Every finding on record at Selmer Post Acute

Based on policy review, medical record review, and interview, the facility failed to follow Physician's Orders related to urology referrals and failed to obtain an order for Percutaneous Endoscopic Gastrostomy (PEG) site care for 2 of 6 residents (Resident #21 and #33) sampled residents reviewed for hospitalizations and PEG feedings. The findings include: 1. Review of the facility policy titled, Enteral Feedings- Safety Precautions, dated November 2018, revealed .Purpose .To ensure the safe administration of enteral nutrition .Assess for leaking around the gastrostomy.with each feeding or medication administration.observe for signs of skin breakdown, infection and irritation.Document all assessments, findings and interventions in the medical record. 2. Review of the medical record revealed Resident #21 was readmitted on [DATE], with diagnoses including Hydronephrosis, Renal and Ureteral Calculous Obstruction (occurs when a kidney stone gets lodged in the tube that carries urine from the kidney to the bladder, Urogenital Implants (medical devices used to address urinary or genital problems), Urinary Tract Infection, Bacteremia (the presence of viable bacteria in the bloodstream), Sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), and Acute Kidney Failure. Review of the progress note dated 6/16/2025, revealed Resident #21 was transferred to the hospital on 5/31/2025 with progressive weakness, poor appetite, and mental status changes. He was found to have a kidney stone and kidney infection with sepsis. He underwent a medical procedure to remove the stone, and a stent was placed in his ureter (tube that carries urine from the kidney to the bladder) on 6/1/2025. He was diagnosed with Sepsis with acute renal failure and renal cortical necrosis (when the small arteries supplying blood to the outer layer of the kidney are injured). Review of the progress note dated 6/16/2025, revealed .N.O. [New Order] per [named Doctor] to refer to a urologist. Stated to hold off on other referrals hospital recommended at this time. To set up appt [appointment] tommorrow [tomorrow] . Review of the Physician's Orders dated 6/17/2025, revealed .Referral to Urologist s/p [status post] stent placement one time only for ureter Stent for 2 Days. Review of the progress note dated 6/18/2025, revealed .called [named Doctor] office .re [regarding]: need for appointment-spoke with [named staff] -states that resident will be a new patient and they will need a referral first-states that she will fax referral papers .as requested-awaiting referral papers . Review of the Care Plan dated 5/29/2025, revealed the care plan was not revised to reflect Resident #21's current medical status. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #21 was moderately cognitively impaired. During an interview on 7/22/2025 at 5:11 PM, Registered Nurse (RN) C confirmed that an appointment with urology was never made for Resident #21. During an interview on 7/23/2025 at 2:21 PM, the MDS Coordinator RN confirmed that the Care Plan should have been revised to reflect the resident status post hospitalization. During an interview on 7/23/2025 at 4:11 PM, the Director of Nursing (DON) confirmed the urology appointment should have been made and stated, .the ball got dropped. 3. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes Mellitus, Mild Protein-Calorie Malnutrition, and Dysphagia. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #33 had moderately impaired cognition, was dependent on staff for Activities of Daily Living (ADLs), and had a feeding tube (PEG). Review of the Physician's Orders for May, June, and July 2025, revealed no order for PEG site care. Review of the Treatment Administration Record (TAR) for May, June, and July 2025, revealed no treatment for PEG site care was completed. During an interview on 7/23/2025 at 8:32 AM, Licensed Practical Nurse (LPN) B confirmed there was no order for PEG site care and there should have been. LPN B was asked how staff would be aware of the need to perform care if it was not ordered. LPN B stated, .I would hope that they know to do it. Observation of Resident #33's PEG site on 7/23/2025 at 9:11 AM, revealed an undated 4x4 split gauze to area. The PEG site was clean and dry. During an interview on 7/23/2025 at 10:31 AM, the DON was asked who performs PEG site care and how do they ensure it is completed. The DON stated, .It will be signed off on the TAR.The nurse does it .they should do it daily . The DON confirmed there was no order for PEG site care and there should have been an order.

