Every finding on record at Advanced Rehabilitation and Healthcare of Bowie

Based on interviews and record reviews, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 9 of 11 confidential residents reviewed for meeting grievances.The facility failed to provide a verbal or written response to the Resident Council addressing the grievances reported from their meetings on April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, and February 2026 which included issues with nursing services, dietary services, and housekeeping services. These failures could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.Findings Included:Record review of the Grievance logs for April 2025 reflected the Resident Council made four grievances. The first grievance involved leaking faucet and toilet not being repaired with one-to-one discussion checked for resolution notification and yes written in date written notification provided. The second grievance involved the pork loin always being tough with one-to-one discussion checked for resolution notification and yes written in date written notification provided. The third grievance involved the floors were not clean with phone conversation checked for resolution notification and yes written in date written notification provided. And the Forth grievance involved the CNAs always being late to take residents out for smoke breaks with one-to-one discussion checked for resolution notification and yes written in date written notification provided.Record review of the Grievance logs for May 2025 reflected the Resident Council made four grievances. The first grievance involved taking an hour to answer call lights, coming in and turning the light out and saying they would be back, not coming back to assist residents with one-to-one discussion checked for resolution notification and yes written in date written notification provided. The second grievance involved bathroom floor needs good cleaning and was still dirty with one-to-one discussion checked for resolution notification and 05/07/2025 written in date written notification provided. The third grievance involved residents getting clothes that do not belong to them with one-to-one discussion & phone conversation checked for resolution notification and 05/07/2025 written in date written notification provided. The fourth grievance involved the sausage is pink and needs to be browned with one-to-one discussion checked for resolution notification and yes written in date written notification provided.Record review of the Grievance logs for June 2025 reflected the Resident Council made three grievances. The first grievance involved the CNAs were not doing good and could improve with one-to-one discussion checked for resolution notification and yes written in date written notification provided. The second grievance involved the fish nuggets were not good, too much chicken was served, and fruit was not needed with one-to-one discussion checked for resolution notification and yes written in date written notification provided. The third grievance involved socks missing in the laundry with one-to-one discussion checked for resolution notification and 06/03/2025 written in date written notification provided.Record review of the Grievance logs for July 2025 reflected the Resident Council made three grievances. The first grievance involved roommate's television was too loud. The second grievance involved staff being rude, resident fell on the floor between the wheelchair and the bed, and roommate having to give call light to the resident. The third grievance involved the chicken was dry. The documents reflected that residents were notified of resolution by one-to-one discussion and date written notification provided was documented yes.Record review of the Grievance logs for August 2025 reflected the Resident Council made three grievances. The first grievance involved staff not coming back to rooms and residents not getting what they needed with one-to-one discussion checked for resolution notification and yes written in date written notification provided. The second grievance involved residents missing clothes with one-to-one checked for notification of resolution and date written notification provided 08/05/2025. The third grievance involved under beds not being cleaned and bathrooms not being cleaned with phone conversation checked for notification of resolution and date written notification provided 08/05/2025.Record review of the Grievance logs for September 2025 reflected the Resident Council made two grievances. The first grievance involved quesadillas which were not good and the food was cold with nothing documented for resolution notification and date written notification provided documented yes. The second grievance involved no toilet paper or paper towels in the bathrooms with one-to-one resolution notification checked and date written notification provided 09/03/2025.Record review of the Grievance logs for October 2025 reflected the Resident Council made two grievances. The first grievance involved bathrooms not being cleaned with one-to-one resolution notification checked and date written notification provided 10/08/2025. The second grievance involved call lights not being answered with staff going in rooms and not coming back to assist the residents no resolution notification checked and yes written in date written notification provided.Record review of the Grievance logs for November 2025 reflected the Resident Council made four grievances. The first grievance involved smoking residents wanting something to lock the wind outside in the smoke area with one-to-one discussion resolution notification checked and yes written in date written notification provided. The second grievance involved resident still missing clothes with one-to-one discussion resolution notification checked and date written notification provided 11/06/2025. The third grievance involved food cold and taking too long to serve out the food with one-to-one discussion checked for resolution notifications and date written notification provided was yes. Record review of the Grievance logs for December of 2025 reflected the Resident Council made three grievances. The first grievance involved therapy going through closet looking for items for resident's roommate with no notification of resolution documented and yes written in date written notification provided. The second grievance involved a resident stating a flashlight and white bowl was taken from his room with one-to-one discussion checked under resolution notification and yes documented on date written notification provided. The third grievance involved therapy going through closet looking for items for resident's roommate with one-to-one discussion resolution notification checked and yes written in date written notification provided.Record review of the Grievance logs for January 2026 reflected the Resident Council made two grievances. The first grievance involved the kitchen putting food on trays that the ticket stated that residents do not like. The second grievance involved residents sitting by the nurses' station. The documents reflected that residents were notified of resolution by one-to-one discussion and date written notification provided was documented yes.Record review of the Grievance logs for February 2026 reflected the Resident Council made two grievances. The first grievance involved the food trays sitting on the hall too long and not getting enough gravy on trays. The second grievance involved a resident who did not get her inhaler at night. The documents reflected that residents were notified of resolution by one-to-one discussion and date written notification provided was documented yes.In a confidential group interview at a confidential date and time, 9 of 11 residents stated they came to Resident Council meetings regularly. The 9 of 11 residents stated that no one had gotten back with them about their grievances in the past. They stated some of the issues continued and they would like to be notified about what the facility was doing to resolve those issues. One resident stated they believed that more residents would come to the Resident Council meetings, if the facility would provide resolution discussions with the Resident Council and stated that residents who attended the meetings had slowly declined. During an interview on 02/25/2026 at 3:50 p.m., AD-A stated she did not go to the resident council meetings regularly but would go when invited. She stated the resident council had a secretary or the president would write down the concerns brought up during the meeting in the resident council minutes. She stated she would go over the minutes with who wrote them to fill out grievance forms. She stated after the grievance forms had been written, she would hand them to the ADM. She stated she had heard the grievances being gone over during the morning stand-up meeting where the management of the facility would go over issues. She stated she did not know if anyone relayed the information to the resident council members. She stated she kept the resident council binder with the minutes and other items for the meetings in her office. She stated she did not get the completed grievance forms back to log into that binder. She stated there was another AD who helped with resident council. During an interview on 02/25/2026 at 3:52 p.m., AD-B stated she was an AD and worked with another AD. She stated she had been in the activities director role for about 2 years. She stated she did not go to the resident council meetings regularly but would go when invited by the residents. She stated she had heard the grievances be gone over during the morning stand-up meeting where management of the facility would go over issues. She stated she did not know if anyone relayed the information to the resident council members. She stated she helped keep the resident council binder with the minutes and other items for the meetings in her office that she shared with AD-A. She stated she did not get the completed grievance forms back to log into that binder.During an interview on 02/25/2026 at 3:58 p.m., the ADM stated that she was the grievance officer. She stated she kept a binder for the grievances. She stated she was aware of the resident council grievances because they were in her binder and she had documented what the facility had done on those grievance forms. She stated the resident council grievances were logged in the binder with what the facility had done to correct the issues. She stated she did not go to resident council meetings unless she was invited by the residents. She stated she would monitor that the grievances had been resolved by going over them during the morning staff meetings and documenting when they had been resolved. She stated she had never been told that the residents felt their concerns were not heard from the council not getting a response about the grievances. She stated she would go down the halls and ask some of the residents including the resident council president if those concerns had gotten better and assumed that was relayed to the council. She stated she was responsible for following up about grievances and when she documented 1 to 1 that meant that she had spoken to the resident council president or another member of the resident council. During an interview on 02/27/2026 at 8:35 a.m., SW-C stated the ADM was responsible for investigating grievances and she was not sure how the ADM notified the parties of the outcome of the grievances. She stated residents may not feel like they were being heard if not told the resolutions of a grievance filed. Record review of the facility's policy titled Grievance Policy revised on 11/19/2016 reflected The designated grievance officer is the Administrator. Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection for residents. Social Service under the guidance of the Administrator is responsible for the following: *maintains a system to keep records (file, log, copy of grievance registration forms, etc.) of all complaints reported which contains the date of report, circumstances, specifics of investigation, action taken, and follow-up with the complainant *Conduct/designate routine interviews with residents and families related to specific areas of facility life and resident ca. Document negative findings on a grievance form. The Administrator (grievance officer) is responsible for the following *Maintains a Grievance Log for 3 years *Review grievances to validate investigation of the facts and circumstances of the grievance *Written findings of fact, conclusion and recommendations and validate with person issuing the grievance timely *Establish a mechanism for all associates to communicate resident or family grievances to the designated staff so that all grievances will be documented and timely response developed and implemented.*Coordinate orientation and in-service training to ensure that all facility associates are knowledgeable of the facility grievance procedures and their role in providing responsive customer service to residents and families in grievance resolution. *Validates designee follows up with resident/family regarding resolution or explanation.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. An open package of spaghetti noodles in the dry food storage room was not placed in a resealable bag or airtight container and was not dated when opened.2. The floor was soiled beneath the reach-in refrigerator and behind the deep fryer units, grill, and ovens.3. Shelves were soiled with food crumbs and spilled cornmeal and granulated sugar.4. The milk refrigerator unit did not have an interior thermometer.5. The two deep fryer units contained dark colored cooking oil and the interior surfaces were soiled with dried and fried food crumbs and breadcrumbs.6. Cleaning schedules were not initialed when tasks were completed. These failures placed residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.The findings included: Observations and interviews on 2/24/26, between 9:35 AM and 10:05 AM, during the initial tour of the facility kitchen, revealed the following:The dry food storage/non-perishable food storage room had wire rack shelf units for storing packaged food items. An open package of dry spaghetti noodles was open to the air (end of the package was cut off), was not in a resealable bag or storage container, and was not labeled and dated when opened. The Culinary Services Director removed the opened package of dry spaghetti noodles from the shelf and stated she would throw it away. She stated chicken spaghetti was served last night and the spaghetti was probably opened yesterday. The floor was soiled beneath the small reach-in refrigerator unit used for storing supplement beverages. A bread knife was stuck to the floor beneath the unit. The Culinary Services Manager tried to pick up the bread knife and was unable to loosen it from the floor. She stated she would have to get water.The milk refrigerator unit did not have an interior thermometer; the unit thermometer on outside of unit was at 35.5 degrees F.There were dried food crumbs on the stainless-steel shelf beneath the counter with the bread toaster.The 2 deep fryer units were covered with inverted rectangular sheet pans; the fryer oil was dark in color and the interior surfaces were soiled with dried, fried food and breading crumbs.The floor was soiled with dark colored/burned food, crumbs, and dust behind the deep fryer units, grill, and ovens.The exterior side of the utensil cabinet, used as a base for the grill, was soiled with a thick grease build up. The grill and base were located near a deep fryer unit and the area of floor was soiled with grease in the area between the deep fryer unit and base for the grill.The back-splash panel behind the grill was soiled with grease build-up.The shelf under the food preparation counter was covered with shelf liner paper that was soiled with corn meal and granulated sugar. 