**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that 4 of 6 residents (R) reviewed for pressure injuries (PI) (R58, R89, R9, and R28) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R58 was admitted with multiple PIs and was at risk for PI development. R58 developed an unstageable PI. The facility did not reposition R58 for several hours. R89 was at risk for PI development. The facility failed to evaluate the effectiveness of current interventions R89 had in place. The facility did not reposition R89 for several hours and did not off-load heels and coccyx. R9 and R28 have existing PIs. R9 and R28 were not repositioned to promote healing of existing PIs or prevent pressure injuries from developing. Findings include: Example 1 R58 was admitted to facility on 01/30/24 with diagnoses which included in part: hypertension, hyponatremia, pressure injury to the right ankle stage 3, unstageable pressure injury to the right heel, stage 2 pressure injury to the sacral region, and bullous pemphigoid. R58's Minimum Data Set (MDS) assessment, dated 01/31/24, identified R58 scored 15 during a Brief Interview for Mental Status (BIMS), indicating cognition intact. MDS identified R58 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R58 was determined to be at risk for PIs. Surveyor reviewed R58's Braden skin risk assessment completed on 01/30/24 scored 15 at risk for pressure injury. Surveyor reviewed R58's admission skin assessment completed on 01/30/24 indicating R58 had a PI to foot stage 3, left heel unstageable PI, stage 3 PI to the right lateral bunion scabbed over at present time. Surveyor reviewed Activities of Daily Living (ADL) CNA [NAME] sheet: -Minimize time sitting in wheelchair to less than 2 hours at a time during meals. -Lay resident down after lunch. -Transfer Hoyer with 2 assists. -The resident is totally dependent on staff for bed mobility and repositioning and turning in bed 1-2 person assist. -Staff is to assist with turning and repositioning. Surveyor reviewed R58's IMPAIRED SKIN Care Plan: -Skin will remain intact initiated on 01/30/24, revised on 06/24/24. -CNA to observe skin during AM/HS cares report changes to nurse initiated on 01/30/24. -Pressure redistribution cushion in chair initiated on 01/30/24. -Pressure redistribution mattress initiated on 01/30/24. -Nurse to complete a systematic skin inspection on assigned bath day. Complete weekly skin assessment observation and wound management, including measurements, when appropriate initiated on 01/30/24. -Assess and record the condition of the skin surrounding the pressure ulcer initiated on 01/30/2024. -Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization weekly initiated 01/30/2024. -Conduct a systematic skin inspection weekly. Report any signs of further skin breakdown initiated 01/30/2024. -Keep clean and dry as possible. Minimize skin exposure to moisture initiated 01/30/2024. -Keep linens clean, dry, and wrinkle free initiated 01/30/2024. -Observe and report signs of osteomyelitis (pain, redness, swelling in affected joint, muscle spasms in affected joint, chills, fever (rapid elevation), diaphoresis, tachycardia, restlessness, irritability) initiated 01/30/2024. -Observe and report signs of sepsis (fever, lassitude or malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting, diarrhea, headache, lymph node tenderness/enlargement). initiated 01/30/2024. -Podiatry and wound care appointments as scheduled initiated 01/30/2024. -Treatment: see TAR for specifics initiated 01/30/2024. -Turn and reposition routinely per protocol initiated 01/30/2024 and reviewed/revised on 06/26/24. Surveyor reviewed weekly skin assessments and noted: -On 06/20/24 a new skin event initiated and indicated pressure ulcer discovered in house acquired stage 1 pressure injury to the right ischium. Right ischium had area of non-blanchable erythema measuring 2x1.5cm with surrounding skin blanchable red measuring 5x4cm. Interventions being used or put into place indicates: *Skin will remain intact initiated on 01/30/24, revised on 06/24/24. *Turn and reposition routinely per protocol initiated 01/30/2024 and reviewed/revised on 06/26/24. *Pressure relieving gel pad on commode initiated on 06/24/24. -On 06/26/24 wound zoom documentation indicates: Right posterior iliac crest Superficial wound measuring 3.4cmx4,4cmx0.10cm. Surveyor's interview with Director of Nursing on 9/9/24 indicates on 6/20/24, the wound nurse noted a red area with a small area that was non-blanchable. Due to its indurated nature, it was monitored closely as it was not easily classifiable due to it possibly being a blister from bullous pemphigoid. In addition, it was found R58's daughter had brought in his previous custom-made ish-dish seat cushion R58 used prior to admission. It was sitting in his recliner at the time of the assessment. R58's daughter brought this when she took him to last wound appointment. The wound nurse immediately took this cushion away and placed the roho cushion to be used. R58's daughter was educated and took it home with her. This ish-dish is hard and would cause pressure on the ischium. On 6/24/24, R58 was admitted to the hospital with possible sepsis related to his chronic UTI. Resident has a suprapubic catheter and history of cancer. The hospital did not note the PI area during his hospital stay and it was not addressed while he was admitted there. R58 returned on 6/26/24 with a declined wound status of right hip. Upon the admission skin assessment, R58 was also found to have a new pressure injury to buttocks, suspicious of DTI. In-house provider saw the resident on 6/27/24 for follow-up. Resident was also experiencing possible extremity cellulitis and another exacerbation of bullous pemphigoid due to illness: Given patient's known bolus pemphigoid it was thought this may be related to a new flare up due to the stress of the acute illness. R58 was seen again by in-house physician on 7/2/24 to follow up on the bullous pemphigoid exacerbation and cellulitis. R58 was started on an antibiotic and Lasix for edema at that time. The wound appears to be intact but continued to be monitored as area of concern. Physician orders in part: On 06/26/24: ADL - Toileting: Suprapubic Catheter, Cont/Incont Bowels, Hoyer A x 2 to commode, 100% non-weight bearing to right lower extremity. Special Instructions: Encourage less than 15 minutes on commode. On 06/26/2024: Check (SpanAm Alternating) air mattress is properly inflated every shift. Special Instructions: Firmness setting to resident's comfort level Three Times A Day. On 06/26/2024: Barrier skin prep to L medial heel discoloration BID. Twice A Day. On 06/26/24: Check (ROHO) cushion placement and proper inflation every shift. Three Times A Day. -On 07/03/24 weekly skin assessment missed. -On 07/03/24 wound zoom documentation indicates: Right posterior iliac crest (ischium) wound measuring 3.6cmx4.0cmx0.00cm. Thick discolored well adhered callous. -On 07/10/24 wound zoom documentation indicates: Right posterior ischium PI unstageable measuring 3.4cmx3.2cmx0.00cm. -On 07/17/24 wound zoom documentation indicates: Right posterior iliac crest wound 3.4cmx3.7cmx0.20cm, Black well adhered leathery necrotic tissue covering majority of open area. **Physician orders: On 07/22/2024: Repositioning 2 hours. Every Shift. On 07/24/24 weekly skin assessment completed. On 07/31/24 weekly skin assessment completed. **Physician orders: On 08/02/24: BLE Rooke boots off at AM, on at HS. Twice A Day. On 08/02/24: Document any refusal of repositioning, sitting on commode, or up in wheelchair every shift. Special Instructions: Patient should be allowed time tilting side to side in bed between meals. Minimize time sitting in wheelchair to less than 2 hours at a time during meals. On 08/06/24: ADL - Skin: Rooke Boots to BLE at HS only, SpanAM Alt. Mat, Roho, Enc Repos Q 2 hours (REPO SHEET), Aquaphor L leg/foot & R leg daily. Physician visit note on 7/11/24 indicates that R58 was out for an appointment with his wife for several hours and was sitting on a hard surface cushion that R58's wife had provided during this outing. On 7/12/24, the facility completed a risk benefit agreement with R58 regarding limiting the time on the commode and educated on the risks of developing a PI, if R58 chose to sit longer on the commode. The facility added a gel cushion to the commode to prevent pressure. Physician note on 8/2/24 in part, It is reasonable to think that this was a bulllous pemphigoid blister that worsened due to resident's choice to sit on commode . Physician orders: On 08/15/24: Try to spend time up in chair limited to 1-2 