Every finding on record at Harmony Health Center

Based on observation, interview and review, the facility failed to store dry foods in accordance with professional standards for food service safety, ensure cold food/dessert was at correct temperature for consumption and failed to ensure facility staff were wearing hair restraints in the kitchen. This has the potential to affect thirty-one (31) residents on thickened liquids, and 91 residents on regular diets out of one hundred and ninety-six (196) residents residing in the facility at the time of the survey. The findings include. On 8/4/25 at 8:22 AM during the initial kitchen observational tour with the Dietary Manager, two 46-ounce Ready Care Thickened Orange Juice Cartons were found to be expired, dated 03/2025 in the dry storage room.Interview on 8/4/25 at 8:30 AM the Dietary Manager revealed, two kitchen staff complete rotation of the items/foods in the dry storage room; every Monday; and stated: I will dispose of these items (two 46-ounce carton of thickened Orange Juice) in the garbage because of the items being outside of their expiration date. On 08/04/25 starting at 11:10 AM during the Tray Line Observation with Dietary Manager. Three Mixed Fruit Cocktail Desserts was sampled for temperature; the recorded temperatures for the three samples was 46 degrees Fahrenheit (F). The Dietary Manager placed the mixed fruit dessert tray in the walk-in refrigerator and stated he will not use the tray of desserts until the temperature is rechecked, and the Fruit Cocktail desserts temperature are lower than 40F and in the future, he will place dry storage Fruit Cocktail cans in the refrigerator a day prior to serving to ensure the temperature is below 40F at serving time.During an additional kitchen observation on 08/05/2025 at 8:25 AM, two Maintenance/construction staff were observed in the kitchen with no hairnets on and conversing with the Dietary Manager,Interview on 08/05/2025 at 8:38 AM, the Dietary Manager revealed hair nets at every entrance door to the kitchen and acknowledged the identified concerns related to the maintenance/construction staff not wearing hairnets in the kitchen.Review of the facility policy and procedure titled Food Storage Policy and Procedure dated March 2022 states: Foods shall be received and stored in a manner that complies with safe food handling.

Based on observations, records reviewed and interviews, the facility failed to provide appropriate treatment to prevent worsening Urinary Tract Infections for one (Resident #2) out of two sampled residents, who had an indwelling urinary catheter; as evidenced by during hygiene care Resident #2's indwelling urinary catheter drainage collection bag and tubing were positioned on the bed below the level of the bladder with backflowing urine noted in the tubing. This deficient practice potentially increases the risk for worsening urinary tract infection and other severe complications. There were four residents with Urinary Tract Infections residing in the facility at the time of the survey. The findings included:Observation on 7/21/125 at 1:28 PM revealed Staff C, a Certified Nursing Assistant (CNA) performing hygiene care for Resident #2, Staff C, CNA positioned the urinary drainage collection bag and tubing between the resident's feet on the bed (photographic evidence) below the level of the bladder. The surveyor observed back flowing urine in the tubing and asked Staff C, CNA if it was okay to leave the bag and tubing on the bed. Staff C, CNA replied, yes, because I emptied it. Staff C, CNA continued with hygiene care leaving the bag and tubing above the level of the bladder. The surveyor exited the room and informed the Director of Nursing (DON) of the identified concern.Record review of a demographic sheet revealed Resident #2 was admitted on [DATE] with diagnosis that included: Bacteriuria (presence of bacteria in urine and can be asymptomatic but If Bacteriuria is accompanied by symptoms it is classified as a Urinary Tract Infection). Record review of Resident #2's physician's order sheet revealed an order dated 6/27/25 indicating: Keep dignity bag covered and attached to urine collection bag below the level of the bladder at all times and order dated 7/14/25 for Medications ordered included: Sulfamethoxazole-Trimethoprim 800-160 Milligrams (a combination of antibiotics used to treat infections including urinary tract infections) give one tablet by mouth every 12 hours for Bacteriuria for 10 Days. During an interview on 7/21/25 at 5:50 PM, the DON revealed the bag should remain below the level of the bladder to prevent urine reflux which can cause a UTI and Resident #2 had a current diagnosis for UTI. Record review of the facility's policy for indwelling catheter care date implemented: 3/2020 Policy: It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections.

Based on observations, interviews and records review, the facility failed to implement infection prevention and control practices in accordance with the facility's policy related to Enhanced Barrier Precautions (EBP) for one (Resident # 2) out of two sampled residents, as evidenced by staff failure to wear required Personal Protective Equipment (PPE) during indwelling catheter care. The findings included: Observation on 7/21/125 at 1:28 PM of Staff C, Certified Nursing Assistant performing hygiene care for Resident #2 who is under Enhanced Barrier Precautions (EBP)due to an indwelling urinary catheter. Staff C, Certified Nursing Assistant…performed hand hygiene donned gloves but did not put on a gown which is a required PPE for EBP and completed Resident #2’s hygiene care. The surveyor exited the room and informed the Director of Nursing (DON) of the identified concern. Record review of a demographic sheet revealed Resident #2 was admitted on [DATE] with diagnosis that included: Bacteriuria (presence of bacteria in urine). Record review of Resident #2’s physician’s order sheet revealed an order dated 6/27/25 for Enhanced Barrier precautions for every shift. Record review of a Medicare 5-day Minimum Data Set (status completed) revealed Resident#2 has no cognitive impairment, required substantial/maximal assistance for toileting hygiene care and had an indwelling catheter. During an interview on 7/21/25 at 3:17 PM, Staff C, Certified Nursing Assistant stated: “I did not put on the gown because I was nervous…I know which residents I need to wear a gown for by the sign on the wall that says Enhanced Barrier Precaution…” On 7/21/25 at 5:50 PM, the DON revealed staff are to wear a gown and gloves when providing hygiene caring for residents on Enhanced Barrier Precaution. Record review of the facility’s Policy titled, Infection Control Policy and Procedure: Enhanced Barrier precautions issued 8/16/2022 revised: 4/1/2024 revealed :Policy: Policy: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Procedures included: Enhanced Barrier Precautions (EBP) consists of the use of gowns and gloves for high-contact care activities which include but may not be limited to: Providing hygiene, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care: any skin opening requiring a dressing.

Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS) Assessment for discharge for one (Resident #196) out of four residents reviewed for resident assessment. There were 192 residents residing at the facility at the time of the survey. The findings included: Record review of Resident #196's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] Section for Identification Information in subsection A 2105 for Discharge Status documented that the resident was discharged to a Short-Term General Hospital. Review of the Physician's Orders Sheet for March 2024 revealed Resident #196 had orders that included but not limited to: Resident transferred to home on 01/13/24. Review of the nurses' progress notes for Resident #196 on 01/13/24 timestamped 09:00 documented: Resident was discharged home. Resident accompanied by family member. Resident is in stable condition and vital signs are within normal limits. Belongings were packed and given to the resident. Medications and discharge information provided to resident. Further review of the medical records for Resident #196 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction, unspecified. Resident #196 was discharged on [DATE]. Record review of Resident #196 's Care Plans dated 01/02/24 revealed the resident's Short-term Discharge Plan: The plan for resident is to be discharged back to the community with family support. Interventions Included: Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan as needed. Provide services according to care plans and in accordance with resident known preferences in an effort to enhance optimum well-being. Interview on 03/28/24 at 10:04 AM with Registered Nurse, Minimum Data Set Coordinator, (Staff A). When the surveyor had Staff A check the nurses' progress notes documented on 01/13/24 that noted the resident was discharged to home with family, and check the Discharge Return Not Anticipated MDS with reference dated 01/13/24, Section A-2105 that documented that the resident was discharged to short term general hospital. Staff A acknowledged the discrepancy, Staff A stated, In this situation we would check the progress note and get the discharge information from the census, to update the resident's MDS, I will make a correction to the MDS immediately. Review of the facility's policy and procedures titled policy and Procedures: MDS Assessments Completion and Accuracy dated 9/2020 states: It is the policy of the facility to adhere to the following procedures related to proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessments of residents will be completed in the format and in accordance with timeframes stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. Procedure 5: The assessment will accurately reflect the resident's status.

Based on observation, record review and interview facility failed to provide the necessary oxygen therapy according to physician's order for one resident (Resident # 453) out of nine residents sampled as evidenced by Resident # 453 receiving oxygen therapy at incorrect rate. The findings included: On 03/25/24 at 7:31 AM Resident #453 was observed in bed with oxygen in progress via nasal cannula at three Liters Per Minute (LPM). (photo evidence) On 03/27/24 at 7:28 AM Resident #453 was observed in bed with oxygen in progress via nasal cannula at a level between 2.5 and three LPM. (photo evidence) Record review of demographic sheet for Resident #453 revealed an admitted [DATE] and diagnosis that included sleep apnea and shortness of breath. Record review of Resident #453's Minimum Data Set (MDS) dated [DATE] Section C for cognitive status revealed a Brief Mental Status (BIMS) score of 6 on a scale of 0-15 indicating severe cognitive impairment. Section GG for functional status revealed substantial/maximal assistance for transfer, partial/moderate assistance for oral hygiene and supervision touching assistance for eating. Section J for pain revealed no shortness of breath when lying flat. Section O for special treatments revealed oxygen and respiratory therapy. Record review of Care Plan initiated on 03/14/2024 and revised on 03/25/2024 revealed Resident #453 is at risk for ineffective breathing pattern related to Sleep Apnea and Shortness of breath (SOB). Interventions included: Oxygen at two LPM via nasal cannula with humidifier at bedtime for SOB. Administer medication/oxygen as ordered. Adjust head of bed and body positioning to assist ease of breathing. Keep head of bed (HOB) elevated to facilitate easy respirations. Monitor resident's anxiety and give support/assistance as needed. Record review of physician orders dated 3/21/2024 revealed orders for oxygen at two liters per minute via nasal cannula with humidifier every night at bedtime for shortness of breath. On 03/27/24 at 8:43 AM Staff B, Registered Nurse (RN) stated: I have been employed for [AGE] years at this facility. When I start my shift, I complete a visual assessment of each resident and make sure oxygen is in progress and at the correct level. [ Resident #453] has an order for oxygen two liters per minute via nasal cannula at bedtime. I remove the nasal cannula when [Resident # 453] wakes up. This morning when I rounded [Resident # 453], oxygen was in progress at two liters per minute, and only nursing staff is allowed to touch the concentrator. The Certified Nursing Assistant (CNA) is allowed to remove the nasal cannula as soon as resident awakens but does not touch the concentrator. I test [Resident # 453] oxygen level with a pulse oximeter daily and saturation was 96 % at 7:05 AM on 3/27/2024 which is normal for this resident. When Staff B was asked why the oxygen level was incorrect, Staff B stated: Maybe I didn't properly visualize the oxygen level because I didn't turn on the light in the room to prevent disturbing the resident. On 03/28/24 at 10:05 AM Staff C, RN stated: The protocol for oxygen administration is to take oxygen saturation before or when arrival on shift, follow physician order, have oxygen at bedside, and make sure nasal cannula is clean. A visual assessment is done before administering oxygen and throughout shift to ensure oxygen level is matching the physician order. Also, we educate family about the amount of liters required, not to touch the concentrator and if they have any question to go to the nurse. CNAs are aware not to readjust the oxygen level and to report to the nurse any concerns. The nurses and CNAs have received in-services about oxygen administration. 03/28/24 10:13 AM Staff D, CNA stated: I have been employed at this facility for [AGE] years. I am the regular CNA taking care of [Resident #453]. I am aware of any resident on my assignment who require oxygen therapy because the nurses verbalize this me. I do not adjust the oxygen settings and if I see any abnormality I report it to the nurse. I am aware that [Resident #453] uses oxygen during the night. In the morning, I notify the nurse to remove the nasal cannula and if she is busy, I remove the nasal cannula. On 03/28/24 at 11:59 AM, the Director of Nursing (DON) stated: When administering oxygen therapy, the nurse is to follow physician orders; only the nurses are allowed to adjust the level of the oxygen. The CNAs are only allowed to place and remove cannulas. The only responsibility of the CNA is to notify the nurse if they see a problem. Moving forward I will do frequent rounding to monitor the oxygen level of residents who have orders for oxygen and educate the staff about oxygen administration. Record review of the facility's Policy and Procedure for Respiratory Care and Oxygen administration Issued: 3/2020. Revised 10/2022. Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guidelines: Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's order for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube care, BiPAP, CPAP or medication administration.