4 bulk storage containers with flour, granulated sugar, food thickener, and corn meal were positioned on top of the shelf liner. The Culinary Services Manager stated a dietary staff member had put the shelf liner on the shelf because she thought it would look nice. The Culinary Services Manager started to remove the shelf liner paper from the shelf and dumped the spilled corn meal and sugar onto the floor. In an interview on 2/26/2026 at 10:55 AM, the Assistant Dietary Manager stated the deep fryer units would be cleaned later today. She stated she tried to schedule cleaning behind the oven and grill appliances on a night following an easy meal. She stated the appliances needed to be pulled out and away from the wall and she needed help to do it. Observation on 2/27/2026 at 9:45 AM revealed cleaning schedule forms on clip boards hanging on a wall in the kitchen. The forms were for dietary aides daily cleaning tasks, cooks daily cleaning tasks, and monthly cleaning tasks. The daily tasks included sweeping and mopping the floors in the morning and evening. The monthly tasks included cleaning the dish room, tray line, food processor, carts, reach-in refrigerator, walk-in refrigerator, shelving, ingredient bins, and delime the steamer. The monthly cleaning schedule for February 2026 had no tasks initialed as completed for Week 4. In an interview on 2/27/2026 at 9:50 AM, the Culinary Services Director stated the staff had cleaning schedules on clipboards for daily and weekly cleaning. She stated the expectation was for the staff to sweep and mop the floors after every shift. She stated the staff were to clean and sanitize. The Culinary Services Director stated the deep fryer units oil was drained and they were cleaned weekly. She stated the steamtable wells were cleaned out after every meal. The Culinary Services Director stated a potential outcome of not cleaning was sickness and illness for the residents. In an interview on 2/27/2026 at 10:09 AM, Dietary Aide D stated she had worked in the facility for about 2 years. She stated she used the weekly cleaning schedule for the dietary aides and the monthly cleaning schedule. Dietary Aide D stated no assignments were made for cleaning tasks and she cleaned when she had time. She stated the expectation was to clean daily. Dietary Aide D stated a potential outcome from not cleaning would be a nasty kitchen that could attract bugs and cause people to get sick. Record review of the facility dietary policy for Environment, dated October 2019, indicated [in part]: PolicyIt is the center policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.Action Steps1. The Dining Services Director will insure [sic] that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.2. The Dining Services Director will insure [sic] that all employees are knowledgeable in the proper procedures for cleaning all food services equipment and surfaces.3. The Dining Services Director will insure [sic] that all food contact surfaces are cleaned and sanitized after each use.4. The Dining Services Director will insure [sic] that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. Record review of the facility dietary policy for Receiving, dated October 2019, indicated [in part]: Policy StatementIt is the center policy that safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items.Action Steps1. The Dining Services Director or designee receives all items and checks each against the order.4. The Dining Services Director or designee ensures that all non-perishable foods and supplies are stored appropriately.6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.7. All food items will be stored in a manner that insures appropriate and timely utilization based on the principles of first in - first out (FIFO). Record review of the facility dietary policy for Food Storage - Dry Goods, dated October 2019, indicated [in part]: Policy StatementIt is the center policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code.Action Steps: Dry Storage5. The Dining Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. The Food and Drug Administration Food Code 2022 specified [in part]:Chapter 3 Food3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of thecontents so that the FOOD is not exposed to ADULTERATION or potentialcontaminants. Chapter 4 Equipment, Utensils, and Linens4-602.13 Nonfood-Contact Surfaces.The presence of food debris or dirt on nonfood contact surfaces may provide a suitableenvironment for the growth of microorganisms which employees may inadvertentlytransfer to food. If these areas are not kept clean, they may also provide harborage forinsects, rodents, and other pests.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, by failing to ensure: A. floors were swept and free from dirt and food crumbs. B. bottom shelves were clean. C. the dishwasher sanitizer did not meet required level for proper sanitization. D. food was open to air and not sealed. E. food was not dated when opened. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings included: In an observation on 11/5/24 at 8:50 AM, during the initial tour of kitchen, revealed the following: 1. Dry storage area had an opened bottle of vanilla that was not dated and covered in dried vanilla down the bottle, there were open cracker packets in a bin with bags of fruit punch mix, sugar and creamer packets lying on the shelves and floor. Observation of dirt, food crumbs, cans of soda and trash underneath the shelves and along the walls. 2. Refrigerator #1, crumbs and unknown dried brown substance was noted on bottom shelf. One container of leftover food noted with a cracked lid and another with premade sandwiches had plastic wrap partially covering food. 3. Beverage station had dried red substance and food crumbs. 4. Refrigerator #2 (small juice fridge) there was a container with 2 baggies that contained shredded cheese and sour cream undated. 5. Main kitchen/Serving Area on the prep station there was a used Styrofoam cup with no lid, the station was dirty with food crumbs near clean dishes/utensils, an open bottle of lemon juice undated, and the storage under the prep area has a black greasy substance where the clean pots and lids were kept. 6. Warmer #1 had trays inside with a dried leftover substance, and under the warmer was a piece of chicken. Behind the stove was a drinking cup, a fryer basket, food container, some plastic wrap and a bottle of lemon juice with no date covered in a greasy substance. In an observation and interview on 11/5/24 at 9:28 AM Dietary Aide A was washing and removing dishes from dish machine then putting them up in the clean part of the kitchen storage. He stated that he or his coworkers check the dish machine several times a day and document on the log . He was unable to voice what proper chlorine sanitization level should read when using test strips. In an observation and interview on 11/5/24 at 9:31 AM Dietary Manager tested the chlorine sanitizer level in the low temperature dish machine which read at a level of 25 parts per million. The Dietary Manger stated this level was not the correct level and should read between 50-100 parts per million when tested . She further stated that lack of proper chlorine sanitization level could lead to sickness. She also stated that she and her staff would review the dishes that were washed at this level and re-wash them. In an interview on 11/7/24 at 7:18pm the Dietary Manager stated the following regarding kitchen cleanliness and sanitation, We have already started cleaning. I told them(kitchen staff) we need a schedule and have put one in place for housekeeping to do the floors once a month. We do have a cleaning schedule, but they are so new that they just do at it if you know what I mean. I told my Assistant Dietary Manager that we must hold them accountable. She stated that an adverse outcome of unclean kitchen could cause bugs or sickness.Facility policies and procedures for food storage and cleaning schedules were requested on 11/7/24 at 7:18 PM from Dietary Manager, but not provided. Record review of the policy Equipment Cleaning Procedures revised 1/2013 revealed the following [in-part]: Policy: It is the policy of this facility that all dietary equipment and environment are cleaned and sanitized in a manner that meets local(if applicable), state, and federal regulations. Fundamental Information: Routine cleaning will be practiced on a regular basis in order to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations. Cleaning is the practice of removing soil and dirt with an approved cleaning agent . Cleaning Frequency: Daily: Equipment and items that are used in food preparation should be cleaned and sanitized after each use. Kitchen and storeroom floors should be swept and mopped daily. Record review of the policy Ware Washing revised 5/2012 revealed the following [in-part]: Policy: The purpose of ware washing is to clean and sanitize utensils and equipment used during the preparation and service of food from the dietary department. Proper ware washing is an essential component m the prevention of food borne illnesses. Procedure: The following temperature and sanitizer strength will be followed: 2. Low temperature Dish Machines b. chemical: Chlorine sanitizer= 50ppm (parts per million) Quat sanitizer= 200ppm (or according to manufacturer's instructions)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #10) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #10. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #10's face sheet dated 11/08/23, revealed an 82- year- old female admitted to the facility on [DATE] with diagnoses including personal history of Covid-19, cutaneous abscess of perineum, constipation, reduced mobility, and Alzheimer's disease. Review of Resident #10's MDS assessment dated [DATE] revealed Resident #10 required substantial/maximal assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #10 was always incontinent of bowel and bladder. Review of Resident #10's Care Plan dated 03/26/23 revealed Resident #10 is incontinent of bowel and bladder related to loss of control/muscle tone, impaired mobility. Observation of incontinence care for Resident #10 on 11/06/24 at 2:30 p.m. revealed CNA A did not wash her hands prior to donning gloves. She retrieved the resident's clean brief and placed it near the soiled brief. Resident #10's brief was soiled with fecal matter. CNA A wiped the resident from front to back. She made 5 strokes of clean with the same soiled wipes. CNA A did not change her gloves and continued to clean Resident #10. She used the same soiled gloves to apply skin protector on Resident #10. CNA A's gloves were visibly soiled with fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before putting Resident #10's clean brief and placing it underneath the resident. She removed the soiled gloves and fastened the clean brief on Resident #10. CNA A retrieved the trash and walked out of Resident #10's room without washing her hands. In an interview on 11/06/24 at 2:41 p.m. with CNA A, she said she should have washed her hands before starting care and changed her gloves during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #10. CNA A stated she has been in the facility since August 2024 and had infection control training last month. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. CNA A added she did not follow standard precautions and good infection practice because she was nervous. During an interview with the DON on 11/08/24 at 10:17 a.m., she stated she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility's protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. The DON explained she was the infection preventionist responsible for training staff and monitoring infection control practices. She stated she monitors the staff by conducting in-services. The DON added the staff receive infection control training annually and in-services at least once a month. Review of the facility's Hand hygiene policy revised 02/11/22 reflected: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 1(Resident #1) of 2 residents reviewed for infection control practice, in that: 1) CNA C and CNA D failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. 2) LVN A failed to perform hand hygiene and change gloves while providing wound care. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 02/13/24, revealed the resident was an 82- year- old female admitted to the facility on [DATE] with diagnoses of personal history of Covid-19, acute candidiasis of vulva and vagina (Fungal infection), and Alzheimer's disease. Review of Resident #1's MDS assessment, dated 11/27/22, revealed Resident #1 required total assistance with most activity of daily living (ADLs) and two-person assist. Resident #1 was frequently incontinent of bowel and always of bladder. Review of Resident #1's care plan, dated 10/30/22, revealed the resident was care planned for being incontinent of bladder and bowel related to impaired cognition and mobility. Observation of incontinence care for Resident #1 on 02/12/24 at 10:32 a.m. revealed CNA C and CNA D was about to transfer the resident from wheelchair to bed when the surveyor entered the room. Both used proper transfer technique to move the resident. Both CNA C and CNA D did change gloves after transferring Resident #1. CNA C removed the resident's soiled brief. She wiped from front to back. Resident #1's brief was soiled with urine and fecal matter. Both repositioned Resident #1. CNA C continued to clean the resident bottom area. CNA C gloves were visibly soiled with urine. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. CNA C applied skin protector on the resident perineal area with same soiled gloves. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves for transferring and repositioning the resident including touching the perineal area and fastened the clean brief to the resident. CNA C and CNA D did not wash their hands before exiting Resident #1's room. In an interview on 02/12/24 at 10:48a.m with CNA C she stated she had been employed at the facility for 2 years and received infection control in-services 4 months ago. CNA C stated cross contamination meant mixing clean with dirty. CNA C stated she should have washed hands and changed gloves before retrieving the resident clean brief. She noted Resident #1 could get an infection for not using good infection control practice. Interview with CNA D on 02/12/24 at 10:52a.m revealed she had been employed at the facility since May 2023 and received infection control training on orientation. She stated cross contamination was transferring germs from one place to another. CNA D stated she should have changed her gloves and washed her hands before fastening Resident #1clean brief. She noted Resident #1 could get sick for not washing hands or changing gloves. Review of physician orders for February 2024 reflected, Sacrum-Apply hydrocolloid dressing FOR MASD (moisture-associated skin damage), every day shift every Monday, Wednesday, Friday. Observation of pressure ulcer on Resident #1 on 02/12/24 at 11:04 a.m. revealed LVN A did not wash his hands but donned gloves before the start of care. He prepared a clean field on a paper spreader. LVN A removed old dressing revealing a thin clear dry wound on the coccyx with granulation (healing) around the wound bed. LVN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean dressing and placing on Resident #1's wound. LVN A picked it up the trash and walked out of the room without washing hands. In an interview on 02/12/24 at 11:12 a.m. with LVN A, he revealed he should have washed his hands before starting care and changed his gloves during care. LVN A also revealed she should have changed his gloves before retrieving a clean dressing and placing on Resident #1's wound. LVN explained he had been employed in the facility since August 2023 and received infection control training during orientation. He said the resident could acquire an infection when he did not follow good infection control practices including washing hands before commencing care. During an interview with the DON 02/12/24 at 11:20a.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the staffs were expected to wash hands don gloves before starting care. Review of the facility Hand hygiene policy implemented 11/12/17 reflected, Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection t other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 1) Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2) Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standard of practice. 3) Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. a) Hands are visibly dirty. b) Hands are visibly soiled with blood or other body fluids. c) Before and after eating . d) Between resident' contacts.