hours at a time, encourage to lay down in bed between meals twice a day. -On 08/21/24 wound zoom documentation indicates unstageable PI to the posterior right ischial 2.7cmx2.9x0.20cm, no tunneling, no undermining. On 08/26/2024: Treatment to Right ischium: Special Instructions: Offload ischium frequently. Use cushion in recliner or similar cushion. Every Shift - PRN Observations were made of resident not being repositioned for 2.5 hours on 08/26/24. On 08/26/24 at 11:01 AM, Surveyor observed R58 sitting in wheelchair, Hoyer sling underneath, and R58 watching TV. On 08/26/24 at 12:33 PM, Surveyor observed R58 sitting in wheelchair, Hoyer sling underneath and R58 watching TV. On 08/26/24 at 1:37 PM, Surveyor observed Registered Nurse (RN) T lay R58 down into bed to complete wound dressing changes. Surveyor reviewed repositioning schedule from 08/26/24 that did not have documentation of R58 refusing to be repositioned. On 08/26/24, documentation indicates R58 stayed sitting in wheelchair from 8:00AM-2:00PM. Observations were made of resident not being repositioned or toileted for 5 hours on 08/27/24. On 08/27/24 at 7:51 AM, Surveyor observed staff place R58 on commode. On 08/27/24 at 8:18 AM, Surveyor observed staff transfer R58 off R58's commode. Staff observed R58 sitting on commode for 27 minutes and staff did not follow R58's care plan. On 08/27/24 at 10:27 AM, Surveyor observed R58 sitting in wheelchair with Hoyer sling underneath R58. Surveyor did not observe R58 repositioned or offered repositioning. On 08/27/24 at 12:22 PM, Surveyor observed R58 still in wheelchair with Hoyer sling underneath R58. Surveyor did not observe R58 repositioned or offered repositioning. R58 sitting in room visiting with family. On 08/27/24 at 12:48 PM, Surveyor observed R58's daughter ask Certified Nursing Assistant (CNA) M if CNA M could transfer R58 to recliner as R58 was requesting to be repositioned off bottom. On 08/27/24 at 1:26 PM, Surveyor observed R58's daughter come out to hallway and scan for staff. Surveyor heard R58's daughter state to R58 that when staff get a chance staff will lay R58 down soon. On 08/27/24 at 1:28 PM, Surveyor observed CNA M enter R58's room and ask R58 if everything was ok. R58 requested to be placed in recliner. CNA M and a student CNA transferred R58 via Hoyer into recliner. On 08/27/24 at 1:38 PM, Surveyor interviewed R58's daughter and asked if R58's daughter had any concerns with R58's repositioning. R58's daughter indicated that she believes the staff try to get to R58 when they have time. R58's daughter indicated she understands there is an issue with a pressure injury on R58's bottom. R58's daughter indicated that R58 wants to relieve pressure off R58's bottom but doesn't always get the help right away but that facility staff do their best. On 08/27/24 at 2:05 PM, Surveyor interviewed CNA M and asked if R58 was repositioned anytime in the day other than before placing R58 into recliner. CNA M indicated that R58 has been in wheelchair all day because R58 refuses sometimes and R58 had a visitor little before lunch time. Surveyor reviewed repositioning schedule from 08/27/24 that did not have documentation of R58 refusing to be repositioned. On 08/27/24 from 6:00 AM until 2:00 PM there was no documentation of refusing or repositioning of R58. On 08/28/24 at 7:58 AM, Surveyor interviewed CNA C and asked how the repositioning schedule charting worked for R58. CNA C indicated that if it is care planned that staff reposition residents every so often then CNAs chart on the repositioning schedule and then it gets scanned in every so often into the EHR. CNA C indicated that R58's repositioning schedule was to reposition every 1-2 hours, and up for maximum of 1-2 hours in chair. CNA C indicated that CNA C documents when R58 is repositioned on the sheet. On 08/28/24 at 9:21 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation was for repositioning R58. DON B indicated that all residents should be repositioned every two hours. Surveyor asked DON B if DON B has a repositioning policy in place. DON B indicated the facility does not have a repositioning policy, but that expectation is for staff to follow standards of practice and reposition every 2 hours. DON B indicated that R58 sometimes refuses but that when this occurs staff should document the refusal in the Electronic Health Record (EHR). Surveyor indicated to DON B that upon review of the repositioning schedule and Surveyor's observations, Surveyor found missing documentation on repositioning or refusals for R58. Surveyor indicated to DON B that Surveyor observed R58 sitting in wheelchair for up to 5 hours without being off loaded off R58's bilateral ischiums and coccyx. Surveyor asked DON B if R58's PI on the right ischium could have been avoidable. DON B indicated that originally facility thought the PI on the right ischium was from sitting on commode for long periods of time. The facility initiated limited time on the commode to 15 minutes, but R58 is his own person and insists on sitting longer at times. A risk benefit education has been done with R58. DON B indicated that staff should have offered; if R58 refused, then staff are to document this. DON B indicated the facility implemented a gel cushion for the commode as well and increased the repositioning frequency. DON B indicated that staff are still to offer or reposition every 1-2 hours with R58 while R58 is up in wheelchair, recliner or lying in bed. On 08/28/24 at 2:05 PM, Surveyor interviewed DON B and Nursing Home Administrator (NHA) A and asked if there was any other information to provide with observations of no repositioning for R58 and evidence of off-loading during Surveyor's observations from 08/26/24 and 08/27/24. DON B indicated that at this time there was no other information to provide. Example 2 R89 was admitted to facility on 08/01/24 with diagnoses which included in part: acute respiratory failure with hypoxia, right heart failure, hypertension, and acute kidney failure. R89's Minimum Data Set (MDS) assessment, dated 08/07/24, identified R89 scored 15 during a Brief Interview for Mental Status (BIMS), indicating cognition intact. MDS identified R89 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R89 was determined to be at risk for PIs. Surveyor reviewed physician orders: -Check ROHO cushion placement and proper inflation every shift. -Check Span AM air mattress is properly inflated every shift. Special instructions pump to resident's firmness preference. -Encourage to float heels. -Encourage to turn and reposition every two-four hour with care. Surveyor reviewed R89's Braden skin risk assessment completed on 08/01/24 scored 13 at moderate risk for pressure injury. Surveyor reviewed R89's admission skin assessment completed on 08/01/24 indicating R89 had gluteal crease and buttocks with incontinence associated dermatitis with fungal involvement. Surveyor reviewed Activities of Daily Living (ADL) CNA [NAME] sheet: -Roho cushion. -Encourage to float heels. -Encourage to turn and reposition every two-four hour with care. -Bed mobility assists of two. Surveyor reviewed R58's IMPAIRED SKIN Care Plan: -Skin will remain intact initiated on 08/01/24. -CNA to observe skin during AM/HS cares report changes to nurse initiated on 08/01/24. -Pressure redistribution cushion in chair initiated on 08/01/24. -Pressure redistribution mattress initiated on 08/01/24. -Nurse to complete a systematic skin inspection on assigned bath day. Complete weekly skin assessment observation and wound management, including measurements, when appropriate initiated on 08/01/24. Observations were made of R89 not being repositioned for 4 hours on 08/27/24. On 08/27/24 at 7:29 AM, Surveyor observed R89 lying in bed supine at a 45-degree angle directly on the coccyx and R89's heels directly on the bed. R89 was sleeping soundly in bed. Surveyor did not observe staff offer or reposition R89. On 08/27/24 at 9:25 AM, Surveyor observed R89 lying in bed supine at a 45-degree angle directly on the coccyx and R89's heels directly on the bed. R89 had just finished eating breakfast. Surveyor did not observe staff offer or reposition R89. On 08/27/24 10:27 AM, Surveyor observed R89 lying in bed supine at a 45-degree angle directly on the coccyx and R89's heels directly on the bed. LPN S entered to give morning medications. Surveyor did not observe staff offer or reposition R89. On 08/27/24 at 11:29 AM, Surveyor observed LPN S and Hospice nurse roll R89 to the right side and perform peri cares. LPN S noted that the slit on R89's coccyx/sacrum area was a new slightly opened area. Surveyor