Based on record review and interview, the facility failed to maintain an accurate record for one (Resident #95) out of seven residents reviewed for hospitalization . There was a total of 192 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's policy titled, Documentation in Medical Record Policy and Procedure (implemented April 2020, revised October 2023) documented: Policy Statement: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation; Policy Explanation and Compliance Guidelines: 1) Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy and 4) Principles of documentation include, but are not limited to b) Documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care and/or responses to care. Review of the Demographic Face Sheet for Resident #95 documented the resident was initially admitted on [DATE] with diagnosis that include but not limited to end stage renal disease, dependence on renal dialysis, diabetes mellitus, hypertension, and absence of right leg below knee. The resident was discharged to the hospital on 3/18/24 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #95 dated 2/25/24 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required total dependence for ADLs (Activities of Daily Living). The resident received dialysis services. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for January 2024, February 2024 and March 2024 documented the resident was receiving medications for diabetes mellitus, depression, and peripheral vascular disease. Review of the Progress Notes for Resident #95 documented: Dated 3/18/24 08:50-Health Status Note: Patient alert and disorient, change mental status, Vital signs were taken; MD (medical doctor) notified, new order carried out; Dated 3/18/24 09:32-[Resident #95 ] Transfer Form Note: Resident transferred to [ local hospital] for other outside dialysis center and Dated 3/18/24 09:55-Health Status Note: Patient transfer to [local hospital] via [local emergency services] as per MD order with diagnosis: Hypoxemia and change mental status. Review of Resident #95's Transfer Form, dated 3/18/24 documented: Sent to [local hospital] on 3/18/24 for outside dialysis catheter. Interview and record review with the Director of Nursing (DON) on 3/28/24 at 1:24 PM. The (DON) stated: On 3/18/24 at 08:50-Health Status Note: Patient alert and disorient, changed mental status, Vital signs were taken; MD notified, new order carried out. On 3/18/24 09:32- [ Resident #95] Transfer Form Note: Resident transferred to [local hospital] for other outside dialysis center. This is an error of the documentation. It should have read the change in mental status and Hypoxemia. The patient was transferred to [local hospital] via [local emergency services] as per MD order with diagnosis of Hypoxemia and change mental status.

Based on observation, interview and record review, the facility failed to ensure food safety by thawing frozen turkeys in an unsafe manner. There were 185 residents admitted to the facility at the time of the survey. The findings included: During the initial kitchen tour on 12/5/22 at 8:36AM with Staff B, the Dietary Manager. Four (4) large packs of frozen turkey were observed in the kitchen thawing in a sink at room temperature. This was observed in the pre wash area for pots. Staff B, acknowledged the turkey wasn't being thawed in the proper manner. After this observation, food service staff placed the turkey in pans and placed them in walk in refrigerator #2. The turkey was on the 12/5/22 dinner menu. Review of the facility's undated policy and procedure for Food: Preparation. The policy statement documents, All foods are prepared in accordance with the FDA (Food and Drug Administration) Food Code. Procedures: 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological and chemical contamination. 5. The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination; Thawing the item in a microwave oven, then transferring immediately to conventional cooking equipment; Completely submerging the item under cold water (at a temperature of 70 F (Fahrenheit) or below) that is running fast enough to agitate and float off loose ice particles; Cooking directly from the frozen state, when directed.

Based on record review and interview, the facility failed to demonstrate effective an plans of correction were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 812 Food Procurement, Store/Prepare/Serve-Sanitary as the facility failed to properly follow meat thawing procedures. This practice has the potential to increase the risk of negative resident outcomes and to affect all 185 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with an exit date of 02/12/2021, Food Procurement, Store/Prepare/Serve Sanitary was cited related to the facility failed to store food at appropriate temperatures at or below 41 degrees Fahrenheit (F) in a walk-in cooler, failed to wash and sanitize dishes under sanitary conditions by operating a dish machine which did not reach the manufacturer recommended wash and rinse temperatures, failed to prepare and store food and clean dishes free from potential contamination, and failed to maintain equipment in two of three nourishment rooms under safe conditions to prevent potential contamination of food. During an interview on 12/08/2022 at 6:05 PM, the Administrator and the Director of Nursing (DON) revealed, the Quality Assessment and Assurance Committee (QAA) meets every fourth Thursday of every month. The administrator stated that the QAA Committee is comprised of the following members: Medical Director, Administrator, Risk Manager, Director of Nursing, and all other head of departments. Administrator noted that in September 2022, they developed a Performance Improvement Plan (PIP) for restorative nursing and in November 2022 they developed a PIP for PASRR. Both the Administrator and DON stated that when there is a deviation from expected performance, they open a Performance Improvement Plan (PIP) and conduct audit process. Administrator stated, we have a meeting with the team, and everybody is made aware of the issue, we also do in-service of what is going on. She stated that if the staff had any quality concerns they could report to the Risk Manager, the Administrator, and the Director of Nursing. The Director of Nursing and Administrator stated that when they recognize a deficiency, they work on the deficiency that is larger. The Administrator stated that they know that corrective actions they have been implemented are occurring effectively primarily through auditing and the involvement of staff depends on the department, and the medical director is always made aware of auditing and any decision-making process. The Administrator continued and added we track to see where the deficiency is occurring and move up or down within the department of the facilities. Moreover, the Administrator and the Director of Nursing stated, we had no concerns with the kitchen or any other department, and if there is a deficiency we are going to do a Plan of Correction, audit, and in-services competency.

Based on observations, records reviewed and interviews, the facility failed to ensure narcotics/controlled substances were reconciled for 1 out of 5 medication carts (Unit 4 cart # 1) observed in the facility. There were 185 residents residing in the facility at the time of this survey. The findings included: On 12/06/2022 at 9:52 AM during the narcotic count and review of medication for cart 1 on unit 4 located on the second floor of the facility with Registered Nurse (RN) (Staff A) revealed, the narcotic count was inaccurate for Resident # 12's Alprazolam tablet 0.25 MG (milligram) and Resident # 82's, Lorazepam tablet 0.5 MG. Review of Resident #12's narcotic count sheet revealed, Alprazolam tablet 0.25 MG (1) tablet was last signed out as given at 7:48 AM on 12/05/2022 and the remaining tablets noted as 19, the medication bingo card had 18 tablets. On 12/06/2022 at 9:54 AM review of Resident #12's Electronic Medication Administration Record (EMAR) with Staff A revealed, Alprazolam tablet 0.25 MG (1) tablet was not signed off as given. Resident #82's narcotic count sheet revealed, Lorazepam tablet 0.5 MG (1) tablet was last signed out as given at 12/5/22 at 5:00 PM, the remaining tablets documented was noted as 27 but the medication bingo card had 26 tablets remaining On 12/06/2022 at 9:55 AM Staff A was observed signing Residents #12's EMAR and narcotic sheet for Alprazolam tablet 0.25 MG (1) tablet as given. Review of the medical records for Resident #12 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Anxiety Disorder Unspecified. Review of the Physician's Orders Sheet for December 2022 revealed Resident #12 had orders that included but not limited to: Alprazolam tablet 0.25 MG. Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 Days. Record review of Resident #12 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C -for Cognitive patterns documented Brief Interview for Mental Status Score (BIMS) 11, on a 0-15 scale indicating the resident is cognitively moderately impaired. Review of the medical records for Resident #82 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Anxiety Disorder Unspecified. Review of the Physician's Orders Sheet for December 2022 revealed Resident #82 had orders that included but not limited to: Lorazepam tablet 0.5 MG. Give 1 tablet by mouth two times a day related to Anxiety Disorder Unspecified. Record review of Resident # 82's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C -for Cognitive patterns documented Brief Interview for Mental Status Score (BIMS) 3, on a 0-15 scale indicating the resident is cognitively impaired. Interview on 12/06/22 at 9:52 AM with Registered Nurse Staff A, when asked about narcotic medications not being signed out, Staff A stated, she gave the resident the Alprazolam 0.25 mg but she forgot to signed it out in the narcotic book and on the EMAR. Staff A stated normally I usually signed out the narcotic right away when I take it out of the bingo card, but the resident was very agitated and I was trying to get her the medicine as soon as possible. During an interview on 12/06/22 at 2:42 PM with the Director of Nursing (DON), and Assistant Director of Nursing (ADON), it was revealed that they did a one-to-one in-service with the nurse, and all nursing staff, starting with the morning shift. Review of the undated facility's policy and procedure titled, Controlled substance Handling, states: All controlled drugs will be subject to special receipt, handling, storage, disposal, and record keeping. Procedure #9-Upon removal of a controlled substance from the packaging for administration, shall document the doses removed on the narcotic descending count sheet record. Procedure #10-Immediately after a dose is administered, the license nurse will document administration in the electronic MAR, or if MAR is on paper, will document all of the following information on the paper medication administration record: Date and time of administration, dose administered, signature of nurse administering the dose. (Do not sign before actually administering the drug).

Based on observations, interviews, and record reviews the facility failed to ensure a clean and sanitary environment as evidenced by face masks and gloves were not appropriately discarded. As evidenced by observation of face mask noted on the ground of the facility's parking lot. The facility deficiency has the potential to affect one-hundred seventy residents residing in the facility at the time of the survey. The findings included: Review of the Physical Environment Policy and Procedures dated 3/2020 revealed that The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. On 02/09/21 observation between 8:00 AM and 08:30 AM, revealed a pair of gloves on the ground of the parking lot near the main entrance to the facility. There was one blue surgical mask lying on the ground facing the main street and 2 blue face masks were observed on the ground in the parking lot at the side visitors parking lot area of the facility and the same items (face mask and gloves) were observed in the same location at 5:00 PM. On 02/10/21 at 8:45 AM, observation revealed two blue surgical masks next to each other lying on the ground of the facility's parking lot that faced the main street. On 02/11/21 at 8:20 AM, observation, revealed eleven face masks on the ground in the parking lot and one pair of gloves (Photograph evidence). On 02/11/21 at 9:18 AM, during an interview with Director of Nursing (DON), Infection Preventionist, Administrator and Vice President of Clinical Services (VPCS) it was revealed that the staff were previously in-serviced not to drop face masks in the parking lot and that they are required to dispose the face masks in the garbage. In addition, they stated that the staff should not leave the facility using gloves, and the gloves and face masks found in the parking lot were not from staff. The Administrator stated that they had staff picking up the face masks and gloves in the parking lot twice a day. The VPCS stated that they would in-service family members, drivers and others non-staff personnel that were coming to the facility. The Vice President of Operations stated that the housekeeping were worried about cleaning the building inside due to annual inspection and they were not paying attention in the cleaning of the parking lot.

