrepair. The measurements are not exact because the damaged areas were irregularly shaped. Multiple small floor areas in disrepair were not measured. A damaged, uncleanable area on the working side of the kettle cookers was 11.5 feet by 4 feet. The 4 foot side decreased to 16 inches at one point. Divots in the space were up to two inches deep. An area of disrepair that revealed broken pieces of what DM-D indicated was a water membrane measured approximately 30 inches by 10.5 inches. The depth was not obtained due to being under the kettle cooker. Surveyor observed a chill tank in the kettle cooking area connected to piping that was actively dripping onto the floor. DM-D explained the piping consistently dripped when the chill tank was operating. Floor in front of the combi ovens was uncleanable in a 4 foot by 16 inch area with divots up to 1.5 inches deep. Surveyor observed a stainless steal drainage lip sticking up from the floor and noted the screw holes were empty. MW-K stated that even 8 inch Tapcon (specialty masonry fasteners) screws did not work to keep the drainage lip secured to the floor. The uncleanable floor space in poor repair between the cooking area and blast chiller entrance was approximately 13 feet by 4 feet with multiple divots between 2 inches and 2-1/2 inches deep. A second uncleanable area of disrepair between the cooking area and blast chiller entrance was 32 inches by 21 inches. In the tray line area, exposed tile with an unsealed cement patch area was 19.5 feet by 11 feet. On 12/6/22 at 11:36 AM, Surveyor interviewed DS-E regarding the kitchen floor. DS-E confirmed DS-E tripped on the uneven flooring. DS-E denied submitting an incident report and explained DS-E was not injured by the incident. DS-E verbalized that tripping on the floor's areas of disrepair was a common occurrence for staff. DS-E recalled people coming through the kitchen over time and taking pictures of the floor disrepair. DS-E indicated DS-E was told there were plans to fix the floor; however, DS-E did not see much effort beyond two recent small test patches. On 12/06/22 at 12:33 PM, Surveyor interviewed DC-I regarding the kitchen floor. DC-I recalled being told over time that a floor fix was in the works, that the facility was waiting for answers and options, and that a fix was not in the budget. DC-I revealed DC-I tripped, fell, and was jarred while pushing a food cart across the broken floor areas. DC-I denied submitting an incident report. DC-I stated that while DC-I was injured, the injuries were not enough to visit a doctor. DC-I said the floor continues to crumble. On 12/6/22 at 12:42 PM, Surveyor interviewed DC-H regarding the kitchen floor. DC-H stated someone told the previous maintenance person, who no longer worked at the facility, not to try fixing the floor anymore. DC-H stated DC-H's back was injured while rolling a rack between the cooking area into the blast chiller. DC-H stated the wheel of the rack caught on the floor and DC-H's back was jarred when the rack wheel suddenly stuck. DC-H verified DC-H submitted an incident report and indicated a workman's compensation claim was still open at the time of the interview. On 12/7/2022 at 12:03 PM, PBS-J responded to incident requests via email and revealed DA-F, who no longer worked at the facility, slipped on a loose piece of floor in the kitchen and twisted DA-F's knee in July of 2022. On 12/7/22 at 12:10 PM, Surveyor contacted Payroll and Benefits Specialist (PBS)-J via email regarding incident reports related to the floor. PBS-J confirmed DC-H was injured in January of 2021 when DC-H was pushing a 20 tier food rack. DC-H stated a wheel caught in a hole in the floor and DC-H's back was jarred.