observed the bilateral coccyx area had redness and superficial breakdown. LPN S applied [NAME] and capisopom as ordered and repositioned R89 back to R89's back. Surveyor observed R89 placed back on back and heels directly on R89's bed. On 08/27/24 at 11:35 AM, Surveyor interviewed LPN S and asked LPN S what process LPN S follows for proceeding with a new finding of skin breakdown for R89. LPN S indicated that LPN S would review orders and progress notes to see if the current treatments being completed presently covers the skin breakdown observed to R89's sacrum/coccyx area. LPN S indicated two weeks ago when he was assessing R89's bottom that the breakdown was not there. LPN S indicated that LPN S will be checking the EHR for skin breakdown changes and report to charge wound nurse as soon as possible and begin standing orders and daily assessments. Surveyor asked what LPN S's expectation for repositioning R89 is. LPN S indicated that R89 should be repositioned off the coccyx area every 2 hours and heels floated. LPN S indicated that LPN S did not reposition R89 off R89's bottom and did not elevate R89's heels at this time as LPN S is unsure the last time R89 was repositioned. On 08/28/24 at 1:36 PM, Surveyor interviewed DON B and asked about expectation for alternating mattress. DON B indicated that the alternating mattress is based on resident's comfort for pressure levels and there is no set parameters or expectations of use. Surveyor asked DON B if R89 had weekly skin assessments completed since admission on [DATE] as Surveyor could only find 08/01/24, 08/09/24, and 08/24/24. Weekly skin assessment was not completed for 08/15/24. DON B indicated that the weekly assessment on 08/15/24 was missed. Surveyor asked DON B when the facility noted a suspected DTI on the left inner heel area and why this was not assessed again on the weekly skin assessments since admission. DON B indicated that there has been a staffing crisis and turnover and that the further assessment of the suspicious DTI on left inner heel has been missed. Surveyor asked DON B what interventions other than redistribution mattress on bed and cushion in chair was in place to prevent further breakdown for R89. DON B indicated that is expectation that R89 be repositioned every 2 hours as the standards of practice. On 08/28/24 at 2:05 PM, Surveyor interviewed DON B and Nursing Home Administrator (NHA) A and asked if there was any other information to provide with observations of no repositioning for R89. DON B indicated at this time there was no other information to provide. Example 3 R9 was admitted on [DATE] from an acute care hospital stay with the following diagnoses, in part, pressure ulcer of right lower back, Kyphosis (is a condition where your spine curves outward more than it should). R9's Braden risk assessment score of 11.0 which indicated R9 was at risk for development of a pressure injury. R9's admission baseline care plan identified R9 had a stage 3 PI to left mid back with interventions in place to reposition every 2-4 hours, a ROHO cushion for R9's buttocks and a waffle cushion for R9's back. R9's admission Minimum Data Set (MDS) assessment, dated 06/03/24, identified R9 was at risk for development of a pressure injury and had a stage 3 pressure injury. On 08/26/24, Surveyor observed R9 sitting in R9's Broda chair from 9:54 AM until 2:01 PM without being repositioned. On 08/27/24, R9 was brought out to the hallway at 9:35 AM where R9 ate breakfast. At 11:48 AM, R9's lunch tray was brought, and no repositioning was offered. On 08/28/24, Surveyor observed R9 from 9:28 AM until 11:20 AM. Resident was not repositioned during that time. At 11:30 a.m., R9's significant other came, and they went to the dining room. On 08/28/24, Surveyor reviewed wound zoom notes for R9. Wound changes on 06/12/24 the mid back PI measured 1.6cm X 1.1cm and on 06/19/24 the same wound measured 2.4cm X 1.9cm with an increase of 2.2cm. Surveyor asked Assistant Director of Nursing (ADON) L for an explanation for this increase in surface area. ADON L informed Surveyor that R9 required an iron infusion on 06/17/24 which R9 had to sit in a standard wheelchair instead of the broda chair for an extended amount of time. Example 4 R28 was admitted on [DATE] with diagnoses, in part, Lewy Body dementia (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), obesity and Parkinsonism. R28's Braden risk assessment score of 14 dated 07/20/24 indicated R28 had a moderate risk for development of a pressure injury. R28's Minimum Data Set (MDS) assessment, dated 07/26/24, identified R28 was at risk for development of a pressure injury and had no unhealed pressure injuries. R28's medical chart, dated 08/04/24 at 4:24 PM, states in part, Writer observed what appears to be a deep tissue injury (DTI) on left buttock measuring 1cm X 1cm. R28's care plan states in part, Possible DTI to left buttock discovered 8/04/24 at 14:00 Discoloration- Non-blanchable purple area to left buttock 1 X 3cm No blood loss wound edges not applicable .Immediate measures taken cleansed area, topical ointment, other- reposition side/side. On 08/27/24, Surveyor observed R28 from 8:15 AM until 12:44 PM; resident remained on the right side in bed no offloading observed with SPAN air mattress on level 3 alternating. On 08/28/24 at 2:08 PM, Surveyor interviewed RN J about the start of R28's DTI. On 08/04/24, R28 was willing to go in bed as opposed to the recliner. Chamosyn was ordered to R28's skin with cares and instituted documentation of refusals of repositioning. On 08/05/24, labs drawn indicated mild dehydration from poor oral intake. This was just prior to R28's UTI. R28's mobility decreased. The SPAN air mattress was instituted on 08/09/24. R28 has documented repositioning refusals on 08/09/24, 08/10/24 and 08/14/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 On 08/27/24 at 11:43 AM, Surveyor observed certified food service cart located at the beginning of resident 500 hallway, between rooms [ROOM NUMBERS]. Surveyor observed CNA C deliver the hot lunch meal trays to residents eating in their rooms in the 500 unit. Surveyor observed CNA C remove hot meal trays from food service cart, remove the covers from main course plate and remove the covers on the cold drinks that included milk and juice. Surveyor observed CNA C carry the uncovered food trays down the hallway, past multiple rooms and people, and delivered the trays to R62, R393, R43, R20, R42, R392 and R73. Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff touched ready to eat foods with contaminated gloves when preparing and serving toast to two residents (R66 and R57). Staff carried uncovered food trays in the hallway for R62, R393, R43, R20, R42, R392 and R73. Findings include: Example 1 Facility policy and procedure entitled, Bare Hand Contact with Food and Use of Plastic Gloves, stated in part, .3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning to work with food) 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed . On 08/27/24 at 6:49 AM, Surveyor observed Certified Nursing Assistant (CNA) O preparing and serving breakfast from the kitchenette on the 200 unit. Surveyor observed CNA O put on gloves and take a piece of bread out of the bag and place it in the toaster. CNA O did not wash hands or use hand sanitizer before putting on the gloves. Surveyor observed CNA O fill two glasses with juice and touched multiple items, cupboard doors, and surfaces in the kitchenette with the same gloves on. CNA O then took the toast out of the toaster with the same gloves on, opened a drawer and took out a knife, buttered the toast, cut it in half, and served it to R66. CNA O then took another piece of bread and placed it in the toaster with the same gloves on that had touched multiple surfaces in the kitchenette and dining area. Surveyor observed CNA O take off the contaminated gloves, wash hands, and put on clean gloves before taking the toast out of toaster. CNA O buttered the toast and served it to R57. On 08/27/24 at 1:48 PM, Surveyor interviewed Culinary Services Manager (CSM) D and described the observation of breakfast service by CNA O on the 200 unit. Surveyor asked CSM D if CNA O was following safe food handling during the observation of preparing and serving toast. CSM D stated, no, staff was supposed to change gloves anytime they touch a potentially contaminated surface, or use a tongs before touching a ready to eat food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R25 was admitted to the facility on [DATE] and has diagnoses that include, methicillin-resistant staphylococcus aureus (MRSA), acute