Based on record review, observation and interview the facility failed to provide [MEDICAL CONDITION] care in accordance with professional standards for one of one resident (Resident #85) sampled for respiratory care and failed to ensure [MEDICAL CONDITION] care kit and supplies were not expired for two of two residents (Resident #85 and #63) who had a [MEDICAL CONDITION] in place at the time of the review. The facility had a total of two residents with [MEDICAL CONDITION] (an artificial opening into the trachea) at the time of the survey. The findings included: Review of the facility's policy titled [MEDICAL CONDITION] Care revision date [DATE] documented .observe (standard) universal precautions or other infection control standards .gather equipment, maintaining sterility and cleanliness .thoroughly clean all equipment used and return to appropriate storage area .suction [MEDICAL CONDITION] using sterile technique .pour .solution in basin .put on gloves . Review of the facility's policy titled Standard Precautions issued on ,[DATE]; no revision date documented during the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces .perform hand hygiene before applying and after removing personal protective equipment (PPE) (e.g. gloves, gown, facemask) .perform had hygiene after removing gloves . Review of the facility's document provided by the facility's Director of Nursing (DON) titled Disinfecting Resident Shared Items no revision or issued date documented goal: to prevent the transmission of potentially infectious organism from transmission from resident to resident via shared equipment .semi-critical items examples include glucometer's .non-critical items examples include but are not limited to .stethoscope oxygen saturation machine Review of Resident #85's clinical record documented an admission to the facility on [DATE] with no readmissions. Residents [DIAGNOSES REDACTED]. Review of Resident #85's physicians order sheet (POS) for February 2021, [MEDICAL CONDITION] every shift and as needed. Suction [MEDICAL CONDITION] needed every shift.[MEDICAL CONDITION] inner cannula change daily and as needed. Review of Resident #85 Annual Minimum Data Set (MDS) assessment dated [DATE] and a quarterly MDS assessment dated [DATE] documented a brief interview of mental status (BIMS) score of 0 out of 15, indicating the resident has severe cognition impairment and is total dependent on staff for care. On [DATE] at 10:56 AM, observation of Resident #85 [MEDICAL CONDITION] care performed by Staff I was conducted. Staff I was observed wearing one surgical mask, goggles and hair cover. Staff I proceeded to enter the resident's room, performed hand hygiene, pulled the privacy curtains closed, which are considered contaminated (dirty), Staff I did not perform hand hygiene and donned gloves. Observation revealed on the covered over bed table had one container of sterile water, one bottle of normal saline solution (NSS) one [MEDICAL CONDITION] mask, one suction kit with a #12 French catheter, a package of gauzes, one red bag, one package of sterile gloves and a disposable Shiley #8 cannula. Staff I retrieved a disposable [MEDICAL CONDITION] care kit from a three drawers white plastic storage box located in the resident's room. Staff I removed her gloves, performed hand hygiene, opened the suction kit, removed and donned the pair of sterile gloves from the kit. Staff I stated that the suction was a sterile procedure and that her gloved right hand was her sterile hand. Staff I then with her left gloved thumb pushed down the sterile water container's foil wrapper and created a small opening. Staff I retrieved the sterile suction catheter and inserted the catheter through the small opening in the sterile water container while touching the outside foil wrapper of the container. Staff I then proceeded to suction Resident #85 using her right hand, which was her sterile hand, then with her sterile gloved hand, Staff I, repositioned the [MEDICAL CONDITION]'s old mask which was considered contaminated/dirty. Staff I turned to the clean field and inserted the suction catheter into the sterile water container and again, observation revealed the suction catheter was touching the foil wrapper. Staff I then removed the resident's [MEDICAL CONDITION] mask with her left gloved hand. Observation revealed an empty opened red biohazard bag on top of the clean field. Staff I discarded the used suction catheter and her gloves into the red biohazard bag. Observation revealed an open package of gauze next to the biohazard bag. Staff I performed hand hygiene and stated that she uses an aseptic technique to perform [MEDICAL CONDITION] care/cleaning. Staff I donned non-sterile gloves, opened the [MEDICAL CONDITION] care kit, opened a bottle of NSS and poured it over a basin retrieved from the kit. Staff I then placed a oxygen saturation machine over the resident right thumb and removed the [MEDICAL CONDITION] drain gauze. Staff I retrieved a clean gauze from the gauze package, soaked the gauze with NSS and proceeded to clean the upper and lower area of the [MEDICAL CONDITION]. Staff I then removed the cannula inserted into the [MEDICAL CONDITION], cleaned the area with NSS, with gloved hands, opened a box of drain sponges in a box located on top of the three drawers storage box, outside of the clean field and placed a clean drain sponge around the residents [MEDICAL CONDITION]. Observation revealed Staff I continued wearing the same pair of gloves and removed the old [MEDICAL CONDITION] mask and placed a clean mask. Staff I removed the resident's oxygen saturation machine, wrapped it with a clean gauze and placed over the three-drawer storage box. A side by side review of the [MEDICAL CONDITION] care supplies expiration dates was conducted with Staff I. The review revealed Staff I used NSS and a [MEDICAL CONDITION] care kit with an expiration date of [DATE]. Observation revealed Staff I collected all extra supplies, placed them all in the biohazard bag, removed her gloves, and without hand hygiene, opened the residents room door and walked to the biohazard room, entered the door key code on the key code pad, entered the room, discarded the biohazard bag then performed hand hygiene. Observation revealed Staff I left the oxygen saturation machine in the room and did not disinfect it after use. Staff I was asked to return to Resident #85's room and was asked how she cared for the oxygen saturation machine. Observation revealed Staff I, noted the machine on top of the storage box, donned gloves, retrieved the machine wrapped in gauzes and stated she needed to clean the machine outside. Staff I then removed her gloves, performed hand hygiene, wrapped the machine with paper towel, walked out of the residents room, retrieved a bottle on top of the nurses station with an Oxyvir label, walked to a sink located in the area dedicated for resident's positive for COVID-19. Observation revealed Staff I sprayed the oxygen saturation machine and without gloves, proceeded to wipe the machine with paper towel. Staff I then walked to her medication cart and without performing hand hygiene, she opened her medication cart, walked to the nurses station, placed the machine wrapped in paper towel and then placed the machine in the medication cart. Observation revealed Staff I wiped the top of the medication cart with the paper towel that she used to wrap the machine. Further, observation revealed Staff I continued to stand at her medication cart without performing hand hygiene. On [DATE] at 11:45 AM, observation revealed the facility's Assistant Director of Nursing (ADON)/Infection Preventionist (IP) standing by the nurse's station across from Resident #85's room. An interview was conducted with the ADON/IP and stated that Staff I used Oxyvir solution, which is poured into a small bottle from a big container, to clean the oxygen saturation machine. The ADON/IP stated that Staff I is to use the Sani Cloth wipe instead of Oxyvir. The ADON/IP was apprised of findings during Resident #85 [MEDICAL CONDITION] care performed by Staff I. The ADON/IP stated that the biohazard bag is not to stand together with the clean supplies. On [DATE] at 12:07 PM, a side by side review was conducted with the ADON/IP of Resident #85 three drawer storage box and the [MEDICAL CONDITION] care supplies. The review revealed four (4) expired [MEDICAL CONDITION] care kits; two (2) with expiration date of [DATE]; one (1) with expiration date of [DATE] and one (1) with expiration date of [DATE]. Further review revealed two (2) pairs of expired sterile gloves, one (1) pair with expiration date of ,[DATE] and one (1) with expiration date of ,[DATE]. The ADON stated that the supplies were coming to the unit from central supply. On [DATE] at 12:20 PM, a tour of the central supply room with the Central Supply Manager (CSM) was conducted. A side by side review of the respiratory care supplies revealed a full box of 24 [MEDICAL CONDITION] care tray with an expiration date of [DATE]. He stated he is responsible for checking the items for expiration dates. The CSM stated that he does not get requests for [MEDICAL CONDITION] care kit much. He added that they may have more [MEDICAL CONDITION] care kits in their supplier room on unit two. A side by side review of unit two supplies room revealed no [MEDICAL CONDITION] care kits in the room, and he added they may have removed them, it used to be there and pointed to the respiratory care supplies section. On [DATE] at 12:35 PM, an interview was conducted with the ADON and the Director of Nursing (DON) they both were apprised of the lack of [MEDICAL CONDITION] care kit in the facility due expired supplies in house. The DON stated she will order supplies stat. They both stated that they were not aware of unit two respiratory supplies in a room. On [DATE] at 12:38 PM, a joint interview was conducted with Staff J, a Nursing Supervisor and Staff I, RN and they both stated the have not removed any [MEDICAL CONDITION] care kits from unit two supply room. On [DATE] at 12:39 PM, during an interview the ADON/IP was asked to review other residents with [MEDICAL CONDITION] supplies. A side by side review was conducted with the ADON/IP of Resident #63, a resident with a [MEDICAL CONDITION] and his [MEDICAL CONDITION] supplies. The review revealed a three drawers white plastic storage box in his room with one [MEDICAL CONDITION] care kit with an expiration date on [DATE]; four (4) pair of sterile gloves with an expiration date of ,[DATE]; and another four (4) pair of sterile gloves with an expiration date of ,[DATE]. Review of Resident #63 Annual Minimum Data Set (MDS) assessment dated [DATE] and a quarterly MDS assessment dated [DATE] documented a brief interview of mental status (BIMS) score of 0 out of 15, indicating the resident has severe cognition impairment and is total dependent on staff for care. On [DATE] at 4:45 PM, during an interview the ADON stated the stat order of [MEDICAL CONDITION] supplies was received.

Based on record review, observation and interview, the facility failed to 1) to ensure that 3 of 4 (unit four, two and one) medication storage room were kept free of expired medical supplies; 2) failed to ensure resident medications were kept safe and attended for 1 of 4 (Resident #61) reviewed for blood glucose monitoring in the facility unit one; 3) failed to ensure that residents respiratory care supplies were not expired as evidenced by [MEDICAL CONDITION] kits kept in 2 of 2 residents (Resident #85 and #63) in unit two who had a [MEDICAL CONDITION] and expired [MEDICAL CONDITION] care kits in the facility central supply. The findings included: 1) On [DATE] at 4:38 PM, a side by side review of the facility's medication room/storage in unit four was conducted with the facility's Assistant Director of Nursing/Infection Preventionist (ADON/IP). The review revealed four (4) 10% [MEDICATION NAME] fixate container with an expiration date of [DATE] and one (1) Starswab with an expiration date on [DATE]. During an interview, the ADON/IP stated she did not know what the [MEDICATION NAME] container was for and did not know why those containers were in the medication room. The ADON/IP stated that the Starswabs are for any culture collection. She added those items may have been brought in the facility by the laboratory staff. On [DATE] at 4:56 PM, a side by side review of the facility's medication room/storage in unit two was conducted with the facility's ADON/IP. The review revealed four (4) collection canisters with drainage tubing with an expiration date of ,[DATE] and two (2) medium foam kit with an expiration date of ,[DATE]. The ADON/IP stated that they do not use those kits. The ADON/IP did not answer when asked; why are they been kept in the medication room/storage if those kit are not used? On [DATE] at 5:13 PM, a side by side review of the facility's medication room/storage in unit one was conducted with the facility's ADON/IP and Staff J, a Nursing Supervisor. The review revealed 12 culture swabs with an expiration date of [DATE]; five (5) 10% [MEDICATION NAME] fixate container with an expiration date of [DATE] and one suction connecting tube with an expiration date of ,[DATE]. On [DATE] at 5:21 PM, a joint interview was conducted with the ADON/IP and Staff J and they both stated that they and the floor nurses have the responsibility to check the medication room for expired items. 2) On [DATE] at 11:45 AM, observation of blood glucose check performed by Staff K, a Registered Nurse, for Resident #61, in unit one, was conducted. After the completion of the blood glucose check, Staff K stated Resident #61 needed insulin administration to cover his blood glucose results. Observation revealed Staff K retrieved the residents [MEDICATION NAME] Flex Pen from the medication cart, placed the pen on a white foam tray, entered the resident's room, placed the white foam tray with the insulin pen on the resident's table. Further observation revealed Staff K left the insulin pen unattended on top of the resident's table and walked to the resident's bathroom to perform hand hygiene. Resident #61 insulin pen was unattended for 71 seconds. Staff K came out of the bathroom and stated she forgot to bring the table with the insulin pen with her to the bathroom. Staff K confirmed that she is required to keep resident's medication with her. 3) On [DATE] at 10:56 AM, observation of Resident #85 [MEDICAL CONDITION] care performed by Staff I, a Registered Nurse, was conducted. A side by side review of the resident's [MEDICAL CONDITION] care supplies expiration dates was conducted with Staff I. The review revealed Staff I used a bottle of normal saline solution and a [MEDICAL CONDITION] care kit with an expiration date of [DATE]. On [DATE] at 12:07 PM, a side by side review was conducted with the ADON/IP of Resident #85 three drawer storage box and the [MEDICAL CONDITION] care supplies. The review revealed four (4) expired [MEDICAL CONDITION] care kits; two (2) with expiration date of [DATE]; one (1) with expiration date of [DATE] and one (1) with expiration date of [DATE]. Further review revealed two (2) pairs of expired sterile gloves, one (1) pair with expiration date of ,[DATE] and one (1) with expiration date of ,[DATE]. The ADON stated that the supplies were coming to the unit from central supply. On [DATE] at 12:20 PM, a tour to the central supply room with the Central Supply Manager (CSM) was conducted. A side by side review of the respiratory care supplies revealed a full box of 24 [MEDICAL CONDITION] care trays with an expiration date of [DATE]. He stated he is responsible for checking the items for expiration dates in the central supply room. The CSM stated that he does not get requests for [MEDICAL CONDITION] care kit much. He added that they may have more [MEDICAL CONDITION] care kits in their supplies room in unit two. A side by side review of unit two supplies room revealed no [MEDICAL CONDITION] care kits in the room, and he added they may have removed them, it used to be there and pointed to the respiratory care supplies section. On [DATE] at 12:35 PM, an interview was conducted with the ADON/IP and the Director of Nursing (DON) they both were apprised of the lack of [MEDICAL CONDITION] care kit in the facility due expired supplies in house. The DON stated she will order supplies stat. On [DATE] at 12:38 PM, a joint interview was conducted with Staff J, a Nursing Supervisor and Staff I, they both stated the have not removed any [MEDICAL CONDITION] care kits from unit two supply room. On [DATE] at 12:39 PM, during an interview with the ADON/IP she was asked to review other residents with [MEDICAL CONDITION] supplies. A side by side review was conducted with the ADON/IP of Resident #63, a resident with a [MEDICAL CONDITION], his [MEDICAL CONDITION] supplies. The review revealed a three drawers white plastic storage box in his room with one [MEDICAL CONDITION] care kit with an expiration date of [DATE]; four (4) pair of sterile gloves with an expiration date of ,[DATE]; and four (4) pairs of sterile gloves with an expiration date on ,[DATE]. All expired [MEDICAL CONDITION] supplies were bagged by the ADON/IP and removed from the resident's room. Review of the facility's policy titled Labeling of Medications Storage of Drugs and Biological's issued on ,[DATE] did not address expired supplies or items in the medication storage room. Review of the facility's policy titled Medication Administration-General guidelines dated ,[DATE] documented medications are administered as prescribed in accordance with good nursing principles and practice .