Based on observation, staff interview, and record review, the facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect all 151 residents. The Warewashing machine (dishwasher) sanitizing rinse did not meet the required minimum temperature of 180 degrees Fahrenheit (F) during observation and per monitoring logs in November and December of 2022. In addition, the internal surface temperature monitoring device did not meet the required 160 degrees F during observation. The kitchen floor was visibly soiled and not cleanable in multiple areas. Findings include: On 12/5/22 at 9:08 AM, Dietary Manager (DM)-D indicated the facility used the Food and Drug Administration (FDA) Food Code as its standard of practice. Dishwashing Machine FDA Food Code 2017 documented at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in ¶ (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: .(2) For all other machines, 82oC (180oF). FDA Food Code 2017 documented at 4-703.11 After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under §§ 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71oC (160oF) as measured by an irreversible registering temperature indicator. A dishwasher manufacturer data plate attached to the machine documented 180 degrees F as the minimum sanitizing rinse temperature. On 12/5/22 at 10:22 AM, Surveyor observed and DM-D verified the dishwasher sanitizing rinse temperature was not operating at 180 degrees F as required by the FDA food code and manufacturer data plate. A sanitizing rinse temperature gauge displayed temperatures between 170 and 177 degrees F during Surveyor's observation. DM-D explained the sanitizing rinse temperature was discussed with maintenance in the past and the response was that as long as the internal surface temperature monitoring device was registering 160 degrees F or higher, the machine was functioning properly. DM-D verbalized that the facility had a practice of running the internal surface temperature monitoring device near the beginning of each of the two dishwashing runs per day. Surveyor requested the internal surface temperature monitoring device be run through the machine. The surface monitoring device registered 146.1 degrees F. DM-D indicated the most recent internal surface temperature monitoring was done prior to Surveyor's request at approximately 6:30 AM. Review of the November and December 2022 dishwasher monitoring logs revealed the dishwasher sanitizing rinse temperature was not met for both dishwashing times on 34 out of 35 days available for review. Surveyor noted earlier during initial tour that maintenance workers were addressing a hot water concern in the kitchen kettle cooker area. DM-D was not able to indicate whether or not hot water was affected throughout the kitchen at the time the issue was discovered in the kettle cooker area. Floor Cleanability FDA Food Code 2017 documented at 1-201.10(B) Terms Defined. 'Smooth' means: .3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. FDA Food Code 2017 documented at 4-202.16 NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. FDA Food Code 2017 documented at 6-101.11 Surface Characteristics. (A) Except as specified in ¶ (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted; (3) Nonabsorbent for areas subject to moisture such as FOOD preparation areas, walk-in refrigerators, WAREWASHING areas, toilet rooms, mobile FOOD ESTABLISHMENT SERVICING AREAS, and areas subject to flushing or spray cleaning methods. FDA Food Code 2017 documented at 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm (one thirty-second inch). (B) The floors in FOOD ESTABLISHMENTS in which water flush cleaning methods are used shall be provided with drains and be graded to drain, and the floor and wall junctures shall be coved and SEALED. On 12/5/22, during an initial tour of the kitchen beginning at 9:08 AM, Surveyor observed and DM-D verified the kitchen floor was in a state of disrepair with soiled build-up visible under and around equipment in the kettle cooker and combi oven area. DM-D indicated the floor under the equipment was supposed to be sprayed and cleaned daily. Surveyor observed food residue in areas of the floor that were no longer smooth. Surveyor stepped over divots in the floor where food residue and other debris settled. Flooring leading into a walk-in cooler and blast chiller had layers pulled away with powdery material visible, white mesh material visible, and black unknown material visible in areas where the blue top coat was worn away. Surveyor noted part of the dishwasher area flooring stood up irregularly at the floor seams. The tray line area had a large area of blue top layer missing with tile and unsealed concrete patches visible. On 12/6/22 at 12:07 PM, DM-D and Maintenance Worker (MW)-K took rough measurements of the largest areas of floor disrepair. Measurements are not exact because the damaged areas were irregularly shaped. Multiple small floor areas in disrepair were not measured. A damaged, uncleanable area on the working side of the kettle cookers was 11.5 feet by 4 feet. The 4 foot side decreased to 16 inches at one point. Divots in the space were up to two inches deep. An area of disrepair that revealed broken pieces of what DM-D indicated was a water membrane measured