Based on policy review, Care Path Fall guideline, medical record review, observation, and interview, the facility failed to document falls, implement fall interventions, and conduct a neurological assessment for 1 of 2 (Resident #4) sampled residents reviewed for falls. The findings include: 1. Review of the facility policy titled, Neurological Assessment (Routine), dated 10/2023, revealed The purpose of the procedure is to provide guidelines for conducting a routine neurological assessment ( neuro checks).Routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury.Routine neurological exams include assessing.mental status and level of consciousness.pupillary response.motor strength.sensation.gait.The following information should be recorded in the resident's medical record.The date and time the procedure was performed.The name and title of the individual(s) who performed the procedure.All assessment data obtained during the procedure.If the resident refused the procedure, the reason(s) why and the intervention taken.The signature and title of the person recording the data. Review of the facility policy titled, Falls and Fall Risk, Managing, dated 12/2007, revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.staff will identify and implement relevant interventions. Review of the CARE PATH Fall guideline signed by the Medical Director on 1/21/2025, revealed .Monitor Neuro checks x [times] 24-72* [hours]. 2. Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] with diagnoses including Dementia, Acquired Absence of Right Leg Above Knee, Acquired Absence of Left Leg Above Knee, and Depression. Review of the Physician's Orders for Resident #4 dated 5/14/2025, revealed .Bed pressure pad alarm when in bed to alert staff of residents attempts to rise unassisted. every shift.Chair/clip alarm while up in chair due to fall risk every shift. Review of the Incidents By Incident Type report dated 4/21/2025-7/21/2025, revealed .Un-witnessed Fall Incidents. on 5/23/2025, 5/26/2025, 6/4/2025, 6/20/2025, 6/23/2025, 7/7/2025, 7/16/2025, and 7/20/2025 for Resident #4. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #4 was moderately cognitively impaired with no behaviors. Resident #4 required partial/moderate staff assistance with bed mobility, substantial/maximal staff assistance with sit to lying, and was dependent upon staff with lying to sitting and transfers. Review of the Nurse's Note dated 5/26/2025, revealed .CALLED TO ROOM AND OBSERVED RESIDENT SITTING ON HIS BOTTOM IN THE FLOOR IN BETWEEN THE TWO BEDS, HE DIDNT KNOW HOW HE SAT IN THE FLOOR. HE THOUGHT HE WAS GETTING HIS WHEELCHAIR . There was no documentation in the medical record that a neurological assessment was conducted for Resident #4's fall on 5/26/2025. Review of the comprehensive care plan dated 5/27/2025, revealed .ASSESS FOR CHAIR/BED ALARM-applied Date Initiated: 2/1/2025 Revision on: 7/8/2025 .Bed alarm to bed, tab alarm when up in chair Date Initiated: 3/15/2025 Revision on: 7/8/2025 .education given to staff to put the bed alarm under bed sheet on top of mattress Date Initiated: 3/17/2025 Revision on: 7/8/2025.inservice staff to ensure bed alarm is in place Date Initiated: 6/23/2025 Revision on: 7/8/2025 . STAFF IN SERVICED TO USE BED PAN WHEN RESIDENT STATES HE NEEDS TO HAVE A BOWEL MOVEMENT AND TO REMOVE HIS BRIEF AND BOTTOM CLOTHING. STAFF ALSO IN SERVICED TO MAKE SURE THAT BED ALARM WAS ON BED,UNDER [BED, UNDER] RESIDENT AND IN WORKING ORDER WHEN HE IS IN BED. Date Initiated: 7/21/2025. There was no Nurse's Note documenting Resident #4's fall on 6/4/2025. There was no Nurse's Note documenting Resident #4's fall on 7/16/2025. Review of the Nurse's Note dated 7/20/2025, revealed .CNA [Certified Nursing Assistant] CALLED THIS NURSE TO RESIDENTS [Resident #4's] ROOM AND RESIDENT SITTING IN FLOOR IN FRONT OF WHEEL CHAIR FULLY CLOTHED ASKING TO FOR HELP [asking for help]. RESIDENTS BED ALARM DID NOT SOUND AS RESIDENT HAD BEEN IN BED HAVING A BOWEL MOVEMENT . Observation in Resident #4's room on 7/22/2025 at 3:35 PM, revealed Resident #4 was seated in the wheelchair (w/c) with a chair/clip alarm attached to the back of the w/c with alarm clip attached to the alarm strap, not the resident's clothing and no bed pressure alarm was present on the bed. During an interview on 7/22/2025 at 3:52 PM, Licensed Practical Nurse (LPN) E confirmed Resident #4's chair/clip alarm was not attached properly and that it should be attached to the resident's clothing. LPN E was asked if Resident #4 uses a bed pressure alarm when in bed. LPN E stated, .I'm not sure. LPN E asked CNA F if Resident #4 uses a bed alarm when in bed. CNA F stated, .no, he only has the clip alarm now. LPN E reviewed the electronic medical record and confirmed that Resident #4 did have an order for a bed pressure alarm when in bed. During an interview on 7/23/2025 at 2:40 PM, the Director of Nursing (DON) confirmed there was no documentation of a neurological assessment for Resident #4 on 5/26/2025. During an interview on 7/23/2025 at 4:11 PM, the DON was asked if she expected her staff to complete a neurological assessment on all un-witnessed falls. The DON stated, .I would prefer them to be done.