Based on observation, interview and record review, the facility 1.) failed to store food at appropriate temperatures at or below 41 degrees Fahrenheit (Fé) in a walk-in cooler, 2.) failed to wash and sanitize dishes under sanitary conditions by operating a dish machine which did not reach the manufacturer recommended wash and rinse temperatures, 3.) failed to prepare and store food and clean dishes free from potential contamination, and 4.) failed to maintain equipment in two of three nourishment rooms under safe conditions to prevent potential contamination of food. This has the potential to affect 154 resident who eat orally out of 170 residents residing in the facility at the time of the survey. The findings included: 1.) Observation during the initial kitchen tour conducted on 2/9/21 at 10:00 AM revealed the temperature of walk-in cooler #1 over 41 degrees Fé. There were two thermometer inside the unit and both registered 58 degrees Fé. The unit contained potentially hazardous food (PHF) items including eight cases of 50/8 ounce milk cartons, 2.5 cases of gallons of milk (4/case), 1/2 gallon cartons of lactose free milk, two container of tuna salad and two containers of egg salad prepared on-site and dated to indicate they were prepared on 2/7/21 and 2/8/21, four - five pounds container of cottage cheese, a case of individual 4 ounce yogurts, sliced yellow American cheese, and turkey luncheon meat. The Food Service Director stated they have had the door to the cooler open. Observation on 2/9/21 at 2:10 PM revealed the thermometers inside walk-in cooler #1 both registered 60 degrees Fé. The internal temperatures of food items stored in the unit were checked using a dial stem thermometer calibrated to 32 degrees Fé in ice water. The egg salad registered 60 degrees Fé, tuna salad 60 degrees Fé, 2 ounce container of milk 58 degrees Fé, lactose free milk 58 degree Fé, cottage cheese 58 degree Fé, and yogurt 60 degrees Fé. Interview with the Food Services Director (FSD) on 2/9/21 at 2:20 PM revealed she would have to call maintenance to check the cooler. When asked about the food items stored in the unit, she stated she would have to instruct the staff to dispose of all of the food stored in this cooler. She stated they check the cooler temperatures twice a day in the morning and evening and she had not checked to see if the temperature came down since the tour conducted this morning. Observation on 2/9/21 at 4:32 PM revealed walk-in cooler #1 was empty and the thermometers inside the unit registered 44 and 48 degrees Fé. Observation on 2/10/21 at 9:15 AM revealed walk-in cooler #1 remained empty and the thermometers inside the unit both registered 40 degrees Fé. Review of the temperature log for 2/9/21 revealed temperatures recorded for walk-in cooler #1 for 10:00 AM was 40 degrees Fé, at 2:00 PM was 58 degrees Fé, and at 7:30 PM was 38 degrees Fé. Observation on 2/11/21 at 10:50 AM revealed walk-in cooler #1 remained empty and the thermometers inside the unit registered 40 degrees Fé and 42 degrees Fé. Interview with the Dietary Supervisor (Staff B) on 02/12/21 at 2:40 PM revealed she arrives daily at 11:30 AM. I check and record the 2:00 PM and 7:00 PM refrigerator temperatures on all the refrigerator logs. They are checked three times a day and the temperatures are recorded on the log. The early morning temperatures are checked by the Director of Maintenance. If there is a problem with any of the refrigerators or freezers in the morning, he will tell the cook who will contact me or (name) the FSD. All coolers should be between 32-41 degrees. Anything over 41 degrees should be reported. Maintenance services the coolers and freezers. I found out when I arrived on Tuesday morning there was a problem with walk in cooler #1. When I arrived, the FSD had already notified maintenance. When you came back at 2:00 PM and the temperature was still too high, we started to empty the unit. Everything was immediately removed from the shelf and taken to the garbage. We called the milk man for a delivery and when the milk arrived we placed it in the cooler #2. This morning when I came the #1 cooler temperature was 33 degrees so it is working now. Interview with the FSD on 2/12/21 at 2:51 PM revealed, every morning (name), the Maintenance Director. checks all of the refrigeration units. They must maintain 38-40 degrees. At 10:00 AM they are checked again and the temperature is recorded on the log. If the temperature is over 40 degrees the staff notifies me and I will call maintenance on my walkie- talkie, have him paged or call his cell phone. He will come in and check the unit , sometimes it will be in defrost mode. We then try to keep the door closed for 30-45 minutes and then recheck the temperatures. He maintains the units. At 2:00 PM, the Dietary Supervisor checks each cooler again and I check at night before I leave and record the temperature. If I am not here I have a diet aide responsible to check the coolers. They will notify me right away if there is a problem and I call maintenance. On Tuesday morning when we saw the temperature at 58 degrees, the staff had been in and out of the cooler. I called maintenance and he told me the defrost timer was off. He started to work on the cooler but I did not remove the food until we saw the temperature was 60 degrees after 2:00 PM. I should have been watching it closely before you came back after 2:00 PM. I did keep the door closed but I did not check the temperature again until you came back and it was still too high. This is when I replaced both thermometers and removed and discarded all the food. Interview with the Director Maintenance on 2/12/21 at 3:00 PM revealed' I make rounds in the kitchen and I check all of the equipment. I check the temperatures on all the coolers and freezers. I keep a log but I only document the temperatures in the log monthly. I checked all of the coolers about 7:00 AM on Tuesday and I found the temperature of the 1st cooler to be about 50 degrees. They were taking the food out of the refrigerator for breakfast. It would be normal for the temperature to go up if the door has been opened. When you went to check the temperature about 10:00 AM the temperature was still too high so they called me. I checked the unit and I found the defrost cycle was stuck. I fixed the defrost and changed it from automatic to manual and then fixed the defrost switch. It takes a while for the temperature to come down. When you went back to the kitchen after 2:00 PM and the temperature was 60 degrees they called me again. The temperature was not coming down so I checked the condenser. The unit was low on Freon so I added Freon. After I added the Freon, the temperature came down and now it has been working fine. Review of the facility's policy and procedure titled Food Safety in Receiving and Storage (undated) revealed: Cold Food Storage Guidelines. Refrigerator temperatures will be checked at least 2 times per day and recorded. Temperatures not in the appropriate range should be reported to the Dietetic Services Supervisor or maintenance immediately. The ambient temperature in refrigerators shall be maintained at 34 to 38 degrees Fé. 2. ) Observation on 2/9/21 at 10:30 AM revealed staff operating a high temperature dish machine. Staff was observed placing racks of soiled dishes through the dish machine. Observation revealed the wash temperature gauge registered 130 degrees Fé, rinse temperature gauge registered 130 degrees Fé and the final rinse temperature gauge registered 100 degrees Fé. Staff was observed operating the dish machine at temperatures below the manufacturer recommended temperature of 150 degrees Fé for wash and 180 degrees Fé for the final rinse temperature. Interview with the Dietary Aide (staff C) on 2/9/21 at 10:35 AM revealed she did not check the temperatures of the dish machine this morning before she started to wash the dishes and she did not record any temperature on the log. Staff C continued to operate the dish machine to wash dishes until the FSD arrived and instructed the staff to stop using the machine and to re-wash and sanitize all of the dishes at the three compartment sink because the dish machine was not working properly. Observation on 2/9/21 at 2:05 PM revealed a technician working on the dish machine. The technician reported the machine was working fine now that the booster heater was turned on. He stated in order for the machine to reach the appropriate operating temperatures, the staff has to turn on both switches. One switch is to turn on the machine and the other is to turn on the booster heater. The booster heater is used to heat the water and they had apparently not turned on the booster heater switch before they started to use the machine. Observation revealed the wash temperature was 160 degree Fé and the final rinse temperature was 180 degrees Fé. The technician stated he would submit a report once he completed the service on the machine. Review of the Dish machine Temperature and Sanitizer Log dated February 2021 revealed entries for Tuesday 2/9/21. The log was completed for all three meals by 10:30 AM on 2/9/21. The FSD asked the aide operating the dish machine why the log was filled out for the whole day when they were just washing the breakfast dishes and she replied she did not write the temperatures on the log this morning. The wash temperatures were documented to be 180 and the rinse temperatures were 160. The instructions on the log indicated the wash temperature should be 150 or higher and the rinse should be 180 or higher. The FSD started a new revised lo for February 2021. Observation 02/12/21 01:50 PM revealed three staff operating the high temperature dish machine. The was temperature was 150 degrees Fé and the final rinse temperature was 180 degrees Fé. Interview with a Dietary Aide (Staff C) on 2/12/21 at 2:00 PM, revealed she works the dish machine during the morning shift after the breakfast meal. I turn on the dish machine and fill the machine. I run the racks through the dish machine empty to check for the temperature before I start to wash the dishes. The wash temperature should be 160 and the rinse temperature in the back of the machine should be 180. I write this down on the temperature log. On Tuesday I forgot to check to temperatures and I did not write anything down on the log. I was operating the dish machine on Tuesday , but someone else had already set it up for me. I do not know if they checked to make sure the temperature was okay and I did not check before I started to wash dishes. I have to push two buttons, one to turn on the machine and one to fill the machine. I try to check the temperature while I am still using the machine to make sure the temperatures are okay, but we only write on the paper once before we start to use the machine. When I run the empty racks through the machine of the temperature is not hot enough, I tell the supervisor. Interview with a Dietary Aide (Staff D) on 2/12/21 at 2:13 PM revealed he has worked 11:30 AM to 8:00 PM. I wash the dishes after the lunch and dinner. To set up the machine I first have to open the machine, turn it on and start to fill it. I have to make sure the water is clear. I have to make sure everything is okay before you start to wash. The wash temperature has to be 150 and the rinse has to be 180. I write the temperatures down on the paper. This is done before every meal. If the temperature is not right, I will call the Supervisor or the boss. If they are not here I will call maintenance. There are two buttons on the machine. The first button is for the water temperature and the second is for the rinse. Observation of the dish machine with staff D on 2/12/21 at 2:26 PM revealed the machine has two switches, one to turn the machine on and off and one for the booster heater. staff D stated when he is getting ready to use the machine he only has to turn the machine on, the other button for the heater stays on all the time. Interview with the Dietary Supervisor (Staff B) on 2/12/21 at 2:29 PM revealed; when I came in on Tuesday morning you had already checked the dish machine. When I arrived I found out there was a problem with the machine temperatures. I spoke to the FSD and we called the man to service the machine. He arrived after lunch. We shut the machine down and rewashed all of the dishes for lunch. We washed, rinsed and sanitized at the three compartment sink. The machine was serviced and it was fixed in time to use it to wash the dishes before dinner. The procedure for set up before using the dish machine is to check to make sure all of the curtain are in place properly, close all of the valves, shut the doors and turn on the booster switch. They have to turn on the booster switch first , then turn on the machine. They have to make sure they have the proper temperature. They test the machine by running our empty baskets through. They have to check the temperatures before they run any dishes through. The wash temperature should be 150 and the final rinse is 180. If the temperatures are not hot enough they report to me or the FSD. If we are not available they call maintenance. We normally contact the company because this is a leased machine. You have to have the booster on for the machine to operate properly. Interview with the FSD on 2/12/21 at 3:08 PM revealed the procedure for operating the dish machine is to turn on the booster to heat the water for the final rinse and turn on the dish machine. The staff are supposed to run four empty racks through the machine first to make sure the wash temperature is 150 and final rinse is 180. Once they are sure the temperature is okay, they record the temperatures on the log and initial the log. In the event it is not functioning properly they are to notify the kitchen supervisor on duty or maintenance. We will then call the vendor to service the machine. If it is not working, we have to manually wash and sanitize the dishes through the three compartment sink. I do not know why they were operating the dish machine on Tuesday with the wash temperature at 130, rinse temperature at 130 degrees and the final rinse at 100 degrees. I was not made aware the machine was not working properly. When I checked the log it showed the correct temperatures. There were entries on the log in the morning documenting the wash and rinse temperatures for the entire day. I spoke to the Dietary Aide (Staff D) and he said he recorded these temperature the day before. He must have documented these temperatures for the wrong date. Review of the facility policy and procedure titled Dishwashing Using a Dishwashing Machine revised 2/2020 revealed: 1.) Check cleanliness of the machine. Wash and rinse tanks should be filled with clear water. 8. Wash dishes in dish machine according to equipment directions. 10. Any problems noted with dish machine not working properly will be referred to the Dietary Supervisor or Food Service Director or Maintenance staff. Review of the Dish machine Temperature and Sanitizer Recordfor February 2021 revealed: Instructions: Document, on the following log, dish machine temperatures and PPM (parts per million) of sanitizer at every meal. Notify your supervisor if the temperature or PPM is not satisfactory. Wash temperature 150 or higher, rinse temperature 180 degrees or higher. 3.) Observation during the initial kitchen tour conducted on 2/9/21 beginning at 10:00 AM revealed the following additional concerns which could lead to contamination of food: The ceiling tiles above a rack used to store clean pots and pans had rust colored stained. There were pots and pans and clean dishes stored directly under these ceiling tiles. Ceiling tiles in the back corner of the dry storage rooms had rust colored stains and a black colored residue over the entire ceiling and brackets that secured the ceiling tiles in this area of the dry storage room. There was a rack used to store food directly under these stained and discolored ceiling tiles. These items included paper cartons of mashed and scalloped potatoes and ready to drink juices. The shelf below a food preparation table was pitted and rust colored. The shelf had been covered with galvanized steel plates. There were gaps in the seams of the steel plates making it difficult to clean the surface. This shelf was in use for storage of canned pureed food and a plastic bin with opened containers of food. The wall in the dish room on the clean side of the machine had a heavy accumulation of dust and black colored debris on the wall. This was directly above the area where the clean dishes exit the dish machine. The spray arms and jets of the fire extinguishing system in the hood were pitted and rust colored. The metal at the back of hood also pitted and rust colored. These jets were directly above equipment in use to prepare food. There was uncovered food on the stove under the hood and fire extinguisher jets. Interview with the FSD on 2/12/21 at 3:08 PM revealed, related to the ceiling tiles, 'I make rounds every day when I come in. We have a log book where I put down what needs to be done for the day. They had just painted the dry storage room and replaced the floor. They were replacing some ceiling tiles as well. Maintenance checks the log daily. Review of the current maintenance request log revealed no entries requesting replacement of damaged ceiling tiles, repairing pitted, rust colored shelves, or clearing the wall in the clean side of the dish room. 4.) Observation in the 200 wing nourishment pantry on 2/11/21 at 4:45 PM revealed, a microwave with damage to the interior surface of the unit. The interior top of the microwave was pitted and rust colored. When touched, particles fell to the interior base of the unit. Observation in the 100 wing nourishment pantry on 2/11/21 at 4:50 PM revealed the interior surface was damaged. The paint inside the front base of the unit and the interior top of the unit was peeling and rust colored. The refrigerator unit used to store a resident's lunch tray had no interior thermometer to check the temperature of the unit. Interview with the Consultant Dietitian on 02/11/21 at 4:47 PM revealed the pantry refrigerators are used to store food for the residents and the microwaves are used to re-heat residents food as needed. She stated, the microwave would need to be replaced.