Based on interview and record review, the facility failed to include resident or the resident's representative in the IDT (Interdisciplinary team) in the comprehensive care planning within 7 days after completion of the comprehensive assessment for 1 of 3 residents (Resident #7) reviewed for care plan timing/revision. The facility failed to ensure Resident #7's care plan was reviewed by the IDT (Interdisciplinary team), which failed to include the resident or the resident's representative after the Comprehensive MDS assessment. This failure placed the residents at risk for not having individual needs identified and care and services provided to meet their needs and promote quality of care, feelings of well-being and quality of life. The findings included: Review of Resident #7's face sheet, dated 09/15/2023, revealed a [AGE] year-old female, with an admitted [DATE] and a re-admitted [DATE]. Diagnoses included: Metabolic encephalopathy (brain dysfunction is disturbed due to disease in the body), Type 2 Diabetes Mellitus (chronic condition the affects the way the body produces blood sugar), and hypotension (low blood pressure). Review Resident #7's MDS assessment history revealed an annual assessment dated [DATE]. Section C revealed a BIMS score of 15, which means the resident is cognitively intact. Review of Resident #7's comprehensive care plan revealed it was last Reviewed/Revised on 04/27/2023 by the MDS Coordinator. There was no documented evidence that a care plan meeting was conducted for this care plan. Record review of Resident #7's progress notes revealed there was not a care plan meeting completed in April or May 2023. The care plan meeting was completed quarterly with the following dates of: 09/26/2023, 06/27/2023, 03/28/2023. Interview with Resident #7 on 09/12/2023 at 10:40 AM revealed the following: She revaled she had not been invited to careplan meetings and would like to dicuss some of the issues she is having with her needs. She revealed if she was invited, she would attend. She revealed that she makes decisions for her care. Interview with the RN MDS Coordinator on 09/14/2023 at 2:00 PM revealed the following: She revealed that they do not go off of the MDS schedule, they do them Quarterly. She revealed that the Social Worker completed the care planning process by contacting the family for the comprehensive care plan meeting. Interview with the Social Worker on 09/14/2023 at 3:23 PM, revealed that every 3 months they have a care plan meeting, this includes annual assessments. She said she does not know what type of assessment it is; she just does one every 3 months; she does not go off of the MDS schedule. She revealed there was not an IDT completed in April 2023 or May 2023, that coincides with the Annual MDS assessment. She revealed since there was not a comprehensive care plan meeting, they did not include the resident or the resident's representative, she revealed this failure places residents at risk of not having family involved in their care planning process. Review of the facility's policy and procedure for Care Plans and CAAS, (05/16/2016), revealed the following [in part]: Care Plan Updates: * The IDT will review the care plans Annually, Quarterly and as needed to ensure all goals and approaches are appropriate. * The IDT will sign their designated sections of the care plan thereby signifying that they have reviewed their section of each care plan. Care Plan Meetings: * The Social Worker will use the facilities designated form for documentation by IDT of meeting. Form will be filed out in the resident's chart.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the health status for 1 of 8 residents (Resident #2) whose MDS assessments were reviewed, in that: 1. Resident #2 had broken natural teeth This failure placed residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings included: Resident #2 Review of Resident #2's Admission Record, dated 09/15/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] diagnoses included: dementia (loss of memory and other thinking abilities), chronic obstructive pulmonary disease (a lung disease that blocks air flow and makes it difficult to breath); muscle weakness; and diabetes (a disease that results in too much sugar in the blood. Review of Resident #2's Admission MDS Assessment, dated 07/07 /2023, revealed she had a BIMS score of 14 (cognitively intact) and had no natural teeth or tooth fragments. During an observation and interview on 09/14/23 at 10:30 AM with the surveyor and MDS nurse B present, Resident #2 was noted to have broken and missing teeth on her upper gums. She stated she had not asked to see a dentist, but she would like to. She stated she had a partial for the top gums, but they did not fit properly. She stated they did not hurt and she was able to eat, but somethings were harder to chew. In an interview on 09/14/2023 at 10:40 AM, the LVN MDS Coordinator B stated she did not have a facility policy for completing MDS assessments. She agreed that the Admission MDS on Resident #2 was not accurately descriptive of her dental status. She stated a part time MDS nurse had completed the assessment She stated she followed the guidelines of the RAI Manual to complete assessments. She stated failure to not complete the MDS accurately could result in the resident not receiving needed care and services. Review of the RAI Manual section L oral dental status, dated10/2019 revealed in Part: This section is intended to record any dental problems present in the 7 days what look back period. Poor oral health has a negative impact on quality of life, overall health, and nutritional status. Assessment can identify gum disease that can contribute to or cause systemic diseases and conditions, endocarditis, and poor control of diabetes. Assessing dental status can help identify residents who may be at risk for aspiration malnutrition, pneumonia, endocarditis, and poor control of diabetes.

Based on interview, and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of four residents (Resident #142) reviewed for Comprehensive Care Plans. The facility failed to develop and implement a comprehensive person-centered care plan to meet care areas triggered (cognitive loss, Visual function, adl assistance, urinary incontinence, falls, nutritional status, pressure area risk, psychotropic drug use and code status). This failure could place residents at risk of not receiving care that is relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings include: Record review of Resident #142's face sheet dated 09/14/23 revealed resident was a 48 -year-old female with an admitted [DATE]. Diagnoses included: diabetes (a medical condition in which there is too much sugar in the blood); hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles); pain disorder; cardiomegaly (enlarged heart); dysphagia (difficulty swallowing); abnormal gait, and lack of coordination. Record review of Resident #142's Admission MDS, dated [DATE] documented Resident #142 had a BIMS score of 11 (moderately cognitively impaired). Resident #142 was able to understand others and make her needs understood. The MDS documented Resident #142 utilized a wheelchair, required extensive assistance with one person assist for personal hygiene and two-person assistance with transfers and bed mobility, she was always incontinent of bowel and bladder, she experienced pain during the 5 day look back period and was on a scheduled pain management regimen, was at risk for pressure ulcers, took an antidepressant and a diuretic, and was a full code. The MDS was signed as completed on 07/07/2023. The CAA was (and care plan decisions) were dated as complete on 07/07/2023. Record review of Resident #142's Care plan revealed that the following care areas which were triggered in the CAA were not addressed in the care plan until: Cognitive Loss - 7/27/23 Visual Function - 7/27/23 ADL Assistance - 09/09/2023 Urinary Incontinence - 09/09/2023 Falls - 06/06/23 Nutritional Status - 08/21/23 Pressure Ulcer Risk - 09/09/2023 Psychotropic Drug Use - 09/09/2023 Code Status - 07/27/2023 In an interview on 09/14/2023 at 10:22 AM, MDS Coordinator A and B said the care plan should have been completed within 7 days of the completion of the comprehensive assessment and within 21 days of admission. They stated they should looked at the CAT (care area triggers) when the MDS was completed and ensure those area were on the resident's care plan They stated it was an oversight that this care plan was not done in a timely manner. They stated this failure could place the resident at risk for staff not recognizing the resident's care needs. In an interview on 09/14/2023 at 1:30 PM, the DON said that it was the responsibility of the MDS Coordinator, social worker, and the nurses to ensure the resident's care needs were documented in the care plan in a timely manner when captured in the comprehensive assessment. Record review of the Facility policy titled Care Plans and CAAS dated 05/16/2016, revealed the following [in part]: The purpose of this guide is to ensure that an interdisciplinary care plan is used in addressing the CAT'S (care area triggers) generated by the MDS assessment in order to thoroughly address the care area assessments and ultimately achieve a comprehensive care plan for each resident

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3(Resident #45) residents reviewed for safe transfers. The facility failed to ensure Resident #45 was transferred with a gait belt. This failure could place residents dependent on staff for assistance with transfers at risk for falls and/or injury. Evidence includes: Record review of Resident 45's face sheet revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of history of unsteady gait, muscle wasting and weakness, psychosis (a mental disorder characterized by disconnection with reality) and lack of coordination. Record review of Resident 45's significant change MDS dated [DATE] revealed she required extensive assistance of 2 with transfer, bed mobility and hygiene. Record Review of the video taken on 09/09/23 by the electronic monitoring camera in resident #45's room revealed during the transfer or resident #45 completed by CNA's E and F (without a gait belt) the 2 aides hooked their arm underneath the resident's armpits with the resident facing in the direction of the bed that she was transferred to. The recliner she was transferred from was approximately 5 feet from the bed. The CNA's fell with the resident itno the bed during the transfer. The resident appeared frightened with the manner with which she was transferred. The resident was not injure. Interview with the DON on 9/14/2023 at 10:00 AM revealed she had viewed the video of the transfer (by CNA E and CNA F) with Resident 45's daughter and she agreed that the family member had a reason to be upset. She stated it was her expectation for the staff to use a gait belt with all transfers and transferring a resident using the technique displayed by CNA E and CNA F in the video was not acceptable and could result in injury to the resident and the aides. She stated it was the charge nurses responsibility to monitor the aides on their shift to see that they were doing safe transfers. She stated she was in-servicing the staff on proper transfer techniques and doing proficiency checks. She stated she had suspended the aides pending the investigation of the complaint by Resident #45's family member. She called the aides that did the improper transfer on the video into her office, and they had received training and a disciplinary action. Observation and interview on 09/13/2023 with CNA C and CNA D, CNA C stated Resident #45's care plan had been updated and she was now transferred with a Hoyer lift. She stated a Hoyer lift was always done with 2 people. The CNA's were observed transferring Resident #45 with the Hoyer lift and their technique was correct and safe. Interview on 09/13/2023 at 2:47 pm, Administrator stated it was expected for CNAs to use a gait belt at all times when transferring a resident. The Administrator stated failure to do so could result in a fall. Record review of policy Transfers of Residents, dated 05/2012, revealed in part: Use a gait belt around the resident to protect both the resident and you. Position the chair so that the 2 transfer surfaces are at a 45-degree angle.