approximately 30 inches by 10.5 inches. The depth was not obtained due to being under the kettle cooker. Floor in front of the combi ovens was uncleanable in a 4 feet by 16 inch area with divots up to 1.5 inches deep. Surveyor observed a stainless steal drainage lip sticking up from the floor and noted the screw holes were empty. MW-K stated that even 8 inch Tapcon (specialty masonry fasteners) screws did not work to keep the drainage lip secured to the floor. The uncleanable floor space in poor repair between the cooking area and blast chiller entrance was approximately 13 feet by 4 feet with multiple divots between 2 inches and 2-1/2 inches deep. A second uncleanable area of disrepair between the cooking area and blast chiller entrance was 32 inches by 21 inches. In the tray line area, the exposed tile with an unsealed cement patch area was 19.5 feet by 11 feet. On 12/6/22 at 12:33 PM, Surveyor interviewed Dietary [NAME] (DC)-I, who was working in the cooking area. DC-I explained the floor could not be cleaned properly because of the unsealed areas where the top blue layer was gone. DC-I expressed a strategy of avoiding the damaged floor areas with water when possible and stated, (The floor) continues to crumble. DC-I explained the damaged floor areas could not be avoided because damage was in the pathway between the cooking area and the blast chiller. On 12/6/22 at 12:38 PM, DC-G stated to Surveyor that the floor was terrible. DC-G shared a cleaning strategy of attempting to get as much debris as possible out of the holes. On 12/6/22 at 12:42 PM, Surveyor interviewed DC-H regarding cleaning the floor. DC-H stated approximately two years prior someone told a maintenance person, who no longer worked at the facility, not to try to fix the floor anymore. DC-H revealed that cleaning the floor meant spreading the crumbling floor bits or having the mop catch on the edges and losing strands of the mop to the floor or having more floor pull up. On 12/6/22 at 12:07 PM, DM-D explained to Surveyor that a previous plan to repair the floor was deemed cost prohibitive in comparison to building a new kitchen building. DM-D provided Surveyor with a document labeled DVA-FOOD SERVICE IMPROVEMENT, draft dated 11/1/22, which documented a cost estimate and timeline of operating out of the replacement kitchen in 2025. DM-D verified the plan did not have an approved budget and still needed to be presented to the legislature. DM-D stated there were two recent test patches on the floor; however, the test was a failure.

Based on observation, staff interview, and record review, the facility did not maintain appropriate infection control procedures to ensure residents' clothing, pillows and linens were protected from contamination in the facility's laundry area. This practice had the potential to affect all 151 residents. The floor in the facility's kitchen kettle room was in disrepair and contained numerous divots and areas of missing flooring. The kettle room was located above the facility's clean storage and laundry labeling area. The laundry area contained a plastic bin that collected approximately 37 gallons of liquid per day that drained from the kitchen floor through a membrane in the ceiling that contained hoses and funnels. The plastic bin was located in an area that contained residents' clothing, labeling equipment, spare pillows and linens. Findings include: On 12/5/22 beginning at 10:47 AM, Surveyor toured the laundry area with Laundry Supervisor (LS)-L. When entering the clean storage and laundry labeling area, Surveyor smelled a foul odor and observed a large plastic laundry container with brownish liquid. The ceiling of the area had a black waterproof membrane with two funnels positioned below and one hose taped into the membrane. Hoses extended from each funnel for a total of three hoses that extended from the ceiling to the plastic laundry container. LS-L stated gallons of liquid leaked each day from the kitchen above and was sometimes smelly. Surveyor noted the room held bags of residents' laundry waiting to be labeled, labeling equipment, spare pillows, lost clothing items, and clean linens on carts. On 12/6/22 at 1:20 PM, Surveyor and Infection Preventionist (IP)-M entered the laundry area together. IP-M stated that while IP-M did auditing in the laundry room, IP-M had not previously entered the clean laundry labeling room and it was IP-M's first time seeing the set-up. IP-M confirmed the kitchen kettle room was above the area where the liquid collected in the laundry container. IP-M indicated the set-up was an infection prevention and control concern because the room contained clean clothing and linens. At the time of the observation, IP-M and LS-L confirmed the foul odor in the room. LS-L stated the laundry container was emptied daily, but denied there was a sanitization procedure in place for the container that collected the liquid drainage. On 12/7/22 at 10:53 AM, Surveyor noted the laundry container holding kitchen liquids was marked 8 bu (bushel). LS-L stated the container got a bit more than half full each day and was emptied daily. Measurement conversion from bushel to gallon at 4 bushels per day is 37.23671 gallons of liquid draining from the kitchen floor in disrepair to the laundry room daily.