respiratory failure, dysphagia, and anxiety disorder. There is a sign on the outside of R25's door that reads contact precautions. The facility's policy titled, Infection Surveillance & Outbreak Prevention, with an updated date of 07/23/24 reads in part, Contact precautions mandatory PPE includes gown and gloves. On 08/28/24 at 12:58 PM, Surveyor observed CNA G come out of R25's room with a lift and was wiping it down with a sanitizing wipe. Surveyor observed CNA G come out of R25's room wearing no PPE. After wiping down lift Surveyor observed CNA G go back into R25's room with only gloves on. CNA G had a sanitizing wipe and was observed wiping down R25's chair remote. CNA G then removed their gloves, picked up some washcloths from R25's room with bare hands, and CNA G pushed the scale chair out of the room along with holding the washcloths. CNA G walked down to the beginning of the hall and into the kitchenette area to get R25 something to drink. CNA G returned to R25's room with a drink, entered the room and did not put on any PPE. CNA G then exited R25's room. Surveyor interviewed CNA G and asked who CNA G used the scale chair for. CNA G indicated for R25. Surveyor asked CNA G if they did anything with the chair before they brought it into the hallway. CNA G indicated they wiped it down. Surveyor then asked CNA G how they know if a resident is on precautions. CNA G indicated there are bins on the outside of the room and during shift report they are updated. Surveyor asked CNA G if they have had any recent training on infection control. CNA G indicated a couple of months ago. Surveyor asked CNA G if they knew the difference between enhanced barrier precautions and contact precautions. CNA G indicated that contact precautions was if you are coming into contact with someone. On 08/28/24 at about 1:11 PM, Surveyor interviewed CNA F and asked how they know if someone was on precautions. CNA F indicated there is a sign on the outside of the door that tells you what kind of precautions. Surveyor asked CNA F if a resident is on contact precautions and you are bringing them a glass of water would you have to put on PPE. CNA F indicated any contact at all they would put on PPE. Surveyor asked CNA F if they have had any recent infection control training. CNA F indicated they get yearly training through Relias and about 2 months ago they went through a CNA boot camp that covered things like infection control, the different types of precautions and what to wear. On 08/28/24 at 3:19 PM, Surveyor interviewed RN E, who is also the infection preventionist and repeated the above observation of CNA G and asked if CNA G used appropriate PPE. RN E indicated no. Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During the 4-day survey Surveyors had multiple observations of staff not following the Centers for Disease Control (CDC) guidance for Personal Protective Equipment (PPE) use during a COVID-19 outbreak. This had the potential to affect all 18 residents residing on the dementia unit. Surveyor observed staff not performing hand hygiene after changing soiled gloves during cares for R64. Findings include: According to CDC Infection Control Guidance: SARS-CoV-2 [COVID-19] last updated 06/24/24, in reference to use of masks or respirators, .If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned . The CDC guidance also includes, .Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters . On 08/26/24 at 9:32 AM, Surveyor entered the 200-dementia unit. Surveyor noted a sign on the outside door to the unit that stated COVID outbreak. N95 masks required for staff and visitors. On 08/26/24 at 9:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN) S who stated there were four residents who tested positive for COVID-19 over the weekend, and one more resident was found to be positive this AM. LPN S stated due to the residents having dementia and wandering, they are unable to keep all of the positive residents quarantined to their rooms. LPN S stated it was also difficult to get those confused residents to comply with wearing a mask, so they were having all staff wear N95 respirators on the unit and trying to assist the residents with frequent hand hygiene. On 08/26/24 at 10:30 AM, Surveyor observed signs outside R64's door stating droplet and contact precautions. Surveyor observed R64 wandering around the hall and dining area touching multiple surfaces. Surveyor observed R64 had a runny nose and was frequently wiping nose with hands. Record review identified R64 had a diagnosis of Alzheimer's disease and had tested positive for COVID-19. On 08/26/24 from 9:30 AM to 12:45 PM, Surveyor had multiple observations of LPN S and Certified Nursing Assistant (CNA) O and CNA U donning and doffing PPE for rooms that were identified as droplet and contact precautions due to COVID-19. Surveyor observed staff wearing a surgical mask over the N95 before entering the droplet precautions rooms. Then when they left the room, they would remove the surgical mask and put a new surgical mask over the N95 without changing the N95. On 08/26/24 at 1:29 PM, Surveyor observed R47 walking down the hallway with walker independently. R47 was not wearing a mask. R47 was pleasantly confused. Record review identified R47 had a diagnosis of vascular dementia and tested positive for COVID-19 on 08/24/24. The record stated R47 was placed on enhanced droplet precautions. On 08/26/24 at 1:35 PM, Surveyor interviewed LPN S and asked what the facility policy was for N95 use in droplet precaution rooms. LPN S stated they were not sure if this was following facility policy, but LPN S was using the surgical mask to cover the N95 to save it or keep it clean. LPN S stated they did not change the N95 when leaving the droplet precaution rooms, just the surgical mask over top. Surveyor asked LPN S if they had a shortage of N95 masks, or were in a contingency plan for PPE due to shortages. LPN S did not think there was a shortage of N95 masks. On 08/27/24 at 6:24 AM, Surveyor observed CNA R exit R47's room. Surveyor noted there was a sign outside the door that said droplet plus contact precautions. Surveyor observed CNA R had a surgical mask on over N95 respirator and goggles on when exiting the room. CNA R removed the goggles and placed in the top drawer of the PPE cart outside the door. CNA R did not wipe off the goggle with a sanitizer wipe before placing them in the drawer. CNA R did not change the surgical mask or N95 after leaving the room. On 08/27/24 at 7:04 AM, Surveyor observed CNA R and CNA O prepare to enter R64's room to provide morning cares for R64. Surveyor observed both CNAs use hand sanitizer and put on a gown and gloves outside the door. CNA O already had an N95 mask on and no surgical mask over the N95. CNA R had an N95 mask with a surgical mask over the N95. Neither CNA put on goggles or eye protection before entering the room. CNA O assisted R64 to wash face and upper body while CNA R assisted with feet and legs. CNA R removed gloves and gown and used hand sanitizer before leaving the room to get more supplies. CNA R returned to the room with a gown, gloves, N95, and goggles on. CNA R did not have a surgical mask over the N95 when re-entering the room. After finishing R64's upper body, CNA O removed the gloves, and put on clean gloves. Surveyor noted CNA O did not wash hands or use hand sanitizer before putting on clean gloves. CNA O washed and dried R64's bottom and removed the old incontinent brief and threw it away. CNA O applied barrier cream to R64's bottom, removed gloves, and put on clean gloves without washing hands or using hand sanitizer. CNA O put a clean brief on R64, and CNA O and CNA R assisted R64 to dress and transfer to a wheelchair. CNA O removed gloves and washed hands in bathroom. CNA O came out with a brush and assisted R64 to brush hair with no gloves on. CNA O returned to bathroom, washed hands, and applied clean gloves. CNA O applied powder to right side of R64's neck. CNA O assisted R64 to the bathroom in wheelchair, removed gloves and put on clean gloves without using hand sanitizer between. CNA O assisted R64 to brush teeth. CNA R removed gown and gloves, used hand sanitizer, and left the room. CNA R did not remove the goggles or N95 before leaving the room. CNA R returned to the room with gown and gloves, an N95 with surgical mask over the N95, and goggles on. CNA R handed a plastic cup to CNA O who helped R64 rinse mouth. Both CNAs removed gowns and gloves and washed hands. CNA O put a gait belt around R64 and assisted her to stand. CNA R removed the surgical mask over N95, left the same N95 and goggles on, and