Based on observation, interview and record review, the facility failed to ensure the accurate administration of medications for 1 of 4 residents observed for medication administration. (Resident #7) Treatment Nurse left a medication at Resident #7's bedside, unattended. This failure could place residents who received medications administered by the treatment nurse at risk of not receiving the intended therapeutic benefit of their medications and a possible medication error to another resident. Findings included: During an observation and interview on 09/12/2023 at 10:42 AM., Resident #7 was lying in her bed. There was a medication cup with cream next to her bed. She revealed that the medication cup was left there the prior day by the treatment nurse. She revealed that she was supposed to administer the fungal ointment herself but that she had not gotten around to it. SH revealed it was not a medication he could self-administer. The Electronic Treatment Record for Resident #7 dated 09/12/2023 revealed a physician's order for treatment on the left breast fold; by applying the antifungal cream Q-day and PRN for prevention every shift for excoriation/redness. The medication was last administered on 09/11/2023 from 6AM to 6PM. During an interview on 09/12/2023 at 11:00AM., LVN B revealed the following: She said that she had not given the treatments for Resident #7 yet that day. She said that she left the antifungal cream at her bedside yesterday and forgot about it. She revealed that she normally does not leave meds at bedside. She looked at the medication cup and said the antifungal treatment had not even been used. She stated this failure could result in the resident putting it on the wrong part or someone else getting it. Policy and Procedures titled Medications- Treatment dated 02/02/2014 revealed the following: 4.Adminsiter the medication according to the physician's orders. 5. Document initials and/or signature for medications and treatments administered on the MAR and TAR immediately following administration. 7. Circle initials for those medications or treatments that were not administered and document the reason for the non-administration on the MAR and TAR.

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program, designed to provide a safe, sanitary, and comfortable environment, and help prevent the development and transition of communicable disease and infection for 8 Staff for COVID-19 (CNA A, CNA B, CNA K, AD C, HR D, HA E, LVN J and Mark F). The facility failed to ensure staff (CNA A, CNA B, CNA K, AD C, HR D, HA E, LVN J and Mark F) to wear face mask, face shield, and perform hand hygiene per facility policy. The Facility failed to ensure Resident #8 stayed in her isolation (warm zone) room. Resident #8 was found playing bingo in the dining room not wearing any PPE and not social distancing from Resident #2. This failure placed residents at risk for contracting an infection/COVID-19. Findings include: According to the CDC: You were exposed if: you were in close contact with someone that was less than 6 feet away from someone with COVID 19 for a total of 15 minutes or more over a 24-hours period. https://www.cdc.gov/coronavirus/2019-ncov/downloads/your-health/qi-guidance-quarantine.pdf Accessed 1/20/2023. Record review of facility's COVID 19 positive logs from 1/2/2023 to 1/10/2023 indicated 26 positive residents and 8 positive staff. Review of Resident #8's face sheet revealed Resident #8 was a [AGE] year-old female, admitted to the facility 2/2/2022. Major diagnosis includes dementia, communication deficit, pulmonary disease, and muscle wasting. Review of Resident #8's Minimum Data Sheet, dated 1/3/2023, revealed BIMS of 5 which indicated severe cognitive impairment. During an observation on 1/9/23 at 1:45 PM, Resident #8 was not in her room. Resident #8 was on isolation due to covid exposure by roommate (Resident #6 who tested positive for covid on 1/9/2023). Resident #8 was found, by investigator, in dining room with 13 other residents, none of the residents were wearing a mask. Social distancing was not being performed between Resident #8 and Resident #2 who were both sitting at the same table playing bingo. During an interview on 1/12/23 at 9:45 AM, DON stated that Resident #2, who was exposed to COVID 19 by Resident #8 during bingo, was tested yesterday 1/11/2023 and resulted negative. She stated that Resident #8 should be remaining in her room (warm zone), with no roommate for a minimum of 7 days because Resident #8's roommate tested positive for COVID 19. She stated the facility did not set up a warm zone and hot zone. She stated the facility set up an entire hall as a hot zone but all residents that are individually isolated (warm zones) are to remain isolated in their rooms by themselves until, they either test positive and are moved to the hot zone or remain symptom free and test negative for 7 days. Record review of COVID 19 testing log, dated 1/11/2023 indicated that Resident #2 and Resident #8 both tested negatives. During an observation on 1/9/23 at 3:35 PM, HA E entered Resident #8's isolation room, (warm zone) to help resident up out of bed and onto side of bed. HA E exited Resident #8's room and went into Resident #5 (cold zone) to hand resident her TV remote off the floor. No hand hygiene was completed before or after exiting either room and no PPE was donned or doffed going into or out of isolation room. During an interview on 1/9/23 at 3:45 PM, HA E stated she did not think much of what she was doing, just going into Resident #8's room very quickly to help the resident and as she left, she saw Resident #5 in the next room trying to pick up his remote. She stated she just reacted to help and did not think about coming out of a quarantine room or hand sanitizing. She stated she knew she is to put on PPE for the resident's protection. Review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old male, admitted to the facility 7/25/2017. Major diagnosis includes major depressive disorder, edema (swelling caused by too much fluid trapped in the body's tissues), rash, and constipation. Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS of 15 which indicated no cognitive impairment. During an interview on 1/10/23 at 9:45 AM, Resident #1 stated he felt PPE is not being used properly. He stated there have been multiple times that he has seen employees/aides go in and out of resident's room without PPE on or coming out of a quarantine room (warm zone) with PPE on but did not doff PPE before going to another resident's room. He stated 3 days ago in the evening, he was out in the hallway and watched an employee come out of the hot zone over to the night pantry, get some ice/snacks for a resident and go back into the hot zone. He stated there is just a lot of observations he has made where PPE is not being worn properly. He stated he could not remember the exact names of any employees. Review of Resident #2's face sheet revealed Resident #2 was a [AGE] year-old female, admitted to the facility 1/16/2013, major diagnosis includes sepsis, pneumonia, chronic respiratory failure, muscle wasting and atrophy. Review of Resident #2's Quarterly MDS 10/5/2022 revealed BIMS of 15 which indicated no cognitive impairment. During an interview on 1/10/23 at 1:45 PM Resident #2 stated she is very concerned about the COVID 19 in the building. She stated she has not been vaccinated and needs to be protected. She stated it is very important that the facility does everything they can to protect her from being exposed. She stated she has seen some employees with their mask pulled down or go into quarantine (warm zone) rooms with no PPE on. She stated, I know they are trying very hard but some of them just don't use the PPE they should. Review of Resident #5's face sheet revealed Resident #5 was a [AGE] year-old female, admitted to the facility 6/18/2016, major diagnosis includes difficulty walking, osteoarthritis, weakness, and muscle wasting. Review of Resident #5's MDS 12/31/2022 revealed BIMS of 13 which indicated no cognitive impairment. During an observation on 1/9/23 at 1:15 pm, 4 employees (CNA A, AD C, HR D, and Mark F) were in the hot zone with only N95 mask on. Employees were not wearing gowns, face shields, or gloves. Each employee went back to their offices, not on the hot zone, no hand hygiene was done by any employee leaving the hot zone. During an interview on 1/10/23 at 2:45 PM, HR D stated the proper PPE to be worn in the hot zone was face shield, mask, gown, gloves. She stated she did not have any of the PPE because she was only in the hot zone to help hang signage on the residents' doors. She stated she should have put the proper PPE on while in the hot zone. During an interview on 1/10/23 at 3:05 PM, AD C stated the proper PPE to be worn in the hot zone was face shield, N95 mask, gown, gloves. She stated she did not have any of the PPE because she was only in the hot zone to help hang signage on the residents' doors. During an interview on 1/10/23 at 3:15 AM, Mark F stated the proper PPE to be worn in the hot zone was face shield, mask, gown, gloves. She stated she did not have any of the PPE because she was only in the hot zone to help hang signage on the residents' doors. During an observation on 1/9/23 at 10:15 PM, a group of 3 employees (CNA B, LVN J, and CNA K) were standing at nurses' desk not wearing mask or had them pull down below their chins. Employees were talking and hanging out. None of the employees were practicing social distancing. During an interview on 1/9/23 at 10:25 PM, CNA B stated he was the CNA for the hot zone. He stated that his shift is from 6:00 AM to 6:00 PM. He stated he is supposed to stay on the hot zone for his entire shift. He stated he only recently stepped out of the hot zone to help the other hallway. He stated he should not have left the hot zone. He stated on the hot zone, the PPE that is to be worn at all times is face shield, mask, gown and gloves. During an interview on 1/9/2023 at 10:45 PM, RN I stated that the PPE to be worn on the hot unit is N95 mask, gown, gloves, and face shield. She stated she always works the hot zone for the night shift. She stated that any employee that was to work the hot zone is to work the hot zone their entire shift and not to leave it. She stated CNA B does work the 6:00 PM to 6:00 AM shift and should always stay on the unit with her She stated that CNA B does go and talk with the other employees at times during the shift, outside of the hot zone. During an observation on 1/10/2023 at 2:15 PM, CNA A went into Resident #6's room to assist resident out of bed and then exited Resident #6 room. CNA A went directly from Resident #6 room into Resident #7's room and helped Resident #7 get call light off the floor and handed it to Resident #7. CNA A had no PPE on except N95 mask, no donning or doffing of PPE was done and no hand hygiene completed. Both Resident #6 and Resident #7 were located on the hot zone. Review of Resident #6's face sheet revealed Resident #6 was a [AGE] year-old female, admitted to the facility 4/27/2022, major diagnosis includes hypokalemia, hyperlipidemia, constipation, lack of coordination, COVID 19 and muscle wasting. Review of Resident #6's Annual MDS 11/14/2022 revealed BIMS of 14 which indicated no cognitive impairment. Review of Resident #7's face sheet revealed Resident #7 was a [AGE] year-old female, admitted to the facility 10/28/2022, major diagnosis includes dementia, weakness, repeated falls, COVID 19 and impulse disorder. Review of Resident #7's Quarterly MDS revealed no BIMS had been completed. During an interview on 1/10/23 at 9:45 AM CNA A stated she was told by DON that while she was in the hot zone, she only had to wear her N95 mask. She stated she was to don PPE on outside the room, help the resident and then doff PPE inside the room. She stated because she was on the hot zone, she did not realize she did not have PPE on and went into the Resident #7's room to help her. She stated she should have donned and doffed PPE before going into both resident's room. During an interview on 1/10/2023 at 2:45 PM, DON stated that the expected PPE to be worn on the hot zone was gown, gloves, goggles/shield, and N95 mask. She stated her expectation for the hot zone would be that all PPE must be always on and donned on and doffed off when entering and exiting a resident's room. She stated she did expect employees to put on goggles or a face shield when entering a resident's room, but she feels if an employee is in the hot zone with regular reading glasses on that is okay if they don't go into the resident's room without having a proper eye coverage. She stated that once an employee comes onto their shift for the day, they are to remain on the hot zone their entire shift and not leave the hot zone for any reason. She stated that all employees should have known what PPE to wear and that it should be on the entire time they are in the hot zone. She stated all staff should know this because she just did an in-service on PPE to be worn on which zone. She stated that the employees that are on that unit, should always stay on that unit and once they come into work they clock in and go to the hot zone unit, they are not to leave unless going home for the day. She stated her employees that were helping on the hot zone should have been in full PPE because it puts other residents at risk. During an interview on 1/10/23 at 11:45 PM, ADMIN H stated that her expectation of the hot zone was that once an employee comes into work, no matter what shift, they are to remain on the hot zone the entire shift and not leave for any reason. She stated her expectation of PPE to be worn while working on the hot zone is face shield, N95 mask, gown, and gloves. During an interview on 1/12/23 at 3:35 AM, DON stated that she felt that mass testing once a week and contact tracing, in between, was enough to slow down the spread of covid19 in the facility. She stated that she started mass testing and overnight on 1/2/23, she had 8 positive residents. She stated by doing the spot checking, 7 more residents tested positive from 1/3/23 to 1/5/23. She stated the next mass test was on 1/9/23 and 11 more residents were positive. Record review of in-service dated 1/9/23, titled COVID 19 Policy and Surveillance, presented by the DON G which covered: Hand hygiene, proper PPE to be worn in cold, warm, and hot zones. Checking residents and employees for any signs or symptoms of COVID 19. How to DON and DOFF PPE properly. All staff were included in the training. Record review of facility Coronavirus Testing policy, dated 10/24/22, section titled: Personal Protective Equipment: 1. Staff who enter the room of a patient with suspected or confirmed COVID 19 infection should adhere to standard precaution and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. (i.e., goggles o a face shield that covers the front and sides of the face).