Based on observation, interview and record review, the facility failed to ensure essential equipment was maintained under safe operating condition as evidenced by 1.) failure to maintain a walk-in cooler in the kitchen at 41 degrees Fahrenheit (Fé) or below, 2. ) failure to maintain a wash temperature of 150 degrees Fahrenheit (Fé) and a final rinse temperature of 180 degree Fé while operating a high temperature dish machine, and 3. ) failure to maintain microwaves in 2 of 4 nourishment pantries free peeling paint and rust colored particles. This has the potential to affect 154 residents who eat orally out of 170 residents residing in the residing in the facility at the time of the survey. The findings included: 1.) Observation during the initial kitchen tour conducted on 2/9/21 at 10:00 AM revealed the temperature of walk-in cooler #1 over 41 degrees Fé. There were two thermometer inside the unit and both registered 58 degrees Fé. The unit contained potentially hazardous food (PHF) items including eight cases of 50/8 ounce milk cartons, 2.5 cases of gallons of milk (4/case), 1/2 gallon cartons of lactose free milk, two container of tune salad and two containers of egg salad prepared on-site and dated to indicate they were prepared on 2/7/21 and 2/8/21, four - five pounds container of cottage cheese, a case of individual 4 ounce yogurts, sliced yellow American cheese, and turkey luncheon meat. The Food Service Director stated they have had the door to the cooler open. Observation on 2/9/21 at 2:10 PM revealed the thermometers inside walk-in cooler #1 both registered 60 degrees Fé. The internal temperatures of food items stored in the unit were checked using a dial stem thermometer calibrated to 32 degrees Fé in ice water. The egg salad registered 60 degrees Fé, tuna salad 60 degrees Fé, 2 ounce container of milk 58 degrees Fé, lactose free milk 58 degree Fé, cottage cheese 58 degree Fé, and yogurt 60 degrees Fé. Interview with the Food Services Director (FSD) on 2/9/21 at 2:20 PM revealed she would have to call maintenance to check the cooler. When asked about the food items stored in the unit, she stated she would have to instruct the staff to dispose of all of the food stored in this cooler. She stated they check the cooler temperatures twice a day in the morning and evening and she had not checked to see if the temperature came down since the tour conducted this morning. Observation on 2/9/21 at 4:32 PM revealed walk-in cooler #1 was empty and the thermometers inside the unit registered 44 and 48 degrees Fé. Observation on 2/10/21 at 9:15 AM revealed the walk-in cooler #1 remained empty and the thermometers inside the unit both registered 40 degrees Fé. Review of the temperature log for 2/9/21 revealed temperatures recorded for walk-in cooler #1 were 10:00 AM 40 degrees Fé, 2:00 PM 58 degrees Fé, 7:30 PM 38 degrees Fé. Observation on 2/11/21 at 10:50 AM revealed walk-in cooler #1 remained empty and the thermometers inside the unit registered 40 degrees Fé and 42 degrees Fé. Interview with the Dietary Supervisor (Staff B) on 02/12/21 at 2:40 PM revealed she arrives daily at 11:30 AM. I check and record the 2 PM and 7 PM refrigerator temperatures on all refrigerator logs. They are checked three times a day and the temperatures are recorded on the log. The early morning temperatures are checked by the Director of Maintenance. If there is a problem with any of the refrigerators or freezers in the morning, he will tell the cook who will contact me or (name) the FSD. All cooler should be between 32-41 degrees. Anything over 41 degrees should be reported. Maintenance services the coolers and freezers. I found out when I arrived on Tuesday morning there was a problem with walk in cooler #1. When I arrived, the FSD had already notified maintenance. When you came back at 2:00 PM and the temperature was still too high, we started to empty the unit. Everything was immediately removed from the shelf and taken to the garbage. We called the milk man for a delivery and when the milk arrived we placed it in the cooler #2. This morning when I came the #1 cooler temperature was 33 degrees so it is working now. Interview with the FSD on 2/12/21 at 2:51 PM revealed every morning (name), the Maintenance Director. checks all of the refrigeration units. They must maintain 38-40 degrees. At 10:00 AM they are checked again and the temperature is recorded on the log. If the temperature is over 40 degrees the staff notifies me and I will call maintenance on my walkie- talkie, have him paged or call his cell phone. He will come in and check the unit , sometimes it will be in defrost mode. We then try to keep the door closed for 30-45 minutes and then recheck the temperatures. He maintains the units. At 2:00 PM, the Dietary Supervisor checks each cooler again and I check at night before I leave and record the temperature. If I am not here I have a diet aide responsible to check the coolers. They will notify me right away if there is a problem and I call maintenance. On Tuesday morning when we saw the temperature at 58 degrees, I told you the staff had been in and out of the cooler. I called maintenance and he told me the defrost timer was off. He started to work on the cooler but I did not remove the food until we saw the temperature was 60 degrees after 2:00 PM. I should have been watching it closely before you came back after 2:00 PM. I did keep the door closed but I did not check the temperature again until you came back and it was still too high. This is when I replaced both thermometers and removed and discarded all the food. Interview with the Director Maintenance on 2/12/21 at 3:00 PM revealed; I make rounds in the kitchen and I check all of the equipment. I check the temperatures on all the coolers and freezers. I keep a log but I only document the temperatures in the log monthly. I checked all of the coolers about 7:00 AM on Tuesday and I found the temperature of the 1st cooler to be about 50 degrees. They were taking the food out of the refrigerator for breakfast. It would be normal for the temperature to go up if the door has been opened. When you went to check the temperature about 10:00 AM and the temperature was still too high so they called me. I checked the unit and I found the defrost cycle was stuck. I fixed the defrost and changed it from automatic to manual and then fixed the defrost switch. It takes a while for the temperature come down. When you went back to the kitchen after 2:00 PM and the temperature was 60 degrees they called me again. The temperature was not coming down so I checked the condenser. The unit was low on Freon so I added Freon. After I added the Freon, the temperature came down and now it has been working fine. Review of the facility's policy and procedure titled Food Safety in Receiving and Storage (undated) revealed: Cold Food Storage Guidelines. Refrigerator temperatures will be checked at least 2 times per day and recorded. Temperatures not in the appropriate range should be reported to the Dietetic Services Supervisor or maintenance immediately. The ambient temperature in refrigerators shall be maintained at 34 to 38 degrees Fé. 2. ) Observation on 2/9/21 at 10:30 AM revealed staff operating a high temperature dish machine. Staff was observed placing racks of soiled dishes through the dish machine. Observation revealed the wash temperature gauge registered 130 degrees Fé, rinse temperature gauge registered 130 degrees Fé and the final rinse temperature gauge registered 100 degrees Fé. Staff was observed operating the dish machine at temperatures below the manufacturer recommended temperature of 150 degrees Fé for wash and 180 degrees Fé for the final rinse temperature. Interview with the Dietary Aide (Staff C) on 2/9/21 at 10:35 AM revealed she did not check the temperatures of the dish machine this morning before she started to wash the dishes and she did not record any temperature on the log. Staff C continued to operate the dish machine to wash dishes until the FSD arrived and instructed the staff to stop using the machine and to re-wash and sanitize all of the dishes at the three compartment sink because the dish machine was not working properly. Observation on 2/9/21 at 2:05 PM revealed a technician working on the dish machine. The technician reported the machine was working fine now that the booster heater was turned on. He stated in order for the machine to reach the appropriate operating temperatures, the staff has to turn on both switches. One switch is to turn on the machine and the other is to turn on the booster heater. The booster heater is used to heat the water and they had apparently not turned on the booster heater switch before they started to use the machine. Observation revealed the wash temperature was 160 degree Fé and the final rinse temperature was 180 degrees Fé. The technician stated he would submit a report once he completed the service on the machine. Review of the Dish machine Temperature and Sanitizer Log dated February 2021 revealed entries for Tuesday 2/9/21. The log was completed for all three meals by 10:30 AM on 2/9/21. The FSD asked the aide operating the dish machine why the log was filled out for the whole day when they were just washing the breakfast dishes and she replied that she did not write the temperatures on the log this morning. The wash temperatures were documented to be 180 and the rinse temperatures were 160. The instructions on the log indicated the wash temperature should be 150 or higher and the rinse should be 180 or higher. The FSD started a new revised log for February 2021. Observation 02/12/21 01:50 PM revealed three staff operating the high temperature dish machine. The was temperature was 150 degrees Fé and the final rinse temperature was 180 degrees Fé. Interview with a Dietary Aide (Staff C) on 2/12/21 at 2:00 PM revealed she works the dish machine during the morning shift after the breakfast meal. I turn on the dish machine and fill the machine. I run the racks through the dish machine empty to check for the temperature before I start to wash the dishes. The wash temperature should be 160 and the rinse temperature in the back of the machine should be 180. I write this down on the temperature log. On Tuesday I forgot to check to temperatures and I did not write anything down on the log. I was operating the dish machine on Tuesday , but someone else had already set it up for me. I do not know if they checked to make sure the temperature was okay and I did not check before I started to wash dishes. I have to push two buttons, one to turn on the machine and one to fill the machine. I try to check the temperature while I am still using the machine to make sure the temperatures are okay, but we only write on the paper once before we start to use the machine. When I run the empty racks through the machine of the temperature is not hot enough, I tell the supervisor. Interview with a Dietary Aide (Staff D) on 2/12/21 at 2:13 PM revealed he has worked 11:30 am to 8:00 PM. I wash the dishes after the lunch and dinner. To set up the machine I first have to open the machine, turn it on and start to fill it. I have to make sure the water is clear. I have to make sure everything is okay before you start to wash. The wash temperature has to be 150 and the rinse has to be 180. I write the temperatures down on the paper. This is done before every meal. If the temperature is not right, I will call the Supervisor or the boss. If they are not here I will call maintenance. There are two buttons on the machine. The first button is for the water temperature and the second is for the rinse. Observation of the dish machine with Staff D on 2/12/21 at 2:26 PM revealed the machine has two switches, one to turn the machine on and off and one for the booster heater. Staff D stated when he is getting ready to use the machine he only has to turn the machine on, the other button for the heater stays on all the time. Interview with the Dietary Supervisor (Staff B) on 2/12/21 at 2:29 PM revealed, when I came in on Tuesday morning you had already checked the dish machine. When I arrived I found out there was a problem with the machine temperatures. I spoke to the FSD and we called the man to service the machine. He arrived after lunch. We shut the machine down and rewashed all of the dishes for lunch. We washed, rinsed and sanitized at the three compartment sink. The machine was serviced and it was fixed in time to use it to wash the dishes before dinner. The procedure for set up before using the dish machine is to check to make sure all of the curtain are in place properly, close all of the valves, shut the doors and turn on the booster switch. They have to turn on the booster switch first , then turn on the machine. They have to make sure they have the proper temperature. They test the machine by running our empty baskets through. They have to check the temperatures before they run any dishes through. The wash temperature should be 150 and the final rinse is 180. If the temperatures are not hot enough they report to me or the FSD. If we are not available they call maintenance. We normally contact the company because this is a leased machine. You have to have the booster on for the machine to operate properly. Interview with the FSD on 2/12/21 at 3:08 PM revealed, the procedure for operating the dish machine is to turn on the booster to heat the water for the final rinse and turn on the dish machine. The staff are supposed to run four empty racks through the machine first to make sure the wash temperature is 150 and final rinse is 180. Once they are sure the temperature is okay, they record the temperatures on the log and initial the log. In the event it is not functioning properly they are to notify the kitchen supervisor on duty or maintenance. We will then call the vendor to service the machine. If it is not working, we have to manually wash and sanitize the dishes through the three compartment sink. I do not know why they were operating the dish machine on Tuesday with the wash temperature at 130, rinse temperature at 130 degrees and the final rinse at 100 degrees. I was not made aware the machine was not working properly. When I checked the log it showed the correct temperatures. There were entries on the log in the morning documenting the wash and rinse temperatures for the entire day. I spoke to the Dietary Aide (Staff D) and he said he recorded these temperature the day before. He must have documented these temperatures for the wrong date. Review of the facility policy and procedure titled Dishwashing Using a Dishwashing Machine revised 2/2020 revealed: 1.) Check cleanliness of the machine. Wash and rinse tanks should be filled with clear water. 8. Wash dishes in dish machine according to equipment directions. 10. Any problems noted with dish machine not working properly will be referred to the Dietary Supervisor or Food Service Director or Maintenance staff. Review of the Dish machine Temperature and Sanitizer Recordfor February 2021 revealed: Instructions: Document, on the following log, dish machine temperatures and PPM (parts per million) of sanitizer at every meal. Notify your supervisor if the temperature or PPM is not satisfactory. Wash temperature 150 or higher, rinse temperature 180 degrees or higher. 3.) Observation in the 200 wing nourishment pantry on 2/11/21 at 4:45 PM revealed a microwave with damage to the interior surface of the unit. The interior top of the microwave was pitted and rust colored. When touched, partials fell to the interior base of the unit. Observation in the 100 wing nourishment pantry on 2/11/21 at 4:50 PM revealed the interior surface was damaged. The paint inside the front base of the unit and the interior top of the unit was peeling and rust colored. Interview with the Consultant Dietitian on 02/11/21 at 4:47 PM revealed the pantry refrigerators are used to store food for the resident and the microwaves are used to re-heat resident food as needed. She stated, the microwave would need to be replaced.