assisted R64 to walk to the dining room. CNA R did not use hand sanitizer when leaving the room. CNA O removed the N95 in the room, carried trash and linen bags to hampers in the hall. CNA O used hand sanitizer and put on a new N95 mask and walked to dining room. Surveyor observed CNA R wearing an N95 and goggles assisting residents in the dining room. On 08/27/24 at 7:38 AM, Surveyor observed Food Service Aide (FSA) N enter the unit wearing a surgical mask with plastic eye shield on the mask. FSA N stated they could not find an N95, and asked the CNA O if it was okay to wear that mask to check the kitchenette. CNA O stated it was their risk. Surveyor observed FSA N walk past multiple residents in the hallway and dining room to get to and from the kitchenette. On 08/27/24 at 8:07 AM, Surveyor observed CNA O use hand sanitizer and put on a gown and gloves. CNA O put a surgical mask over the N95 CNA O was already wearing and prepared to enter room [ROOM NUMBER]. Surveyor noted a sign outside the room that stated droplet plus contact precautions. Surveyor asked CNA O which resident in the room was on precautions. CNA O stated it was R13 who was on precautions due to COVID-19. CNA M stated they were going to assist R13 go to the bathroom and get washed up and dressed for the day. CNA O did not put goggles on before entering room. On 08/27/24 at 9:05 AM, Surveyor observed LPN P administer medications to R13. Surveyor noted a droplet plus contact precautions sign outside the door to R13's room. LPN P used hand sanitizer and donned a gown, gloves, goggles, and surgical mask over the N95 that LPN P was already wearing. After administering the medications, LPN P removed the gown, gloves, and surgical mask in the room and exited the room with the same N95 on. Surveyor interviewed LPN P who stated they were instructed to keep their N95 on at all times and put a surgical mask over the N95 when going in droplet precaution rooms. LPN P stated they remove the surgical mask when exiting the room and keep the same N95 on. On 08/27/24 at 9:36 AM, Surveyor interviewed Registered Nurse (RN) E who is the facility's infection preventionist. Surveyor explained multiple observations of staff inconsistently using goggles when entering droplet precaution rooms and staff not sanitizing the goggles after leaving those rooms. RN E stated everyone should be wearing goggles when entering droplet precaution rooms. RN E stated the multi-use goggles should be sanitized after use. RN E stated they have the surgical masks with the plastic eye protection attached, and they would prefer staff use those over their N95 instead of the multi-use goggles. Surveyor asked RN E what guidance they were following for N95 use in their COVID-19 unit. RN E stated they follow CDC guidance for N95 use. Surveyor asked if it was CDC guidance to wear a surgical mask over the N95 and not change the N95. RN E stated because the unit was a closed dementia unit and they were unable to keep all of the COVID-19 positive residents quarantined in their rooms, they were having the staff keep their N95s on and using a surgical mask over to decrease their risk with removing the N95s multiple times. Surveyor clarified that they were not doing this due to a supply issue and were not specifically following CDC guidance. RN E stated this was correct, they had modified the guidance and have staff wear the surgical masks over the N95 to reduce the frequency of changing the N95s on the outbreak unit. RN E stated all staff should remove the N95 when leaving the unit. Surveyor explained the observations of CNAs removing and putting on clean gloves during morning cares for R64 without performing hand hygiene between glove changes. RN E stated that was not following the facility policy. RN E stated staff should perform hand hygiene after every time they remove contaminated gloves. On 08/27/24 at 2:45 PM, Surveyor observed R47 propel self in wheelchair down the hall from room to sitting area at the end of the 200 hall. R47 was not wearing a mask. Surveyor observed R47 coughing and wiping nose with the back of hand. On 08/28/24 at 8:41 AM, Surveyor observed FSA Q exit the 400 unit with a rolling metal cart with beverages on it. FSA Q removed the surgical face mask they were wearing and put on an N95. FSA Q did not use hand sanitizer before or after doing the mask change. FSA Q carried the surgical mask that had been removed in one hand and pushed the metal cart into the 200 unit. At 8:45 AM, FSA Q exited the 200 unit with the rolling cart. FSA Q was still holding a surgical mask in one hand. FSA Q removed the N95 and placed it on the rolling cart. FSA Q put the surgical mask on that they were holding in one hand. FSA Q took the N95 from the cart and threw it away in the trash. FSA Q pushed the rolling metal cart down the hall. FSA Q did not use hand sanitizer before or after any of the mask changes observed. FSA Q did not wipe the metal cart with a sanitizer wipe placing the used N95 on the cart during mask change. On 08/28/24 at 9:16 AM, Surveyor observed FSA Q exit the 400 unit with a surgical mask on. FSA Q walked to PPE bin outside 200 unit, took out N95 mask and put it on over the surgical mask they were already wearing. FSA Q did not use hand sanitizer. FSA Q entered the 200 unit. At 9:24 AM, FSA Q exited the 200 unit and removed the N95 mask and threw it in the trash. The surgical mask that FSA Q was wearing under the N95 came off at the same time. FSA Q put that same surgical mask back on and then used hand sanitizer. Surveyor asked if FSA Q had received training on PPE use and hand hygiene. FSA Q stated yes they were trained, but it was a long time ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each residents' drug regimen was free of unnecessary medications for 1 (R23) of 3 sampled residents reviewed for unnecessary medications related to monitoring of prophylactic antibiotic use. R23 has been on a prophylactic antibiotic for an excessive duration without adequate assessments/monitoring for continued use. This is evidenced by: R23 was admitted to the facility on [DATE] and has diagnoses that include, in part: Alzheimer's disease, dementia and history of recurrent urinary tract infections (UTI). On 08/08/23, at 10:00 AM, Surveyor reviewed R23's Electronic Health Record (EHR). Review of EHR shows R23 has a physician's order for cephalexin capsule 250 mg with instructions to give 250 mg (1 capsule) daily for prophylaxis related to prevention of UTI with start date of 05/27/21. Review of nurses' notes in EHR shows that facility nurses are not documenting or monitoring R23's ordered antibiotic. Review of care plan for R23 shows that there is no care plan for the implementation, monitoring or evaluation of R23's prophylactic antibiotic. Review of infection control line list shows that R23 is not on the facility's line list for surveillance and/or antibiotic stewardship. On 08/08/23 at 11:50 AM, Surveyor requested supporting documentation for the prolonged use of R23's prophylactic antibiotic. On 08/08/23 at 2:19 PM, Surveyor interviewed Director of Nursing (DON) B about the prophylactic antibiotic use. DON B stated that their previous infection preventionist, who left employment 4 weeks ago, had removed resident from the infection control line list and it is unknown why. DON B states that they usually do a checklist for prophylactic antibiotics so that it does not get missed on the line list, care plan and documentation for monitoring. DON B states that R23 is not on the line list and does not have a care plan for the prophylactic antibiotic. DON B states that there is no supporting documentation for the monitoring of the effectiveness or appropriateness of the antibiotic.