Based on observation, interviews and record reviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 resident (Resident #1) reviewed for accidents and supervision in that: The facility failed to ensure CNA A requested assistance from another CNA prior to repositioning Resident #1 when performing incontinence care. Resident #1 required extensive assist of 2 staff. This resulted in Resident #1 falling out of bed and sustaining a fracture to the right femur. This failure resulted in actual harm to Resident #1 on 8/27/2022. It was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. The findings included: Record review of Resident #1's face sheet, dated 9/03/2022, revealed a [AGE] year-old-female who was originally admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] (body mass index of 40 or above), Major Depressive Disorder, recurrent, and [CONDITION(S)] (mental disorder which people interpret reality abnormally). Continued review of the face sheet revealed Resident #1 was readmitted to the facility on [DATE] from the hospital and Resident #1's diagnoses included Displaced Comminuted Facture (broken in at least two places) of Shaft of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Urinary Tract Infection, Acute Posthemorrhagic [CONDITION(S)] (loss of red blood cells quickly), Type II Diabetes, Hypertension (high blood pressure), Chronic Pulmonary Disease (lung disease), and Interstitial Pulmonary Disease (scarring of the lung tissue). Record review of Resident #1's quarterly MDS, dated [DATE], revealed resident #1 required total assistance for bed mobility, bathing, dressing, personal hygiene, and toileting. The record review revealed Resident #1 had a BIMS score of 13, which indicated intact cognitive response. Record review of Resident #1's care plan revealed Resident #1 had an ADL Self-Care Performance Deficit and was at risk for not having her needs met with date initiated 2/18/2020 and revised on 8/10/2022. Information on the care plan revealed, Performance deficit was related to: Dependence on staff for completion of most ADLs, poor activity tolerance related to [CONDITION(S)] and obesity, muscle wasting, impaired strength, impaired balance/coordination, and increased weakness due to multiple recent hospitalization s. Interventions include in part, Bed Mobility: Extensive Assist of 2, and Transfers: total assist x2 and Hoyer Lift. Another focus area included toileting which indicated Resident #1 was not to be taken to the toilet, incontinent care per staff was documented as - Extensive assist x2. Record review revealed Resident #1 did not walk and required extensive assist x2 for dressing. Record review of Resident #1's progress note, dated 8/27/2022 at 5:05 a.m., written by LVN A, read in part, Resident #1 fell on to the floor when being changed by CNA A. Rolled on left side and stated, I kept rolling. LVN A entered the room and noted Resident #1 was lying on her stomach, on the floor. Assessment done, Resident #1 voiced complaint of right knee pain and two lacerations to the right shoulder and right mid-arm. LVN A was unable to obtain blood pressure. Resident #1 was rolled onto her back with the assistance of three staff, pillow placed under her head while waiting on ambulance to arrive. Physician, DON, and family contacted. Record review of Resident #1's progress notes, dated 8/27/2022 at 10:50 a.m., read in part, LVN B contacted the admitting hospital and received confirmation Resident #1 had a broken femur and would require surgery. LVN B contacted Resident #1's family. Record review of Resident #1's medical records from the admitting hospital dated 8/27/2022 documented Resident #1 had an Acute Comminuted facture involving the distal femoral metadiaphyseal (neck portion) region due to a fall. Surgery would be completed on 8/28/2022. Resident #1 received the surgery to repair the fracture on 8/28/2022 with no complications. During an interview and observation on 10/18/2022 at 3:15 p.m., Resident #1 said she had fallen out of bed on 8/28/2022 when CNA A tried to turn her over to change her brief and she broke her femur in her right leg and hurt right shoulder and arm. Resident #1 said CNA A tried to put her on her side to pull the brief out from under her by himself and Resident #1 said she asked CNA A to get another aide to help and CNA A said no that he could do it by himself. Resident #1 said CNA A put her too close to the edge of the bed and Resident #1 said she rolled off the bed. Resident #1 said she fell on the floor and hit her right shoulder on the bed side table. Resident #1 was observed wearing a hospital gown and her right shoulder had a large blue contusion (bruise) with multiple scabs. Resident #1's right wrist and hand were propped on a pillow and noted to be swollen and purple in color. Resident #1 said her leg where her femur was broken hurt worse than her arm. Resident #1 said she was a two-person assist with all her grooming activities and Resident #1 said she told CNA A to get another aide to help him when CNA A was changing her brief. Resident #1 said CNA A told her he could do it by himself. During an interview on 10/18/2022 at 3:58 p.m., the Administrator said she was familiar with the incident with Resident #1 that had occurred on 8/27/2022. The Administrator said CNA A admitted he attempted to perform care on Resident #1 who required two-person assistance by himself even though CNA A said he knew he needed another aide to assist. During an interview on 10/18/2022 at 6:08 p.m., LVN A said she had been employed at the facility for approximately five months. LVN A said she was the nurse on duty when Resident #1 fell out of bed. LVN A said she was at her medication cart in front of the nurses' station when she heard a cry for help and entered Resident #1's room and saw CNA A on the floor and Resident #1 on her stomach with her right arm bent behind her back. LVN A said CNA A told her he was by himself, and that Resident #1 had told CNA A to go ahead and change her brief because Resident #1 was impatient. LVN A said she knelt down and looked at Resident #1's face to see if she was conscious due to the position Resident #1 had landed, which was on her back but leaning toward her right side. LVN A said Resident #1 was moved with the assistance of approximately five staff because her arm was twisted behind her back. LVN A said 911 was called and Resident #1 was lifted onto the emergency stretcher by use of the Hoyer lift once paramedics arrived. During an interview on 10/18/2022 at 6:20 p.m., CNA B said he had worked at the facility nearly four years. CNA B said he was familiar with Resident #1 and was on duty the night Resident #1 rolled and fell off the bed. CNA B said CNA A was in Resident #1's room alone when he entered the room after CNA B heard CNA A yell for help. CNA B said he saw Resident #1 on the floor, laying on her stomach. CNA B said he called for the nurse and once enough staff were present, they turned her over and repositioned her off her arm. CNA B said Resident #1's right arm was bent behind her back. CNA B said the staff used the Hoyer lift to pick up Resident #1 and put her on the stretcher once paramedics arrived. CNA B confirmed CNA A was in the room by himself and stated he had attempted to change the brief for Resident #1. During an interview on 10/18/2022 at 4:30 p.m., the DON said she was familiar with the incident with Resident #1. The DON said she knew CNA A had admitted he was in the room with Resident #1 by himself and admitted he had attempted to change Resident #1's brief by himself even though CNA A stated he knew Resident #1 required two staff during all care tasks. The DON said her expectation was for all staff to follow the interventions documented in the Care Plan and to utilize the information on the Care Tools. The DON said staff were in-serviced on the use of the Care Tools after the incident with Resident #1 as part of interventions put in place to ensure Resident #1's safety. Record review of the Fall Management System Policy, dated 06/2011, revealed all facility staff would be orientated to the specific needs of the individual resident through assessment and developed with appropriate goals and interventions utilizing the Fall Management Plan of Care Form. Evaluation included assessment of the resident's need/appropriateness of toileting. Record review of Abuse Policy, dated 9/13/2017, revealed the purpose of the Abuse/Neglect policy was to provide and ensure has the right to be free from abuse, neglect, misappropriation of property, and restraint. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. Record review of the In-person Interview with CNA A, dated 08/27/2022, obtained and documented by the DON and signed by CNA A as his statement of the incident revealed CNA A said he was turning Resident #1 and had changed her before and turned her with no problems. CNA A said this time he changed her alone, and Resident #1 started rolling and CNA A tried to catch her . CNA A reported he had access to the information that showed him how to provide care to all the residents he cared for. CNA A said he did not seek assistance from another staff when aiding with incontinence care during the incident with Resident #1. CNA A said he had completed by himself before with no problems and if he thought something would happen, CNA A said he would have asked for help. CNA A said he knew Resident #1 required 2-person assistance when providing care services. Multiple interview attempts were made to contact CNA A by phone on 10/18/2022 at 3:45 p.m. and 5:05 p.m. Voicemail messages were left requesting a return call including name and number, but no return contact was received prior to exit on 10/18/2022. The surveyor determined the facility was in non-compliance from 8/27/2022 - 8/31/2022. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: Record review of the Associate Disciplinary Form, signed by CNA and DON, dated 8/27/2022, revealed the facility suspended CNA A immediately upon initiating the investigation of the incident. During an interview on 10/18/2022 at 3:58 p.m., the Administrator said CNA A was terminated from employment on 8/31/2022. Record review of in-services dated 8/27/2022, 8/29/2022, and 8/31/2022, revealed CNAs and nursing staff attended the following in-services that covered the following topics: Abuse/Neglect policy was reviewed, the responsibilities of the charge nurse were reviewed, the post-fall evaluation of a resident and the post fall evaluation form was reviewed, documentation on how to document a fall and the post-fall evaluation was completed, and who to notify included the physician and family. Record review of in-services dated 8/27/2022, 8/29/2022, and 8/31/2022, revealed staff were trained on policy of customer service to include treating each resident with respect and person-centered. Record review of in-services dated 8/27/2022, 8/29/2022, and 8/31/2022, revealed the following policies were included in the trainings: Fall Management System, Post-Fall Education Form, Pain Management, Resident Rights, and Standard Code of Conduct. Record review of in-services dated 8/27/2022, 8/29/2022, and 8/31/2022, revealed staff were trained on resident care tools, which were defined as a written document that listed each residents' daily care needs to be completed by the assigned CNA on each shift. The document was a in check-off form and located in a binder located at each nurses' station. The resident care tool was used as a guide to enable CNAs to know the care and services that each resident may need. During an interview on 8/27/2022 at 4:43 p.m., CNA C said she attended the in-services conducted and the topics covered the abuse/neglect policy. CNA C said if she attempted to provide care to a resident by herself and knew the person required at least 2 staff for assistance, she would consider her actions to be neglect. CNA C stated her definition of abuse was to knowingly inflict pain or neglect. CNA C said the in-services covered the care tools, falls, post-falls, and the need to have two staff present if a resident required a two-person assist. During the interview, CNA C was observed going to the nurses' station and obtaining the binder that contained the care tools. During an interview on 8/27/2022 at 5:44 p.m., CNA D said she attended the in-services that covered falls, fall prevention, staff code of conduct, abuse/neglect, and resident rights. CNA D said she was trained on the use of the care tools and said she knew that if a resident's care plan and care tool stated two-staff assist, then CNA D would ensure two staff were present prior to attempting any care task. During an interview on 8/27/2022 at 5:53 p.m., LVN C said she had been at the facility for a year and had attended the in-services that were triggered by Resident #1's fall and fracture. LVN C the in-services covered abuse/neglect, the care tools, falls, post-falls, and rights. LVN C was able to identify the information covered for the charge nurse. During an interview on 8/27/2022 at 6:02 p.m., LVN A said the in-services after the incident with Resident #1 covered the need to have two staff present when providing care and assistance if the resident required 2-person assist. LVN A said the in-services covered falls, the need to wait on the nurse to assess prior to moving a resident after a fall, the CNA care tools, residents' rights, and abuse/neglect policy. During an interview on 8/27/2022 at 6:20 p.m., CNA B said she attended the in-services after the incident with Resident #1 and they covered the need for two-person assist and the information would be in the care tools located in the in the CNA book. CNA B said the tool would contain the resident's level of assistance, whether he/she was incontinent or not, if he/she used a Hoyer lift, or if he/she was at risk of falling. CNA B said the in-services covered falls, fall prevention, and abuse/neglect. During an interview on 10/18/2022 at 6:49 p.m., Resident #1 said two staff had assisted her with all her grooming and care needs since she had returned from the hospital on 9/03/2022.