Based on interviews and record reviews the facility failed to address and file a grievance in a timely manner for one (Resident # 59) out of one resident sampled for missing personal items (Resident # 59). There were one hundred and seventy residents residing in the facility at the time of the survey. The findings included : Interview with Resident # 59 on 02/09/2021 at 2: 28 PM revealed he was missing a blanket with colors. He stated this happened about two months ago and he reported it to the nurse. Resident #59 reported the nurse spoke with the laundry staff but the staff did not follow up and he had received any response and the blanket had not been replaced. Review of Resident # 59's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was assessed to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated his cognitive status was intact. Interview with Registered Nurse (Staff A) on 02/11/2021 at 12:26 PM revealed Resident #59 had reported a missing blanket about two weeks ago. Staff A revealed he reported it to the laundry department and laundry stated they would start looking for the blanket. Staff A stated that Resident #59 described the blanket has two hearts and after he reported it to the social services department he thought they would have replaced it. Staff A stated, I do not remember if social services filed a grievance but since the laundry did not find it, I reported it to them. Interview with Social Services Director on 02/12/2021 at 9:55 AM revealed all staff members are able to fill out the grievance forms on behalf of family members or the residents if they have concerns. The Social Services Director stated if an employee has grievances they can fill out the form, if they can try to handle the grievance immediately they are encouraged to do it, and then I can follow up or the staff can come to me to report the problem and I handle it with the department that it pertains to. If the grievance is from the laundry department they try to look for the item, and if they cannot find it or it is not resolved, administration is involved to replace the lost item. The Social Services Director stated she was aware that Resident #59 had lost a blanket, she went to the resident and asked him what type of blanket was it and the resident stated it was from { retail store name}. The Social Services Director stated that because it was not found she spoke to the administrator and ordered a replacement and the item is supposed to be delivered. She stated the resident was not on the grievance log because the grievance log was provided in the morning and this happened in the afternoon, and grievances are ongoing and she could provide a copy of the most updated grievance log. Review of the grievance log for January and February 2021 did not indicate any documentation related to Resident #59's missing item. Review of Grievance form provided revealed the grievance was not addressed until during the survey and dated February 9, 2021. Review of facility's grievance policy and procedure titled Resident and Family Concern/Grievances implemented March 2020 revealed information on how to file a grievance will be available to the resident. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official b.Written complaint to a staff member or grievance official c.Written complaint to an outside party d. Verbal complaint during resident or family council meetings. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Take immediate actions needed to prevent further potential violations of any resident right. Forward the grievance form to the Grievance Official as soon as practicable. The Grievance Official will take steps to resolve the grievance, and record the information about the grievance and those actions, on the grievance form. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances.

Based on observation and interview, facility failed to ensure dignity during dining for 4 of 41 residents ( Resident #43, Resident #20, Resident #117, and Resident #6) that ate independently as evidenced by failure to ensure residents and roommates that ate independently were served meal trays within a timely manner. The findings included: Dining observation on 02/09/2021 at 11:58 AM revealed, Resident # 20 in room [ROOM NUMBER], received his lunch tray from the first food cart at 11:58 AM and his roommate Resident # 43 in room # 122 received his tray at 12:57 PM. Resident # 117 in room [ROOM NUMBER], received her lunch tray from the first food cart at 11:58 AM and her roommate Resident # 6 received lunch her tray at 12:59 PM. Residents ate independently. A second dining observation on 02/10/2021 at 11.58 AM revealed the first food cart arrived at the floor at 11:58 AM. Resident # 20 in room [ROOM NUMBER] received his lunch tray at 12: 09 PM. Resident # 6 in room # 126 received her tray at 12:10 PM. Both residents ate independently. The second food cart arrived at 12:31 PM and the third food cart arrived at 12:40 PM. Resident #43 in room [ROOM NUMBER] received his lunch tray at 12: 42 PM, when his roommate had already finished eating his lunch. Resident # 117 in room [ROOM NUMBER] received her lunch tray at 12: 45 PM after her roommate had already finished eating her lunch On 02/11/2021 a third dining observation at 12:14 PM revealed the food cart arrived at the first floor at 12:14 PM. Resident # 43 in room # 122 received his lunch tray at 12:40 PM after his roommate already finished his lunch. On 02/11/2021 at 12:40 PM, Resident # 43 stated that he received his food when his roommate had already finished eating his lunch, Resident # 43 reported that this happened every day and that he was used to seeing his roommate eat first, and then he received his food. Interview on 12/12/2021 at 3:55 PM with Certified Nursing Assistant (CNA) Staff E revealed, that the process to distribute food trays was for the residents that ate independently to be served first. The residents that needed to be fed were second and then, staff would proceed with feeding these residents and a third cart that came to the floor. Staff E explained that Residents # 20 in room # 122 and Resident # 6 in room # 126, food came in the first cart. Resident # 43 in Room # 122 and Resident # 117 in room # 126 food came in the third cart. Staff E stated that the carts were prepared to be served like that in the kitchen. The Food Services Director on 02/12/21 at 04:16 PM, stated during an interview that Residents # 43 and Resident # 20 in room # 122 were set up in different carts and time. Resident # 20 had not complained about the time his food was served. The Food Services Director stated that Resident # 43 complained to her when the food requested was not on his tray and she will follow up on that.