Example 2 On 08/08/23 at 8:05 AM, Surveyor arrived on memory care unit and observed medication cart sitting in hall by dining area. NT F was observed in the dining area away from the medication cart. Medication cart was unlocked and medication cart keys were left sitting on top of it. Medications were not secured in a locked compartment, when NT F walked away. Based on observation and interview, the facility did not ensure all drugs and biologicals were stored in locked compartments and did not ensure only authorized personnel had access to the keys. This occurred for 1 of 6 medication carts observed. During the three-day survey, observations were made of medication carts left unlocked with the keys on top of the cart when unattended and out of view of staff. One observation was made of resident medications left on top of the medication cart when the cart was unattended and out of view of staff. Findings include: Example 1 On 08/08/23 at 7:32 AM, Surveyor observed a medication cart on the 400 unit unattended in the hallway. The cart was unlocked, and the nurse keys were on top of the cart. There was a tube of Diclofenac gel and a bottle of refresh artificial tears labeled with a resident's name sitting on top of the unattended cart. At 7:40 AM, Surveyor observed Nurse Tech (NT) F return to the medication cart and place the medications back in a drawer on the cart. NT F began preparing medications for another resident. On 08/08/23 at 8:17 AM, Surveyor interviewed NT F about leaving the medication cart unlocked with keys and resident medications on top when the cart was left unattended. NT F stated they usually place all medications in the drawers, lock the cart and take the keys with them when leaving the cart unattended. NT F stated earlier there was a resident trying to get up and NT F rushed to make sure the resident did not fall. NT F stated they accidentally left the medication cart unlocked with medications and keys on top at that time. On 08/09/23 at 9:55 AM, Surveyor interviewed Director of Nursing (DON) B about observations of the medication carts left unlocked with resident medications and nurse's keys on top when the cart was left unattended in resident care areas. DON B stated that was not acceptable. DON B stated the staff was taught they should always lock the cart when leaving it and never leave medications or keys on the cart when the cart was unattended. DON B stated they did not think they had a policy and procedure that stated this, but it was standard nursing practice to lock medication carts when unattended.

Example 3 CNA Q and CNA E did not perform hand hygiene before putting on gloves to provide cares to R58. CNA Q touched her own hair without hand hygiene after providing toileting cares to R58. On 08/08/23 at 8:44 AM, Surveyor observed CNA Q enter R58's room and put on gloves without using Alcohol Based Hand Rub (ABHR). R58 was taken to bathroom via E-Z stand lift. R58's clothes were removed to shower. During shower, CNA Q washed R58's buttocks with a new washcloth and then went to wash residents' hair without hand hygiene and new gloves. R58 was observed as taken back to her bathroom; the lift was used to put R58 on the toilet. R58 told CNA Q that she was not sitting right on the toilet. CNA E entered the room. CNA Q asked CNA E for assistance to help put R58 on the toilet right. CNA E put on gloves without using ABHR. Resident was lifted and lowered back on the toilet right. CNA Q removed gloves, used ABHR and left room. Example 2 On 08/08/23 at 1:28 PM, Surveyor observed CNA D empty R67's catheter. CNA D put on gloves; no hand hygiene was performed. CNA D put a barrier down on the floor, opened catheter port, drained urine in a graduate, wiped port with alcohol swab, closed catheter port, measured urine, dumped in toilet, got water from clean graduate, rinsed out dirty one, then removed gloves. CNA D washed hands with soap and water. Surveyor asked CNA D what do you do before you put on gloves. CNA D said, Sanitize my hands. I forgot to do that. Based on observation, interview and record review, staff did not perform hand hygiene when warranted during cares for 3 (R79, R58, R67) of 7 residents observed for cares. Certified Nursing Assistants (CNA) I and J did not perform hand hygiene when warranted during R79's morning cares. CNA D did not perform hand hygiene before putting on gloves to empty a catheter for R67. This is evidenced by: Surveyor requested and received the facility policy titled Standard Precautions with most recent date of 4/26/23. The policy in part reads: Purpose: Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection and are to be used to care for all residents regardless of diagnosis or presumed infection status. Hand Hygiene: Employees must wash their hands for at least 20 seconds .under the following conditions: ~After contact with resident mucous membranes and body fluids or excretions. ~After handling soiled or used linens . ~After removing gloves. Example 1 On 8/08/23 at 8:06 AM, Surveyor observed CNA I and CNA J assist R79 with her morning cares. CNA I and J performed hand hygiene and placed needed supplies on R79's bedside table. CNA I and J donned gloves. CNA I rolled R79 slightly in bed and washed her face. CNA J removed pillows from under R79's legs and obtained a clean brief from cabinet in R79's room. CNA J lowered R79's gown and washed and dried under R79's arms. CNA I removed her gloves and donned clean gloves. CNA J removed his gloves, went into the bathroom, performed hand hygiene and obtained bags. CNA I applied lotion to R79's arms. CNA I removed her gloves and donned clean gloves. CNA I did not perform hand hygiene. CNA I obtained the clean brief from the bedside table as CNA J checked R79's brief for incontinence. CNA J removed R79's brief and informed Surveyor the brief was a little wet. CNA J performed perineal care, rolled R79 in bed and removed his gloves. CNA J donned clean gloves without first performing hand hygiene. CNA J rolled R79 in bed and washed and dried R79's backside. CNA J again removed his gloves and donned clean gloves without performing hand hygiene. CNA J applied barrier cream to R79's backside. CNA J rolled R79 in bed and applied R79's clean brief and clean gown. Both CNA I and J removed their gloves and assisted with positioning R79 with pillows in bed. CNA J and I performed hand hygiene. Following the observation, Surveyor spoke with CNA I and J about hand hygiene with glove change and when going from a dirty task to a clean task. CNA I and J expressed hand hygiene should be done to prevent the spread of germs and for infection control. On 8/08/23 at 1:32 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B expressed she would expect staff to doff gloves, perform hand hygiene and don clean gloves when going from dirty to clean task during resident cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 On 08/07/23 at 9:58 AM, Surveyor observed Licensed Practical Nurse (LPN) C go into R1's room and left resident info up on computer screen. Anyone who walked by in the hallway could see R1's medication information. Example 4 On 08/08/23 at 8:05 AM, Surveyor arrived on memory care unit and observed medication cart sitting in hall by dining area. NT F was observed in the dining area away from the medication cart. Medication cart was unlocked, computer screen was open with resident information exposed and medication cart keys were left sitting on top of it. The resident information on the computer screen was visible to anyone walking past the medication cart. There was a resident who is ambulatory that was sitting in a chair next to where the unlocked medication cart was parked. Example 2 Facility policy entitled, HIPAA Privacy Rule dated December 2019, stated in part: .Medical charts and confidential/health information should not be left unattended where it is easily readable by unauthorized persons . On 08/08/23 at 7:32 AM, Surveyor observed the medication cart on the 400 unit unattended in the hallway. The computer screen was open with R23's Medication Administration Record (MAR) visible to anyone who walked by the cart. At 7:40 AM, Nurse Tech (NT) F returned to the medication cart and began preparing medications to administer to another resident. On 08/08/23 at 8:17 AM, Surveyor interviewed NT F about leaving the medication cart unattended with resident information visible on the computer screen on the cart. NT F stated they usually close the laptop so a resident's MAR was not visible. NT F stated earlier there was a resident trying to get up and NT F rushed to make sure the resident did not fall. NT F stated they accidentally left the MAR visible at that time. On 08/09/23 at 9:55 AM, Surveyor interviewed Director of Nursing (DON) B about observations of medication cart left unattended with MAR screen open and resident information visible. DON B stated that was not acceptable and the nursing staff was taught the computer screen must be closed or minimized so that resident information was not visible when the cart was left unattended. Based on observation, interview and record review, the facility did not maintain confidentiality of resident medical record information for 12 of 12 sampled and supplemental residents reviewed. Surveyor observed resident (R79, R142, R83, R33, R45, R54, R15, R20, R73 and R39) dietary information on index cards in plastic upright holders on tables in the [NAME] dining room. The resident information was easily read by the Surveyor when passing by the tables