Based on observation, interview and record review, the facility failed to ensure a resident who needs resporatory care is provided care consistent with standards of practice and the care plan for two of two residents (Resident #118 and #65) reviewed for respiratory care, in that: Resident #118's nebulizer and T piece (plastic portion of the nebulizer kit shaped like a T used for delivering inhaled medications) was laying on top of Resident #1's dresser exposed (without being secured in a bag to prevent contamination) with medication in the medication delivery nebulizer. Resident #65's nebulizer and mask were laying on top of Resident #65's dresser without being secured or in a bag to prevent contamination with medication in the medication delivery nebulizer. This failure could place residents who use small volume nebulizer at risk for exposure to communicable diseases and infections. The findings include: Review of Resident #118's undated Face Sheet revealed he was a [AGE] year-old male admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #118's admission MDS assessment, dated 06/28/22 revealed he had a BIMS score of 15 out of 15, indicating he was cognitively intact and able to make his needs known. Review of Resident #118's care plan, dated 6/28/22 revealed: -Stoma to Throat - Resident has a surgical wound and is at risk for infection, pain, and decrease in fictional abilities. -Goal: Resident 's wound will be free from the signs and symptoms of infection . -The care plan did not include the process of changing nebulizer cups or sanitary storage. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 07/19/22 at 2:53 PM, Resident #118 was resting in bed awake and alert and visiting with his sister. A dirty towel was noted on top of his dresser with medication nebulizer and tail piece extending from the nebulizer cup was uncovered with a slight amount of medication remaining in the medication cup, loose oxygen tubing laying inside of the drawer and attached to the power unit that pumps air to the nebulizer creating a mist of medication. During an interview on 07/19/22 at 3:15 PM, with an unidentified nurse identifying herself as the charge nurse for floor Resident #118 resided in, confirmed the nebulizer was not covered and not dated and should have been dated and, in a bag, to protect the device from being contaminated. Review of Resident #65's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65 did not have a s care plan. This surveyor requested but was not provided prior to exit. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 07/19/22 at 3:15 PM, Resident #1 was resting in bed awake and alert. A nebulizer cup attached to a mask was noted on top of her dresser with medication nebulizer and mask was uncovered with a slight amount of medication remaining in the medication cup, loose oxygen tubing attached to the power unit that pumps air to the nebulizer creating a mist of medication During an interview on 07/19/22 at 3:15 PM, CNA A confirmed that the nebulizer was not covered and not dated and should have been dated and in a bag, to protect the device from being contaminated. Review of facility's policy and procedure title, Respiratory: Nebulizer Mist Therapy dated 4/16/2014 revealed the following [in part]: .20. Store nebulizer, t-piece, and mouthpiece in separate, labeled plastic bag (change all disposable parts once a week and label with date and initials). Review of website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 84 on 07/22/22 revealed the following: Problem: Although many improvements in patient safety have been made in the nation's health care system, medication errors and health care-associated infections (HAIs) still top the list of problems .

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen observed for pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of roaches in the kitchen. The facility's failure placed the residents at risk for foodborne illness and/or disease spread by pests. The findings include: During an observation and interview on 7/22/22 at 10:17 AM, live roaches were observed in the dishwashing machine area and in the food preparation/cooking areas on the floor and wall behind the storage and cooking equipment. Further observation showed utensils and trash were found under equipment and in corners. The Dietary Manager said she was aware of the problem and had been working with the Pest Control Vendor. Review of the dietary department cleaning records, provided by the Dietary Manager on 7/22/22, revealed staff had not been cleaning behind and under the kitchen equipment. The Daily Cleaning Schedule was last initialed and dated on 7/03/22 by the 1 PM to 8:30 PM shift staff. Review of the facility's contract with the pest control company, undated, revealed the contracted pest control company would provide bi-monthly service. Review of the facility's pest control service manual, used to organize the service invoices, revealed there was nothing mentioned or documented regarding any problems in the kitchen. Review of the contracted pest control service invoices revealed the following: - 7/12/22 - Treatment for General Pest, Scorpions and Mice/Rat bait stations. Treatment area- Common Areas, Entry Ways, Hallways. The Technician Comments did not mention pests/roaches in the kitchen. - 6/27/22 - General pest. Treatment area- Common Areas, Entry Ways, Hallways. The Technician comments documented met with DM (Director of Maintenance), he had no issues, spoke with kitchen staff, had no issues. - 6/13/22 - Treatment for General Pests, target areas - Bathrooms, Breakroom, Common Areas, Entry Ways, Hallways. Technician comments: DM had no issues, Kitchen no issues. In a telephone interview on 7/22/22 at 11:13 AM, the pest control service personnel stated she was unaware of any problems in the facility's kitchen and the service technician's records showed he had not been treating areas in the kitchen. In an interview on 7/22/22 at 2:01 PM, the Maintenance Director stated the pest control service technician told him what was done and/or found during the service visit. He stated he was unaware of any problems in the dietary department until today. Review of the facility's Pest Control Policy, undated, revealed the following [in part]: .this facility will maintain an on-going Pest Control program to ensure that the building is kept free of insects and rodents .

Based on observation, interview, and record review, the facility failed to ensure on a daily basis to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care for each shift was posted in a prominent place accessible to residents and visitors for 1 of 1 facility observed for staffing postings. The facility did not include the total numbers of actual hours worked for RNs, LVNs, and CNAs on the daily staffing post. This failure could place residents and/or visitors at risk of not having access to information regarding staffing data and facility census. The findings included: Observation and record review on 7/19/2022 at 11:30 AM, revealed the daily nursing staffing hours form was posted by the employee time clock on a short side-hallway located in the front part of the building. Titled Facility Staffing Disclosure dated 7/19/2022, revealed the facility failed to document the actual hours worked for the day and night shifts, including RNs, LVNs, and CNAs. The form documented the staff numbers for two shifts, Day (6 AM - 6 PM) and Night (6 PM - 6 AM). But failed to include the number of actual staff hours worked each shift. Observation and record review on 7/20/2022 at 10:30 AM, revealed the daily nursing staffing hours form was posted by the employee time clock on a short side-hallway located in the front part of the building. Titled Facility Staffing Disclosure dated 7/20/2022, revealed the facility failed to document the actual hours worked for the day and night shifts, including RNs, LVNs, and CNAs. The form documented the staff numbers for two shifts, Day (6 AM - 6 PM) and Night (6 PM - 6 AM). But failed to include the number of actual staff hours worked each shift. Observation and record review on 7/21/2022 at 11:30 AM, revealed the daily nursing staffing hours form was posted by the employee time clock on a short side-hallway located in the front part of the building. Titled Facility Staffing Disclosure dated 7/21/2022, revealed the facility failed to document the actual hours worked for the day and night shifts, including RNs, LVNs, and CNAs. The form documented the staff numbers for two shifts, Day (6 AM - 6 PM) and Night (6 PM - 6 AM). But failed to include the number of actual staff hours worked each shift. Observation and record review on 7/22/2022 at 11:00 AM, revealed the daily nursing staffing hours form was posted by the employee time clock on a short side-hallway located in the front part of the building. Titled Facility Staffing Disclosure dated 7/22/2022, revealed the facility failed to document the actual hours worked for the day and night shifts, including RNs, LVNs, and CNAs. The form documented the staff numbers for two shifts, Day (6 AM - 6 PM) and Night (6 PM - 6 AM). But failed to include the number of actual staff hours worked each shift. In an interview on 7/22/2022 at 1:00 PM, the Administrator stated, the DON is responsible for ensuring the daily staffing was posted. She further stated, failure to post the actual hours worked would prevent residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily. In an interview on 7/22/2022 at 1:30 PM, the DON stated she was responsible for posting the daily staffing sheets but was not sure what the facility policy and procedure was for daily nursing staff posting. She stated she just knew they were supposed to post it daily. She further stated, the actual hours worked are documented on the daily staffing form the following day for the prior day and filed in the office. However, the DON did reveal, she could see that not posting the actual staff hours worked would prevent the residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily. Review of the facility's policy for Nurse Staffing Posting Information, dated 1/16/2020, revealed the following [in part]: Policy It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: I. Registered Nurses II. Licensed Practical Nurses/Licensed Vocational Nurses III. Certified Nurse Aides 2. The facility will post the nurse staffing data at the beginning of each shift. 3. The information posted will be: a. Presented in a clear and readable format. b. In a prominent place readily accessible to residents and visitors. 4. A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current. a. The information shall reflect staff absences on that shift due to call-outs and illness. After the start of each shift, actual hours will be updated to reflect such 5. Nursing schedules and posting information will be maintained in the Human Resources Department for review for at least 18 months or according to state law, whichever is greater

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases for 1 (Resident #3) of 2 residents reviewed for infection control practices. CNA C and CNA D failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #3. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #3's face sheet, dated 01/18/21, revealed the resident was an 80- year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's Minimum data set (MDS) assessment, dated 12/22/21, revealed Resident #3 required extensive assistance with most activity of daily living (ADLs) including med mobility, dressing, toileting, eating and personal hygiene and two-person assist. Resident #3 was always incontinent of bowel and bladder. Review of Resident #3's care plan, dated 08/30/20, revealed the resident was care planned for being incontinent of bladder and bowel related to impaired mobility and cerebral infarction. Observation of incontinence care for Resident #3 on 01/18/22 at 2:38 p.m. revealed CNA C and CNA D did not wash their hands or perform hand hygiene before the start of care. Both CNAs donned gloves after retrieving the gloves from their pockets. CNA C removed the resident's soiled brief. She wiped from front to back. Resident #3's brief was soiled with urine and fecal matter. CNA C briefly moved the clean brief to a different position on the bed with soiled gloves. CNA C's gloves were visibly soiled with urine. She did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #3's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #3. She wiped Resident #3 after he was repositioned. CNA D wore the same gloves for repositioning the resident including touching the perineal area and fastened the clean brief to the resident. They both changed their gloves. Additionally, 2 pillows from Resident #3's bed fell on the floor and CNA D picked it up and put back on the resident's bed without changing the pillowcases. There were brown looking stains on the resident's bed which was not changed. CNA C and CNA D did not wash hands before exiting Resident #3's room with the trash bags. In an interview on 01/18/22 at 2:48 p.m. with CNA C she stated she had been employed at the facility about 1 month and did not receive infection control training. CNAC said she did not receive infection control during initial orientation. CNA C stated cross contamination meant mixing clean with dirty. CNA C acknowledged she should have washed her hands and changed gloves before commencing care and retrieving the resident's clean brief. She stated Resident #3 could get an infection for not using good infection control practice. Interview with CNA D on 01/21/22 at 2:54 p.m., she said she had been employed at the facility for 1 year and received infection training about 3 months ago. She stated cross contamination was transferring germs from one place to another. CNA D acknowledged she should have changed her gloves and washed her hands before fastening Resident #3 clean brief. She also said she should have changed the pillowcases that fell on the floor. During an interview with the Regional Nurse Consultant (RNC) on 01/18/2022 at 4:07 p.m., she said she was aware of some of the concerns raised about infection control. She said the staff were expected to wash hands before providing care and changed gloves at appropriately times. She explained they should properly differentiate between clean and dirty parts while providing care Review of Facility Hand hygiene policy revised 11/12/2017 reflected, Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: I. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply a palmful of product to palm of one hand and rub hands together. b. Cover all surfaces with the product until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water because repeated exposure to hot water may increase the risk of [CONDITION(S)]. b. Apply enough soap to cover all hand surfaces. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use towel to turn off the faucet. 6. Additional considerations: a. The use of antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves. c. Bar soap used for hand washing must be kept in a strainer allowing the soap to drain. d. Liquid soap reservoirs must be discarded when empty. If refillable, dispensers must be emptied and cleaned, rinsed and dried according to manufacturer instructions. e. Antiseptic solution may be applied to hands after proper hand washing. f. If sinks are not readily available, a waterless antiseptic may be used between tasks normally requiring hand washing unless hands are visibly soiled. Hands should be washed with soap and water as soon as possible.