Based on observation, record review and interviews, the facility failed to ensure appropriate treatment and services were provided to maintain or maximize the resident's functional abilities for 1 of 2 residents (Resident #29) sampled for Activities of Daily Living (ADL's) as evidenced by Resident #29 had significant change in his ADL's and did not receive services from therapy or the Restorative Nursing Program. The facility had a total census of 170 residents residing in the facility at the time of this survey. The findings included: On 02/09/21 at 11:22 AM, observation revealed Resident #29 sitting in a wheelchair and looking out to the parking lot through a locked sliding door. An interview was conducted with the resident who was unable to vocally communicate but was able to nod his head side to side and up and down when questions were asked. Review of Resident #29 clinical record documented an admission to the facility on [DATE] with no readmission. The resident's [DIAGNOSES REDACTED]. Review of Resident #29's Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented a BIMS (Brief Interview of Mental Status) score of 11 out of 15 which indicates moderate cognition impairment. The assessment documented that the resident required extensive assistance for his Activities of Daily Living (ADL's) such as during bed mobility, transfer, toilet use and walking in the room and required physical help with bathing. The assessment documented that the resident was using a walker and a wheelchair for mobility. Further review revealed that Physical, Occupational Therapy or Restorative Nursing program was not provided seven days prior to the assessment. Review of Resident #29's Minimum Data Set (MDS) Significant change assessment dated [DATE] documented a BIMS (Brief Interview of Mental Status) score of 9 out of 15 which indicates moderate cognition impairment. The assessment documented that the resident required extensive assistance for his activities of daily such as bed mobility and declined from extensive assistance to total dependent on staff for transfer, toilet use and bathing. The assessment documented that Resident #29's walking in the room did occur and that Physical, Occupational Therapy or Restorative Nursing program was not provided seven days prior to the assessment. Review of Resident #29's care plans revealed a care plan initiated on 11/18/20 titled Resident ability to perform ADL (Activities of Daily Living) has deteriorated and is impaired related to decrease mobility, decrease in function . Active care plan dated 06/18/20 with a target date of 07/16/20 titled Resident is on Restorative Nursing Program (RNP) to maintain joint mobility and strengthening with interventions to include Restorative Nursing Program as indicated .side to side two times with 10 repetitions as tolerated three times a week for four weeks to be performed by the Restorative Certified Nursing Assistant . The care plan was not revised on 11/18/20 after a significant change related to ADL. Further review of Resident #29's care plans revealed no documentation of the resident refusal of care or ADL. On 02/10/21 at 12:47 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that Resident #29 had a significant change assessment on 11/18/20 due to a decline related to his activities of daily living and significant weight loss. She stated the resident declined from maximum assistance to total dependent on staff for transfer, ambulation, and bed mobility. She added that the resident needed two-person assistance with transfers from bed to chair and has to be transferred via a mechanical lift. The MDS coordinator stated that the resident was not receiving physical therapy or restorative nursing program at the time of the assessment. On 02/11/21 at 12:54 PM, Staff K, a Registered Nurse stated during an interview that Resident #29 is alert and oriented and can communicate his needs via a communication board. On 02/12/21 at 9:08 AM, an interview was conducted with the facility's Rehabilitation Director. She stated that typically if there is a consistent decline for several days, the nurses will document and call the doctor. She added that the doctor may change orders as he deems appropriate. The Rehabilitation Director stated that Resident #29 had Physical Therapy (PT) and Occupational Therapy (OT) evaluation on 04/23/20, received treatment and was discharged from therapy on 06/17/2020. The Rehabilitation Director stated that the resident then was referred to the facility's Restorative Nursing Program with a functional status of requiring maximum assistance with two people. She added that the physical therapist recommendations were to continue with nursing care for functional mobility, positioning in wheelchair and transfer techniques as well as Range of Motion (ROM) for bilateral lower extremities. She stated that Resident #29 reached his maximum potential for rehabilitation. The Director stated that the Occupational Therapist recommendations were for ROM exercises for bilateral upper extremities. She stated again that the resident had reached maximum rehabilitation potential and was referred to the Restorative Nursing Program to maintain the functional status at the time. She added that the resident had no functional changes since last rehabilitation evaluation on 08/19/2020. The Director stated that on 08/19/2020 Resident #29 was evaluated by a Physical Therapist due to need for use of a mechanical lift to transfer the resident from bed to chair. She added that the use of a mechanical lift was recommended to be used by the staff to increase safety and minimize risk of fall or injuries. She added that the resident's physical status did not change functionally to require PT or OT. The Rehabilitation Director stated that Resident # 29 needed maximum assistance for bed mobility and was dependent for ambulation and transfer. She stated the resident was not a candidate for PT or OT. The Rehabilitation Director stated that they do quarterly screening and Resident #29 last screening was done on 11/20/2020. The screening documented that the resident functional status was maximum assistance for bed mobility, dependent for transfer using a mechanical lift at that time. The Rehabilitation Director stated that the Restorative Nursing Program is to maintain functional status and to avoid contractures. She added that the RNP ideally do once or twice a year assessment to make sure there is no further decline. On 02/12/21 at 10:09 AM, an interview was conducted with Staff G, a Licensed Practical Nurse/ Restorative Nurse (LPN/RNP) assigned for unit one. Staff G stated that if a resident has a decline, reported by the floor nurse, the resident is referred to her or the restorative aide. She added that then she will do an assessment, check for level of ADLs participation with dressing, grooming, transfer, eating and ambulation. She then speaks with the therapist to see if they can pick the resident up for therapy. Staff G stated she calls the doctor to obtain an order for [REDACTED]. She stated Resident #29 is not currently receiving services from the Restorative Nursing and she did a significant change assessment on 11/18/20. Staff G stated that the resident had a significant change from maximum assistance to total assist with his ADLs and transfers requiring two people to transfer with a mechanical lift. Staff G stated she thought the resident was not picked up at the time of the significant change to participate in the Restorative Nursing Program. Staff G stated Resident #29 was missed and was not started on the Restorative Nursing Program as required back in 11/18/20. On 02/12/21 at 10:57 AM, a joint interview was conducted with Staff F, a Restorative Certified Nursing Assistant (RCNA) and Staff G, a Restorative Nurse (LPN/RNP). Staff F did not recall when was the last time he provided RNP and stated he provided upper and lower extremities ROM for Resident #29 last time he was providing Restorative Program services. Staff F stated that unit one has about 56 residents and that they cannot all be on the Restorative Nursing Program. Staff G stated that they rotate the residents on the Restorative Nursing Program and if a resident decline they picked the resident right the way. Staff G added that they picked different residents for the program so they can maintain or improve their functional status. On 02/12/21 at 2:21 PM, an interview was conducted with Staff H, a Certified Nursing Assistant. Staff H stated she is familiar with Resident #29. Staff H stated she does the resident's personal care and uses a mechanical lift to transfer him in and out of bed to the wheelchair. Staff H stated that the resident is able to lift his arms for her to dress him. Review of the facility's policy titled Specialized Rehabilitative and Restorative Services issued 03/2020, documented .the facility will provide restorative services such as but not limited to walking, transfer training .Range of Motion (ROM) .when necessary as indicated by the assessment of the interdisciplinary team. Review of the facility's policy titled Activities of Daily Living (ADLS) Maintain Abilities issued 03/2020, documented .It is the policy of the facility .that the care and services provided are person-centered .the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish the facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living .the facility will provide care and services for the following activities of daily living .Mobility-transfer and ambulation, including walking .

Based on observation, interview and record review, the facility failed to ensure that a midline catheter dressing was kept secured for one of one resident (Resident #173) reviewed for Intravenous (IV) medication administration in unit two of the facility. The findings included: On 02/10/21 at 2:01 PM, during IV medication administration for Resident # 173 being performed by Staff M a Registered Nurse (RN). Staff M, RN stated that the resident has a PICC (Peripherally Inserted Central Catheter). A side by side review with Staff M was conducted of the physician orders [REDACTED]. On 02/10/21 at 2:11 PM, observation revealed Staff M,carrying a white foam tray with the following supplies: one bag of [MEDICATION NAME] (an antibiotic) 2 grams (gm) in a 100 millimeters (ml) normal saline solution, one red port cap, two normal saline flush syringes, six alcohol pads and an IV tubing package. Staff M entered residents' room, placed the white foam tray on the resident's table, pushed the table to the bathroom, performed hand hygiene. Observation revealed Staff M with bare hands pushed the resident's table back to his bedside and without hand hygiene, Staff M donned gloves. Staff M then pulled the IV tubing from the packaging, connected the tubing to the [MEDICATION NAME] bag, set the tubing dial flow to 200 ml, hanged the IV bag on the pole and prime the tubing line. Staff M removed her gloves and performed hand hygiene and donned gloves. Observation revealed Staff M with an alcohol pad removed the red cap connected to the residents PICC line on his right antecubital region (elbow region), wiped the PICC line port with one alcohol pad multiple times with a side to side motion outside and inside the port. Staff M then without flushing the PICC line with a normal saline flush syringe, proceeded to connect the IV tubing. Observation revealed the IV solution was not dripping. Staff M stated that she forgot to flush the catheter and proceeded to disconnect the tubing. Observation revealed Staff M removed Resident #173's PICC line dressing from the top site close to the elbow and then from the bottom of the dressing. Resident #173 was not facing away from the dressing. Resident #173 was talking during the procedure directly to Staff M. Observation revealed Staff M with regular gloves touching the PICC line insertion site, then left the dressing loose and exposed to air. Staff M stated that she removed the dressing to check and see if there was a clamp underneath the dressing that was occluding the PICC line. Staff M then called Staff J, Licensed Practical Nurse (LPN)/ Nursing supervisor. Staff J was apprised of the situation and stated that she will place a hep lock (indwelling venipuncture device designed for intermittent injection or infusion therapy) to administer the resident's 2:00 PM IV [MEDICATION NAME] antibiotic dose. On 02/10/21 at 2:42 PM, observation revealed Staff J a Nursing Supervisor entered Resident #173's room with a [MEDICATION NAME] 2 gm/100 ml bag, IV tubing packaging, an IV start kit, alcohol pads and placed them on the bed table. Staff J performed hand hygiene, open the IV start kit, donned gloves, bends over to apply a tourniquet to canalize a peripheral vein to insert the hep lock in his right hand. Observation revealed Staff J Identification Badge (ID) on a lanyard around her neck. The lanyard was long (from neck to mid abdomen) hanging from her neck and touching the resident's linens. Continue observation revealed Resident #173 PICC line continues to be loose while Staff J was looking at his veins on the same arm (right hand). Staff J then removed her gloves, performed hand hygiene, and returned to the resident bedside. Furthermore, observation revealed Staff J continues to have the lanyard with her ID badge hanging over her neck and touching the resident's linens. Staff J then pushed the residents table close to his bed with clean bare hands, donned sterile gloves without hand hygiene after touching a highly contaminated surface and inserted the hep lock. Observation revealed Staff M and Staff J did not attempt to cover the PICC line site while attempting to canalize a peripheral vein on his right arm. Review of Resident #173 clinical record documented an admission to the facility on [DATE] and a readmission on 01/28/21 with [DIAGNOSES REDACTED]. Review of Resident #173's Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented a BIMS (brief interview of mental status) score of 15 out of 15 which indicates intact cognition. The assessment documented that the resident needed extensive assistance from the staff and was not receiving IV therapy prior to the assessment. Review of Resident #173's Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a BIMS (brief interview of mental status) score of 15 out of 15 which indicates intact cognition. The assessment documented that the resident needed extensive assistance from the staff and received IV therapy and antibiotics prior to the assessment. On 02/12/21 at 3:45 PM, during an interview, Staff J was apprised regarding her lanyard and ID badge touching the resident's linens. Staff J confirmed it is an infection control concern. Staff J stated Resident #173's PICC dressing was changed after the hep lock insertion. On 02/12/21 at 4:40 PM, during an interview with the facility's Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP was apprised of cross contamination findings during Resident #173's IV medication administration observation. Review of the facility's policy titled Midline dressing changes revised 12/2011, documented .the procedure is to prevent catheter-related infections associated with .loosened .catheters-site dressings .to remove an old dressing .resident should be positioned with head facing away from the dressing site .