in the dining room. During the three-day survey, Surveyors had three observations of computer screens left open and unattended on medication carts with resident (R) identifiable information visible. (R23, R1.) This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled HIPPA Privacy Rule dated December 2019. The policy in part reads: ~Employees only have the right to see and read residents' confidential/health information on a need to know basis in order to perform their duties. ~Medical charts and confidential/health information should not be left unattended or where it is easily readable by unauthorized persons. ~Remember: Confidentiality is everyone's job, share information responsibly, Be aware of your surroundings . On 08/07/23 at 1:13 PM, Surveyor observed lunch in the [NAME] dining room. Surveyor observed R79 and R142 being assisted with their meal. In front of R79 and R142 Surveyor observed a plastic standing tray with an index card. The card could easily be read by the Surveyor while passing R79 and R142's table. The card noted the following information: R79: Name, Room number, Diet: General and beverages of cranberry and black tea for lunch and Dinner. As well as a note dated 8/06/23 with a diet order of 3 day trial pureed. R142: Name, Room number, Diet: General and beverages of water and coffee at lunch and dinner. Surveyor noted there were 8 other ticket holders on tables with resident dietary information, some of which were written in large black letters. Again the information was easily read as Surveyor passed the dining room tables. The information included the following: R83: Name, room number, Diet: General, 2000 cc fluid restriction, skim milk. R33: Name, room number, Diet: Mech soft with grd mt, nectar thick liquids, gravy and sauce, gry weighted utensils, plate guard, covered cups. In large black letters: Take frequent drinks, take small bites. R45: Name, room number, Diet: Mech soft with chopped meat/low k+ (potassium). Avoid foods high in K+ (potassium), beverage choices: water, skim milk and coffee for lunch and dinner large whole sandwich for dinner. R54: Name, room number, Diet: General, lunch: 2 chocolate milk and dinner: 2 chocolate milk and whole sandwich. R15: Name, room number, Diet: LCS (low concentrated sweets), Low K (potassium). Lunch: cranberry juice with low sugar sub and coffee, Dinner: Lettuce salad for dessert, cranberry juice with sugar sub. decaf coffee. R20: Name, room number, Diet: General, plate guard, ice water, covered cups, skim milk. R73: Name, room number, Diet: LCS (low concentrated sweets) 2000 fluid restriction, NSS (non sugar sweetener), Lunch: Large, small dessert, ice water. Dinner: Large whole sandwich, ice water. R39: Name, room number, Diet: Mech soft with grd mt, honey thick liquids. Plate guard. Lunch and Dinner: strawberry kiwi. On 8/07/23 at 1:26 PM, Surveyor noted resident lunch was over, the tables in the [NAME] dining room have been covered with clean tablecloths and tray ticket holders with the same dietary tickets are on the tables. Surveyor observed staff in and out of the dining room collecting dirty linens and cleaning the dining room. On 8/08/23 at 10:17 AM, Surveyor observed Dietary Aide (DA) G setting the same card holders with the dietary cards at the tables with the resident dietary information. Surveyor spoke with DA G about the resident dietary information. DA G indicated she has been on staff almost 5 years and it is part of her daily routine to set tables. Further expressing she generally sets up the dining room, including the resident dietary tickets at 10:15 am for lunch and 2:45 pm for supper. Surveyor asked DA G what information is on the resident dietary tickets. DA G explained the tickets in the upright holders say what kind of diet each resident is on such as pureed, what to drink at each meal and if liquids are thickened, allergies, and adaptive wear needed. All information is resident specific and placed where residents usually sit. The Dietary Manager or [NAME] fills out tickets. On 08/08/23 at 10:28 AM, Surveyor spoke with the Food Service Director (FSD) H who has been at the facility for 11 years. FSD H indicated it has always been the facility process to fill out dietary tickets with resident diet, preferences, resident name, room number and allergies. The cook or manager fills out the cards and the dietary aides may add resident preferences. The dietary tickets are placed in a holder on tables in front of residents when tables are set by the dietary aides. Surveyor asked FSD H if the resident information is private and if the information should be available for others to see. FSD H indicated the information is resident private information and should only be seen by those staff, such as certified nursing assistants, who need to know the information. Surveyor asked if the current process protects resident private health care information. FSD H responded, Probably not. It is the facility policy that resident information should be kept private, only staff who need to know the information should have access. On 8/08/23 at 1:29 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B expressed there was a past issue, before her time when staff were not following diet orders. DON B expressed she understands the diet information should be private but also wants to ensure resident safety with eating. DON B indicated she understands the privacy concern and believes there are ways to inform staff of dietary needs of residents that is more private than the large cards in the stands at the tables.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has a potential to affect all 100 (R) residents who reside in the facility. Surveyor observed 4 expired half gallons of buttermilk during initial tour of kitchen. Surveyor observed a cart of uncovered leftovers in the walk-in freezer. Surveyor observed a tray of 10 ice cream dishes uncovered. Surveyor observed 4 trays of applesauce dishes uncovered. Surveyor observed 2 pans of leftovers incorrectly dated. Surveyor observed a garbage container that was full and uncovered. Surveyor observed staff serving dessert dishes by placing their thumbs inside of the dishes with no gloves on and plate guards being attached to plates with bare hands with no hand hygiene. Surveyor observed 6 expired mighty shakes in the freezer on the 400-unit. Surveyor observed freezer door shelves dirty and with crumbs. Surveyor observed undated opened gallons of fat free milk, whole milk, low fat chocolate milk, and half and half cream in the refrigerator on the 400-unit. Surveyor observed 3 expired boxes of cranberry juice in the refrigerator on the 400-unit. Surveyor observed in the refrigerator on the 200-unit undated opened gallons of whole milk and low-fat chocolate milk and a box of cranberry juice expired. Surveyor observed under the microwave glass plate built up rust on the 200 unit. Surveyor observed on the [NAME] Servery undated opened gallons of fat free milk and whole milk. This is evidenced by: The facility policy, entitled Food Storage, dated 2017, states, in part: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and by methods designed to prevent contamination or cross contamination. Procedure: .7) .c. Food should be dated as it is placed on the shelves if required by state regulation .13) Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2013 Federal Food Code . 14) Refrigerated food storage: .f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. g. All foods should be stored to allow air circulation .15) Frozen Foods: a. All freezer units will be kept clean and in good working condition at all times .c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe dates or discarded . The facility policy, entitled, Food Safety and Sanitation, dated 2017, states, in part: Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary department of food and nutrition services. Procedures: .d. Employees will wash their hands just before they start to work in the kitchen and .touching .surfaces or items with potential for contamination .4) Food Storage .a. Stored foods is handled to prevent contamination and growth of pathogenic organisms .Food is protected from contamination (dust .) .All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored . The facility policy, entitled, Food Safety- Director of Food and Nutrition Services, dated 2017, states, in part: . Responsibility .3. Proper waste disposal methods will be used .5. Employees will follow sanitary practices and good personal hygiene at all times . The facility policy, entitled, Employee Sanitary Practices, dated 2017, states, in part: . 