Based on observations, interviews and record review, the facility failed to provide to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for 5 of 5 residents (Residents #103, 118, 116, 42, and #128) reviewed for respiratory care in that: Resident #103 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence of cleaning or maintenance on Resident # 103's treatment administration records. Residents# 118, 116, 42, and 128 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk for improper [CONDITION(S)] use, settings or respiratory infections due to the potential for microorganisms infiltrating their [CONDITION(S)], equipment and supplies causing a decline in physical health The findings include: Record review of Resident# 103 face sheet revealed that she is a [AGE] year-old female, admitted on [DATE] diagnosed with asthma. Resident #103's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident chart showed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #103's May 2021 MAR/TAR revealed there were no orders for [CONDITION(S)] settings, maintenance, or resident monitoring. Resident #103's Vital sign record review revealed that her pulse oximetry had been measured and recorded twice since her admission to the facility. 1/15/21 at 2:20PM with a reading of 97% on room air, and 1/17/21 at 8:34AM with a reading of 97% on room air. Observation and interview on 5/11/21 at 11:05 AM revealed a MediLogix C-PAP at Resident #103's bedside, resident stated that she has used one for years. She brought this one from home when she was admitted in January. Tubing and mask were noted to be laying on top of the machine uncovered and undated. In an interview with Resident #103 on 05/13/21 at 01:06 AM she stated, I don't use oxygen, but I do use a C-PAP at night. Resident stated that she does not recall ever seeing anyone cleaning her [CONDITION(S)] or replacing her tubing or mask since she got here in January. According to the National Institute of Health.Gov website, accessed on 05/05/21, under the reference for Association of [CONDITION(S)] Bacterial Colonization, condensation could promote the growth of bacteria that could invade the respiratory system. In an interview with DON on 5/14/21 at 12:42 PM, she stated that her expectations regarding C-PAP or [CONDITION(S)] would be at least weekly care and maintenance. She stated this should be documented in the resident's care plan and should have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview with resident #103's physician on 5/14/21 at 12:55 PM, he stated that, he was unaware of the resident having a [CONDITION(S)], but he would expect to be notified or made aware of a resident needing/using a [CONDITION(S)] or [CONDITION(S)] on admission. He stated he writes orders on admission or initiation of [CONDITION(S)]/[CONDITION(S)] for settings, care and maintenance of the [CONDITION(S)]/[CONDITION(S)]. He stated he knows that the cleaning is typically ordered weekly but couldn't recall at that moment what length of time they order replacement of accessories. In interview with LVN A and B on 5/14/21 at 2:35 PM LVN A stated that the night nurse is responsible for cleaning [CONDITION(S)]/[CONDITION(S)] and changes out tubing and filters and other respiratory equipment. They wear the [CONDITION(S)]/[CONDITION(S)] at night and they are usually off when day shift gets here. She verified by looking in chart and TAR/MAR that orders and tasks were not there for resident #103's [CONDITION(S)]. Additionally, LVN B reviewed the electronic chart and paper chart and when interviewed stated, There are no orders for her [CONDITION(S)] anywhere in here. Observation and interview in Resident #118's room on 5/12/21 at 11:58 AM oxygen tubing and humidification noted to be undated, and Nebulizer tubing connected to the nebulizer machine was dated 5/2/21. Resident stated she has new oxygen tubing and points to tubing laying on overbed table. Resident stated, They needed a different connection. They are supposed to put the new one on later today. 5/12/21 at 1:58 PM oxygen noted to be running at 3L via nasal cannula humidification in place, tubing now dated 5/9/21. Nebulizer accessories are gone from bedside and machine only remains. 05/15/21 at 03:31 PM Nebulizer accessories and masked are now noted at bedside, are undated. She stated, the last time I used that was 2-3 days ago. Review of #118's MAR, revealed the resident's oxygen tubing and nebulizer were documented as changed on 5/9/21. Resident #118 had orders dated 5/3/21 02 tubing bagged and stored when not in use every shift every day and night shift; Change 02 humidifier bottle weekly on Sunday when in use on night shift; Change 02 tubing every week when in use; on night shift every Sun, clean 02 filter every week on Sunday when in use on night shift. Review of Resident # 128's orders dated 1/31/21 revealed the following: 02 tubing bagged and stored when not in use every shift every day and night shift; Change 02 humidifier bottle weekly on Sunday when in use on night shift; Change 02 tubing every week when in use; on night shift every Sun, clean 02 filter every week on Sunday when in use on night shift. Review of Resident # 42's orders dated 3/15/21 revealed the following: 02 tubing bagged and stored when not in use every shift every day and night shift; Change 02 humidifier bottle weekly on Sunday when in use on night shift; Change 02 tubing every week when in use; on night shift every Sun, clean 02 filter every week on Sunday when in use on night shift. Review of Resident # 116's orders dated 11/23/18 revealed the following: 02 tubing bagged and stored when not in use every shift every day and night shift; Change 02 humidifier bottle weekly on Sunday when in use on night shift; Change 02 tubing every week when in use; on night shift every Sun, clean 02 filter every week on Sunday when in use on night shift. Observation in Resident #116's room on 5/11/21at 2:45PM revealed oxygen tubing dated 5/9, oxygen humidification and nebulizer accessories dated 5/2/21. Oxygen was noted to be in use at 3 liters via oxygen concentrator and tubing and humidification were in use. Nebulizer accessories were noted to be in a bag, labeled with the resident's name. Review of Resident #116's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in Resident # 42's room on 5/11/21 at 1:05PM revealed oxygen tubing and nasal cannula noted to be laying in the resident's floor. Tubing was note undated or labeled, and it was not covered. The O2 concentrator was noted to be running at 3 liters even though not in use and tubing was not covered or bagged. Review of Resident #42's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/11/21 at 1:05pm Resident #42 interview stated that she uses it every night, when she naps, and as needed Observation in Resident #128's room on 5/12/21 at 3:29PM revealed oxygen tubing and humidification was dated 4/26/21. Oxygen concentrator noted to be in the corner and unplugged. Resident stated he uses it as needed and rarely. Resident did not appear to be short of breath. Tubing was not covered and was laying on top of concentrator. Observation on 5/13/21 at 2:00PM in resident #128's room revealed the tubing was noted to still be uncovered and the tubing and humidification were still dated 4/26/21. Regional nurse consultant provided policy titled: [CONDITION(S)]-[CONDITION(S)] Guidelines, dated 9/13/2014 with a last review date of 2/12/2020. This document read [in part]: Procedure: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Pressure settings for [CONDITION(S)] or [CONDITION(S)] Type of mask Frequency of treatment Oxygen and/or humidification if applicable Equipment: Pressure generator machine O2 tubing Oxygen source Pulse oximetry Stethoscope/BP cuff Suction equipment Personal protective equipment as indicated Wash cloth, water, mild soap. Procedure: Initial set up should be done by respiratory therapist or respiratory company representative Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Obtain vital signs (BP, pulse, respirations) Wash hands and apply personal protective equipment as indicated Explain the procedure to the patient Wash the patient's face (to remove facial oils and achieve a better fit) Elevate the head of bed at least 30 degrees Check the mask, nasal pillow or facial mask for breaks or cracks Connect the patient to continuous pulse oximetry Turn on pressure generator Confirm settings Apply facial mask or nasal pillow to proper fit to prevent leaks Assess patient according to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Notify the physician as ordered or for the pulse ox reading less than 90 and/or respiratory distress Document patient evaluation/assessment and response to procedure.