Based on observations, interviews, and policy review, the facility failed to ensure a clean, safe and sanitary environment as evidenced by failure to maintain resident rooms free from soiled, damaged walls and ceiling tiles in two (room [ROOM NUMBER] and room [ROOM NUMBER]) of 92 occupied rooms. The findings included: Observation in room [ROOM NUMBER] on 2/09/21 at 12:26 PM revealed stained ceiling tiles in the bathroom. Two ceiling tiles had rust colored stains and rust colored support brackets. There was a gap between the tile and the support bracket leaving a hole in the ceiling. Observation revealed rust colored stains on the ceiling tiles in the room above the base of bed A. (photos submitted) Observation in room [ROOM NUMBER] on 2/09/21 at 1:53 PM revealed a rust colored stains stain on the ceiling tile above bed A. The wall near bed B had a hole to the right side of air conditioner (AC). There was a gap in the wall leading to the outside. Interview of Resident #66 revealed that sometimes drops of water come through the area were the rust colored stain is above her bed. (photo submitted) Observation in room [ROOM NUMBER] on 2/09/21 at 1:21 PM revealed the wall surrounding the AC unit was damaged near bed B. There was blue painter's tape on the wall surrounding the AC unit. There was a hole in the wall to the right side of the unit. The wall just above the baseboard at bed B was damaged. The paint was peeling and the integrity of the wall board was not intact. The resident in bed B was observed in a low bed close to the area where the wall was damaged. There was a black colored substance on the wall next to the bedside table. (photo submitted) During a follow up observation on 2/12/21 at 4:00 PM with the Director of Maintenance revealed the damaged areas identified on 2/9/21 had not been repaired. Interview with the Director of Maintenance revealed he had maintenance staff on each unit and they made rounds to identify areas that needed to be repaired. He revealed the facility also uses a maintenance job request form for staff to complete if they identified any maintenance concerns. He revealed the AC unit in room [ROOM NUMBER] had been replaced a few weeks ago, but the hole in the wall next to the AC had not been repaired. He was not aware of the wall damage above the baseboard, the black colored substance on the wall or the damaged, stained ceiling tiles. He stated he would need to schedule his staff to make these repairs. Review of the facility's policy titled Physical Environment: Housekeeping and Maintenance dated 3/2020 revealed: The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility will maintain the facility premises and equipment and conduct its operation in a safe and sanitary manner.

Based on observations, interviews and record review the facility failed to provide care and services for one resident sampled with limited range of motion (ROM) to maintain, and/or improve to his highest level of range of motion (ROM) and mobility and/or to prevent further decrease in range of motion for one of three residents sampled for rehabilitation (Resident #43). The findings included: On 02/09/21 at 11:52 AM, observation and interview revealed Resident #43 was not in his room. Staff N, a Registered Nurse stated the resident spend his time in the dining room. Observation revealed Resident #43 sitting in a wheelchair in the dining room. The resident reported during the beginning of the interview after being introduced that he is upset because the staff was not walking him or giving him therapy. The resident added that he was using the walker before and can use the walker now, but the facility is not helping him to walk. Staff N interjected and told the resident, Staff F, a Restorative Certified Nursing Assistant walks you. Resident #43 stated I am not going to lie. Review of Resident #43 clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's [DIAGNOSES REDACTED]. On 02/10/21 at 9:06 AM, during an interview Staff K, a Registered Nurse, stated that Resident #43 can walk with help and that he requested therapy. On 02/12/21 at 9:29 AM, during an interview the facility's Rehabilitation Director stated that, the therapy department sees Resident #43 once or twice a year. She added the resident is a very motivated resident. The Rehabilitation Director stated that Resident #43 had rehabilitation treatment from 03/05/2020 until 04/29/20 when he was discharged . The Director stated Resident #43 was able to ambulate 200 feet with a rolling walker and contact guard upon discharge on 04/29/20. The Rehabilitation Director stated that on 04/29/20 the therapist documented the resident had achieved his maximal rehabilitation potential, able to standby with assistance and functional mobility with a rolling walker. The Rehabilitation Director stated that the resident was to continue under nursing care. She added that the staff was educated on transfer techniques, body mechanics and resident's mobility to maintain his current level of function. She added that education was given to the Restorative Nursing Assistant to assist the resident to maintain his functional status. The Rehabilitation Director stated that they do quarterly screening. Resident #43 screening were completed on 09/03/20 and 12/08/20 and the resident had no change, no decline in his functional status. The Director was apprised that Resident #43 complained that he has not been ambulating on the unit. The Rehabilitation Director stated that the floor Certified Nurses Assistants should be able to help him with ambulation to prevent decline. The Rehabilitation Director stated Resident #43 had received Restorative Nursing Program services and is currently receiving Physical (PT) and Occupational (OT) therapy since 02/11/21. The Director stated that PT and OT evaluation was done on 02/11/21 because the resident requested. The Director was apprised that Resident #43 complained that he was not ambulated on the unit. The Rehabilitation Director stated as per nursing documentation on 02/10/21, the resident was requesting PT, requires minimal assistance with one-person transfer and that he ambulates with a rolling walker with assistance, the doctor was contacted, and therapy evaluation was done on 02/11/21. The Rehabilitation Director stated PT short term goals was to ambulate 40 feet with contact guard (one-person assistance), bed mobility and transfer with contact guard. The PT treatment plan is for three to five times a week for eight weeks. She stated the OT short term goals as self-care- hygiene and grooming with supervision; toileting with minimum to moderate assistance and for the upper extremities- dressing with handheld assistance (contact guard); and extremities strength. The OT treatment plan is four to five times a week for 8 weeks. On 02/12/21 at 10:09 AM, an interview was conducted with Staff G, a Restorative Nurse (LPN/RNP) assigned for unit one. Staff G stated that if a resident has a decline, it is reported by the floor nurse, they will do a referral for the resident to her or the restorative aide. She added that then she will do an assessment, check for level of activities of daily living (ADL's) participation with dressing, grooming, transfer, eating and ambulation. She then speaks with the therapist to see if they can pick the resident up for therapy. Staff G stated she calls the doctor to obtain an order for [REDACTED]. She stated Resident #43 is not currently receiving Restorative Nursing Program (RNP) service because he has not had a decline on his functional status. Staff G stated Resident #43 last restorative nursing program service started on 08/28/20 The resident received service for ambulation and transfers three times a week for six weeks. She added resident was discharged from the Restorative Nursing Program service on 09/28/20. Staff G stated the resident was not showing any decline with his skills and was discharged from the service to the floor Certified Nursing Assistant. Staff G stated that the floor Certified Nursing Assistant is responsible to assist the resident with ambulation in the room, but not in the hallway. Staff G added ambulating a resident in the hallway is the Restorative Nursing Program staff responsibility. Staff G stated Resident #43 last quarterly assessment was completed on 12/04/20 and the assessment documented the resident needed minimal assistance with his Activities of daily living (ADL's) including ambulation, transfer by one person and no decline was documented. Staff G was asked if she ambulated Resident #43 down the hallway during her assessment to check for decline in ambulation and stated that she only walked him in his room. Staff G added that the resident usually walks halfway to the hallway as tolerated. On 02/12/21 at 10:32 AM, a joint interview with the Rehabilitation Director, Staff G and Staff F was conducted. Staff F stated he has not provided restorative nursing services to Resident #43 since 09/2020. Staff F added that they rotate the residents in to the Restorative Nursing Program. Staff G stated that if a resident declined, they will then contact therapy or the doctor for services as required. Staff G added that they pick up different residents so they can maintain or improve their functional status. Staff G stated Resident #43 had not received restorative nursing services since 09/28/2020. Staff F was asked if Resident #43 had asked him to be ambulated. Staff F stated back in October 2020, the resident asked for him to ambulate him and he did. Staff F added the resident was not on the Restorative Nursing Program service at that time and he did not refer him. Staff F added that they have 56 residents and not all the residents can be on the Restorative Nursing Program services. The Rehabilitation Director stated that before COVID-19 they had programs incorporated to maintain resident's functional status such as Walk to dine program where Resident #43 was able to ambulate to the dining room. Staff G stated that Resident #43 was not receiving Restorative Nursing Program services because his functional status was not declining. The Rehabilitation Director, Staff F and Staff G were asked, why if Resident #43 is very motivated and was able to ambulate 200 feet with a rolling walker and contact guard, why is Restorative Nursing Program service not been provided? Why wait until the resident declined rather than maintain functional status? Staff G stated that they rotated residents in the Restorative Nursing Program. The Rehabilitation Director stated that Resident #43 can benefit from Restorative Nursing Program service. Staff G was apprised that Resident #43 complained that he has been assisted with ambulation. On 02/12/21 at 2:36 PM, an interview was Staff O, a Certified Nursing Assistant, was conducted. Staff O stated she has been taking care of Resident #43 for more than two years. Staff O stated the resident had recovered a lot and added that five months ago, he used to be total care, now he can stand up and goes to the bathroom. Staff O added that the resident is on bowel and bladder training and he is improving. Staff O stated that, Resident #43 does not have a walker, was on Restorative Nursing Program and therapy was started two days ago. Staff O stated that residents are to be ambulated by the Restorative Nursing Program Certified Nursing Assistant. Staff O explained that they will not walk the resident to the shower room and added that they are not authorized to walk the resident. Staff O stated she does not ambulate the resident in his room. Review of Resident #43's annual Minimum Data Set (MDS) assessment dated [DATE] documented resident required limited assistance with bed mobility, transfers, and dressing. Resident required total assistance with toilet use. The assessment documented Resident #43 had no impairment in his upper and lower extremities, was walked three days and did not receive passive or active ROM or Restorative Nursing Program service. Review of Resident #43 quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident required limited assistance with bed mobility, transfers, and dressing. Resident required total assistance with toilet use. The assessment documented Resident #43 had no impairment in his upper and lower extremities and did not receive passive or active ROM or Restorative Nursing Program service between the annual and the quarterly assessment period. Review of the facility's policy titled Specialized Rehabilitative and Restorative Services issued 03/2020, documented .the facility will provide restorative services such as but not limited to walking, transfer training .Range of Motion (ROM) .when necessary as indicated by the assessment of the interdisciplinary team. Review of the facility's policy titled Activities of Daily Living (ADLS) Maintain Abilities issued 03/2020, documented .It is the policy of the facility .that the care and services provided are person-centered .the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish the facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living .the facility will provide care and services for the following activities of daily living .Mobility-transfer and ambulation, including walking .