10. a. Have clean hands .c. Pick dishes up by their rims . The facility policy, entitled, Hand Washing, dated 2017, states, in part: Policy: Employees will wash their hands as frequently as needed throughout the day using proper hand washing procedures .Procedure: Clean hands and exposed portions of arms (or surrogate prosthetic devices) immediately before engaging in food preparation .j. After engaging in other activities that . The facility policy, entitled, Waste Disposal, dated 2017, states, in part: Policy: Garbage will be disposed of and as needed throughout the day and at the end of each day. Procedure: 1. Prior to disposal, all waste shall be kept in a leak-proof, non-absorbent, fireproof container that are kept covered when not in use . On 6/6/22, at 11:30 AM, Surveyor did walk through in the kitchen with CS (Cook/Supervisor) E. Surveyor observed 3 unopened half gallons of cultured buttermilk with expiration dates of 6/4/22 and 1 opened half gallon of cultured buttermilk with an expiration date of 6/1/22. CS E indicated all 4 buttermilks were expired and set them aside. On 6/6/22, at 11:30 AM, during kitchen walk through with CS E, Surveyor observed a metal cart with uncovered leftovers of 17 burgers, a small pan of jojo fries and a pan of mashed potatoes set in the freezer just inside door. Surveyor asked CS E if the leftovers should be covered, and CS E indicated they cool food per Serv Safe. On 6/6/22, at 11:30 AM, during kitchen walk through with CS E, Surveyor observed an uncovered tray of 10 ice cream dishes in the freezer by the tray line. Surveyor asked CS E if the tray should be covered, and CS E indicated yes. On 6/6/22, at 11:30 AM, during kitchen walk through with CS E, Surveyor observed 5 trays which consisted of 35 applesauce dishes with saran wrap covering the top tray and then draped down the front of all five trays in the refrigerator by the tray line. Surveyor asked CS E if all five trays should be covered, and CS E indicated no since the saran wrap was draped down the front of the trays. On 6/6/22, at 11:30 AM, during kitchen walk through with CS E, Surveyor observed in the walk-in refrigerator 2 pans of leftovers. One pan consisted of turkey and gravy labeled with a date of 6/11/22. The second pan consisted of mashed potatoes and boiled potatoes with a date of 6/11/22. CS E indicated leftovers are marked with the date they are put in the refrigerator and are good for 5 days. CS E indicated the date marked must have been done in error. On 6/6/22, at 11:30 AM, during kitchen walk through with CS E, Surveyor observed an uncovered small garbage container that was full sitting under the counter at the end of the three-compartment sink. Surveyor observed a large mixer and small mixer on a table close to garbage where splatter from garbage could contaminate. On 6/7/22, at 07:45 AM, Surveyor observed 2 strawberry mighty shakes with use by dates of September 2, 2021, 4 vanilla mighty shakes with use by dates of March 23, 2022, and the five door shelves in the 400-unit freezer with a dried brown substance and crumbs on. Surveyor asked CS D if the mighty shakes were expired, and CS D indicated yes and disposed them in the garbage. Surveyor asked CS D if the five shelves on the freezer door were clean, and CS D indicated they were dirty and needed to be cleaned. Surveyor observed in the 400-unit refrigerator an opened gallon of fat free milk with no open date, an opened gallon of whole milk with no open date, and an opened gallon of low-fat chocolate milk with no open date. Surveyor observed a Half and Half opened with no open date and 3 boxes of cranberry juice with expiration dates of March 2022 and April 2022. Surveyor asked CS D if the three boxes of cranberry juice was expired and CS D indicated yes, all three boxes were expired. Surveyor asked CS D how one would know if the milks were expired, and CS D indicated when the milks are opened they are to be dated to expire 7 days out from opening. CS D indicated the milks were not dated so should be considered expired. On 6/7/22, at 08:00 AM, Surveyor observed in the 200-unit refrigerator an opened gallon of whole milk and an opened gallon low-fat chocolate milk that had no open dates. Surveyor observed a box of cranberry juice with an expiration date of May 11, 2022. Surveyor asked LPN (Licensed Practical Nurse) H if the cranberry juice was expired, and LPN H indicated yes. Surveyor asked LPN H when does the whole milk and low-fat chocolate milk expire and LPN H indicated LPN H was not sure but would find out. LPN H came back and indicated if there is no open date the expiration date would be the best by date on the jugs otherwise 7 days from opening the milk. Surveyor asked LPN H when the 2 gallons of milk expire and LPN H indicated she would go by the best by date. Surveyor asked LPN H who was responsible for dating the milk once opened. LPN H indicated dietary stamps the date on the milks but if nursing opens the milk nursing puts the open date on it. On 6/7/22, at 08:15 AM, Surveyor observed an opened gallon of fat free milk and an opened gallon of whole milk with no open dates in the refrigerator in the [NAME] Servery. Surveyor asked DA F ( Dietary Aide) what the expiration dates are for the whole milk and fat free milk. DA F indicated 7 days from today because DA F just opened them that morning. Surveyor asked DA F how one would know when it expires by looking at the undated milks and DA F indicated DA F is supposed to date them when opened but DA F had not that morning. On 6/7/22, at 10:31 AM, Surveyor observed CS D put her ungloved right hand in her pants pocket and retrieve a black marker and then used the marker to cross off an item on her list, then put the marker back into pants pocket. Surveyor observed CS D continue to serve food by grabbing plates and putting plate guards on and grabbing dessert dishes with thumb inside of dishes. Surveyor observed DA (Dietary Aide) F moving food carts around then grabbing dessert dishes with thumbs inside the dishes with no gloves on. Surveyor observed no hand hygiene being performed by CS D or DA F. On 06/08/22, at 09:08 AM, Surveyor interviewed DM (Dietary Manager) C. Surveyor asked DM C asked who is responsible for dating the milks on the units when opened and DM C indicated nursing should be dating the milks when opening. Surveyor informed DM C of undated opened milks on the units and asked if the milks would be considered expired. DM C said the milks would be considered expired with no dates marked when opened. Surveyor informed DM C of expired mighty shakes, cranberry juices, half and half and milks. DM C indicated she would be sure they were removed off the units and disposed of. Surveyor informed DM C of the freezer with a dried brown substance and crumbs on the five door shelves and DM C indicated yes they are considered dirty. DM C indicated there is a sign on each refrigerator on the units to wipe out spills. DM C indicated the expectation is nursing and dietary use a team effort and work together on cleanliness of units. Surveyor informed DM C of the 4 expired buttermilks in refrigerator observed on walk through. DM C indicated the expired milks should have been caught and pulled since deliveries come every Tuesday and Thursday. DM C indicated the expired buttermilks should not have been on the shelf in circulation. Surveyor informed DM C of the 5 trays of applesauce dishes with the top tray covered with saran wrap and the other four having the saran wrap draped down the front of the trays. DM C indicated each tray should have been covered. Surveyor informed DM C of the tray of ice cream dishes in the freezer and DM C indicated the tray should be covered. Surveyor asked DM C what the expectation of handling dishes with food is on the tray line without gloves. DM C indicated staff should be grabbing dishes underneath, otherwise gloves should be on if unable to handle from underneath the dish. Surveyor informed DM C of the 2 pans of leftovers with date of 6/11/22 and DM C indicated leftovers should have the date they were put in the refrigerator not 6/11/22 since it is only 6/08/22. Surveyor asked DM C if cooling food in the freezer should be covered, and DM C indicated they follow Serv Safe. Surveyor asked DM C with the cart being right inside the door could dust or contaminated particles spread onto leftovers. DM C indicated yes, being that close to door with traffic going in and out of freezer. Surveyor informed DM C of the uncovered garbage container under the three compartment sink that was full and the rust under the microwaves glass plate on the 200 unit.