Based on interview and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review PASARR Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 2 of 5 residents ( Resident #81 and # 127) reviewed for a mental illness, intellectual disability or developmental disability. Resident #81 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 127 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed residents at risk of mental health needs not being met. The findings included: Resident ID # 81 A Record review of Resident ID # 81's face sheet dated 5/16/21 revealed his initial admitted was 7/1/19. A record review of a PASARR Level I (PL1) Screening, dated 05/28/20, indicated Resident # 81 had no indication of mental illness. No PASARR Level II (PE) Screening or Form-1012 ( Mental Illness / Dementia Resident Review) was found in the clinical record. A record review of Resident #81's most recent annual MDS assessment, dated 04/03/2021, under section I5900, showed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section N (Medications) indicated the resident had been receiving antipsychotic, antianxiety, and antidepressant medications. Section N (Medications) of the same MDS indicated the resident had been under N0450 - Antipsychotic Medication Review: A Part 1. Yes - antipsychotics were received on a routine basis only. This assessment was dated 04/03/2021. A record review of the last Care Plan revised and dated 01/07/21, with a Problem Start Date of 06/09/20, indicated under the problem category [CONDITION(S)] Drug Use: Resident uses [CONDITION(S)] medications (antipsychotics, anxiolytics, antidepressant) related to anxiety and [CONDITION(S)]. A record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 25 mg 1 po q AM and [MEDICATION(S)] 50 mg 1 po q PM (75 mg total) for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident ID # 127 Resident ID # 127's face sheet revealed she was initially admitted to the facility on [DATE]. A record review on 5/13/21 of a PASARR Level I (PL1) Screening, dated 03/06/13, indicated Resident ID# 127 had no indication of mental illness. No PASARR Level II (PE) Screening or Form-1012 was found in the clinical record on this date. A record review of the last Care Plan revised and dated 03/11/21, with a Problem Start Date of 06/12/13, indicated under the problem category [CONDITION(S)] Drug Use: Resident uses antidepressant medication related to depression. A record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ½ po q am for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident ID# 127's most recent annual MDS assessment, dated 05/04/2021, under section I 5800 indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section N (Medications) indicated the resident had been receiving antianxiety, and antidepressant medications. During an interview, on 05/13/2021 at 10:30 AM, in regard to Resident ID'S #'s 81 and 127, the Social Worker stated she was responsible for entering PL1's and PE's and for completing the form 1012 and for entering them into the long-term care portal. She stated she did not complete a new PL1, PE or form 1012 on resident ID #'s 81 and 127. The only PL1 completed was one done on 3/6/13 (for resident ID# 127). She stated she was not sure why another PL1 was not completed after the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed that she was the only Social Worker in the facility and was responsible for monitoring for resident status changes related to MI/ID and completing a Form 1012 (Mental Illness/Dementia Resident Review) or PL1 form if there was a change in their status. She acknowledged that there should be a positive PL1, and Form 1012 should have been completed with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was familiar with this requirement. She stated the forms had been missed because she had not compted an audit. In an interview on 5/14/2021 at 10:35 AM, the DON stated she had only been employed in the facility for two weeks. She stated she was not sure who was responsible for monitoring residents for changes in resident status related to ID/MI and completing a Form 1012. She stated she would find out. In an interview on 5/16/2021 at 1:30 PM, the Regional Vice President stated the Social Worker was responsible for entering information PL1's, PE's and completing Form 1012's ( Mental Illness / Dementia Resident Review) She verified that a Form 1012 should have been completed on Resident ID #'s 81 and #127 and they should have been evaluated for PASSAR services if necessary. She stated the social worker was responsible for performing audits checking each resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated most facilities do theses audits quarterly. Facility policies and procedures for PASSR provided by the Regional Vice President, titled Preadmission Screening Resident Review (PASARR) Rules stated in part: It is the intent to meet and abide by all State and Federal Regulations that pertain to resident Preadmission and Screening Review (PASARR) rules. The Social worker or designee enters the Positive PL1 into the Simple LTC Portal. The Social worker monitors the Simple LTC portal for the PE. The social worker / designee prints the PE and files it on the chart. In the event the facility identifies a change in the resident status related to ID/MI, the facility will submit a Form 1012 to have the LA/LMHA conduct a PE.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, by failing to ensure: A. soap and paper towels were available at the handwashing sink; B. floors were swept and free from grease and food crumbs; C. counters were clean; D. appliance surfaces were clean; E. dish machine, refrigerator, and freezer temperature logs were documented; F. cleaning schedules were utilized per facility dietary policies and procedures. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: In an interview on 3/26/21 at 12:55 PM, the Dietary Services Manager stated she had started employment in the facility on 3/08/21. She stated the Assistant Dietary Manager was no longer employed in the facility, and she was not sure how long it had been since the last Dietary Manager had left. The Dietary Manager stated she had 12 total dietary employees, and 2 new hires that had not yet started working. She stated the staff had been using disposable containers/dishes only when short staffed in the kitchen. She stated they had used paper for breakfast this morning, because staff started calling in. She stated she was able to reach people to work and used regular dishes for lunch. Observations on 3/26/21 at 1:00 PM of the dietary department revealed the following: - the handwashing sink in dirty dish room had no soap in the dispenser and no paper towels in the dispenser; - floors were soiled with grease, food crumbs, and dried spilled liquids; - stainless steel counters were soiled with food crumbs, dust, and dried spilled liquids; - the top exterior surface of the ice machine was soiled with dust; - the exterior surfaces of the stainless-steel refrigerator units were soiled with food and dried liquid splatters. In an interview on 3/26/21 at 1:05 PM, the Dietary Manager stated the staff did not use the handwashing sink in the dirty dish room. She stated the staff used the other handwashing sink in the food preparation area. During and observation and interview on 3/26/2 at 1:05 PM, Dietary Aide A was operating the low temperature dish machine with chemical sanitizer. She proceeded to measure the chlorine sanitizer content at 50 ppm. She stated she usually washed the dishes for the breakfast and lunch meals. Review of the Dishwashing Machine Form, dated March 2021, revealed Dietary Aide A had not documented the water wash and rinse temperatures and sanitizer level on the daily dishwashing machine form for the breakfast and lunch meals. The DSM wrote 50 for the sanitizer content for the breakfast meals on 3/25/21 and 3/26/21. No breakfast wash/rinse temperatures and sanitizer had been documented 3/16//21-3/26/21. The lunch meal had no temps or sanitizer levels documented 3/11/21-3/26/21. The Dinner/Supper meal had no temperatures or sanitizer documented 3/04/21-3/25/21. Review of the refrigerator and freezer unit temperature checklists, dated March 2021, revealed the unit temperatures were not consistently documented two times daily during March 2021. During an observation and interview on 3/26/21 at 1:40 PM revealed the floor tiles under and around the fryer unit were sticky and there was cooking oil on the floor tiles. There were fried food crumbs on the floor along the base of the wall behind the fryer unit. The DSM observed the grease and food on floor behind the fryer unit and stated, it wasn't from today. In an interview and record review on 3/26/21 at 1:45 PM, the DSM stated she had not found any cleaning schedules or checklist to initial as tasks were completed. She stated she had found printed cleaning assignments for 8 specific staff, which were in plastic sheet protectors. She reviewed the names and assigned responsibilities and stated 5 of 8 dietary staff were no longer employed in the facility, 1 was on medical leave, and 2 continued to be employed. The DSM stated she did not know who the dietary employees were, and stated they were gone prior to her start date on 3/08/21. She stated she would look for cleaning schedule forms and a policy/procedure for cleaning. She stated she had been teaching the staff how to cook and would conduct staff inservice training regarding cleaning schedules. During an observation and interview on 3/26/21 at 1:50 PM, Cook B was sweeping the floor in the food preparation area. She stated she had been employed in the dietary department for 6 years, but only recently started to cook. She stated the dietary staff had cleaning schedule checklists, and they were taken down in September 2020 when the Assistant Dietary Manager took over. She stated the staff just clean as we go, and no cleaning schedules or assignments were being used. In an interview on 3/26/21 at 2:00 PM, Dietary Aide C and Dietary Aide D stated they both were dish washers and worked during the evening shift/meal. They stated the dietary department had been short staffed and they were the only 2 staff at night. The dietary aides stated they had to cook and do the dishes. They stated that was why they had used disposable dishes/containers to serve meals at night, because they couldn't do it all. The dietary staff members stated they started using disposable dishes and containers for everyone during mid-November 2020 when COVID hit and the residents and staff had it. In an interview on 3/26/21 at 4:45 PM, the Administrator stated the Dietary Manager told him the surveyor had identified cleaning concerns in the kitchen. The Administrator stated the QA Committee had identified concerns regarding the dietary department and developed an action plan on 3/12/21. He stated the dietary staff had done cleaning in the kitchen since the QAPI action plan was developed 3/12/21. Review of the facility's QAPI Action Plan, dated 3/12/21, revealed the identified concern of dietary department sanitation noncompliance. The plan documented interventions included to implement a cleaning schedule. Review of the facility's policy and procedure for Equipment Cleaning Procedures, dated as revised 1/2013 and reviewed 2/2015, documented the following [in part]: Policy: It is the policy of this facility that all dietary equipment and the environment are cleaned and sanitized in a manner that meets local (if applicable), state, and federal regulations. Fundamental Information: Routine cleaning will be practiced on a regular basis in order to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations. Cleaning is the practice of removing soil and dirt with and approved cleaning agent . Sanitizing is the practice of using effective heat or chemical treatment to destroy or reduce microorganisms . Cleaning Frequency: Daily: Equipment and items that are used in food preparation should be cleaned and sanitized after each use. Kitchen and storeroom floors should be swept and mopped daily . Procedure: 1. As part of dietary orientation, dietary staff will receive thorough training on the use and maintenance of dietary equipment. The Dietary Services Manager (DSM) will maintain staff training records. 2. The Dietary Services Manager or designee will instruct each employee on how to clean equipment. The DSM will schedule routine cleaning of all dietary equipment and the environment . 5. Daily cleaning assignments will be given to Dietary staff . 6. Regardless of assigned task, each employee is responsible for cleaning up after themselves . Review of the Food Service Department Sanitation Checklist, printed and provided by the DSM on 3/26/21, revealed it included personal standards, storerooms, refrigerators, freezers, pot-washing area, dishwashing area, general sanitation, maintenance, and safety awareness. Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, by failing to ensure: A. soap, hot water, paper towels, and covered trash receptacles were available at hand washing sinks; B. ice machine scoops were stored to prevent contamination; C. all the appliance interior and exterior surfaces were free from grease, and grime; D. floors were clean; E. kitchen staff were not chewing gum; F. kitchen staff were wearing hair and beard restraints; G. chlorine sanitizer level for the low temperature dishwashing machine was being checked and recorded. This failure could affect the residents by placing them at risk for foodborne illness. The findings included: Observation on [DATE] at 09:25 AM, during the initial tour of the facility's kitchen, revealed the following: - no soap, hot water, paper towels, or a trash can, at 2 of the 3 hand washing sinks, and no hot water, or soap at the second hand washing sink; - There was an uncovered ice scoop sitting beside the Hoshizaki ice machine; - The tops of all the appliances, including the beverage machines, and coffee maker were covered in a light coating of grease and grime; - There was dirt and food crumbs behind the appliances, preparation tables, and under the sinks; - There was dirt and food crumbs behind and under the dry food storage shelves; - a kitchen staff was not wearing a hair restraint. In an interview on [DATE] at 09:30 AM, the Dietary Manager stated that the soap dispensers were broken, and she immediately went and retrieved new soap dispensers. In an interview on [DATE] at 02:55 PM, the Dietary Manager stated the kitchen staff, who was not wearing a hair restraint, had a hard time keeping it on her head and she was instructed to pin the hair restraint in place. Observation on [DATE] at 11:36 AM, revealed the following: - no hot water at 2 of the 3 hand washing sinks; - a kitchen cook was chewing gum; - the maintenance man was not wearing hair or beard restraints; - the chlorine level for the low temperature dishwasher was not being recording. In an interview on [DATE] at 11:30 AM, the Dietary Manager stated she did not think hand washing sinks required hot water. In an interview on [DATE] at 04:15 PM, the Dietary Manager stated that all the kitchen staff were responsible for cleaning all areas of the kitchen. She stated that all kitchen staff should wear hair and beard restraints at all times, but she had a difficult time getting the maintenance man to wear one. She stated she did not know why there was not a log for the low temperature dishwasher chlorine level and it had been like that for a long time. She stated we check the chlorine 3 times a day. She stated she would have the Dietician create a new log that included the low temperature dishwasher chlorine level and the dishwasher temperature. She stated the new log would be completed before 5 PM that day. She stated she would perform an in-service for the dishwasher, wearing hair restraints, and cleaning. In a record review on [DATE] at 04:18 PM, the kitchen daily cleaning log indicated that all floors and surfaces were cleaned last night. In a record review on [DATE] at 04:21 PM, the dishwasher log book contained a log with days of the month, the temperature for 3 times a day, initials of the staff. No space was provided to record the chlorine level 3 times a day and the chlorine level was not being recorded. The temperature of the dishwasher was being recorded 3 times a day. In a record review on [DATE] at 04:21 PM, the policy titled Ware Washing documented the following Procedures: #3 For low temperature machines the chemical sanitizer strength will be tested and recorded as well.