Based on policy review, medical record review, and interview the facility failed to obtain a Physician's Order for catheter care and failed to provide catheter care for 1 of 1 sampled resident (Resident #27) reviewed for indwelling urinary catheter. The findings include: 1. Review of the facility policy titled, Catheter Care, Urinary, dated August 2022, revealed .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse the labia [folds of skin around the vaginal opening] Use one area of the washcloth (or wipe) for each downward, cleansing stroke.Change the position of the washcloth (or wipe) and cleanse around the urethral meatus [the opening of the urethra, a tube that carries urine from the bladder to the outside of the body]. Do not allow the washcloth/wipe to drag on the resident's skin or bed linen.With a clean washcloth (or wipe), rinse using the above technique.The following information should be recorded in the resident's medical record.The date and time that catheter care was given.The name and title of the individual(s) giving the catheter care . 2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Retention of Urine, and Cerebral Infarction [occurs when a lack of blood flow to the brain causes brain cells to die]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #27 was cognitively intact, required assistance with activities of daily living (ADLs), and had an indwelling catheter. Review of the Physician Orders for July 2025, revealed there were no active orders for catheter care. Review of the Treatment Administration Record (TAR) for July 2025, revealed, .B&B [Bowel and Bladder]: Foley catheter Care every shift and prn [as needed].start date.7/2/2025.D/C [discontinued] date.7/11/2025. Review of the TAR dated July 2025, revealed there was no foley catheter care documented after Resident #27's return to the facility on 7/18/2025, following hospitalization for altered mental status (AMS) and urinary tract infection (UTI). Catheter care was not documented for 6 days. During an interview on 7/23/2025 at 8:00 AM, Resident #27 was asked if staff provided catheter care. Resident #27 stated, .I was told catheter care should be performed daily, but it is not always done. Sometimes they do it and sometimes they don't . During an interview on 7/23/2025 at 9:33 AM, LPN A was asked if Resident #27 had an order for catheter care. LPN A was unable to provide an order and confirmed residents with indwelling foley catheters should have an order for catheter care. During an interview on 7/23/2025 at 10:21 AM, the Director of Nursing (DON) was asked about the process to ensure catheter care is provided. The DON confirmed there should be an order for catheter care to be completed and documented daily.

Based on policy review, facility investigation review, weather website review, medical record review, and interview, the facility failed to ensure a safe environment with adequate supervision to prevent elopement for 1 of 3 sampled residents (Resident #1) reviewed for elopement/wandering behaviors. The facility's failure to ensure residents were adequately supervised resulted in Immediate Jeopardy when Resident #1, who had severe cognitive impairment, exited the rear dining room door and self-propelled her wheelchair (W/C) approximately 100 feet across the back parking lot. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Regional Nurse Consultant were notified of the Immediate Jeopardy (IJ) on 12/5/2022 at 12:15 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and a severity of J, which is Substandard Quality of Care. The IJ existed from 11/20/2022 through 11/28/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 11/28/2022. The facility was cited for past noncompliance for F-689 and is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients dated 6/21/2022, revealed, .facility ensures that residents .who are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Seizures, Rheumatoid Arthritis, Anxiety, and Hallucinations. The admission Minimum Data Set (MDS) assessment dated [DATE], and the quarterly MDS dated [DATE], revealed Resident #1 had severe cognitive impairment and required extensive assistance with activities of daily living. Review of the Wander book, a list of residents with high-risk for elopement, revealed 12 residents listed including Resident #1. Review of the Care Plan dated 10/23/2022 revealed, .has physical behavioral symptoms directed at others .10/23/22 .Resident wandering in and out of residents [residents'] rooms .has exhibited Wandering Behavior .11/18/22 .Episodes of exit seeking behavior noted .11/20/22 .Exit seeking behavior noted-Initiated Q [every] 15 minutes checks x [times] 24 hours . Review of the nurses' notes dated 11/20/2022 at 18:48 [6:48 PM] written by Licensed Practical Nurse (LPN) #1 revealed, .This nurse observed employee pushing resident in W/C from outside into facility at approx. [approximately] 1450 [2:50 PM]. Assisted resident to nurses [nurses'] station via W/C. Resident alert, confused .Impaired cognition limits resident's ability to explain what occurred .Resident has been up in W/C this shift self-propelling self about facility with frequent redirection required from staff . Review of Timeanddate.com website revealed the outside temperature on 11/20/2022 at 2:50 PM was 41 degrees Fahrenheit. During an interview on 11/28/2022 at 12:51 PM, the Administrator was asked about the elopement incident for Resident #1 on 11/28/2022. The Administrator stated, She [Resident #1] was seen at 14:40 [2:40 PM] in the facility and spotted at 14:50 [2:50 PM] in the parking lot by [named Floor Technician #1] .There are no videos of the incident . During an interview on 11/28/2022 at 1:21 PM, Dietary Aide #1 was asked about the elopement on 11/20/2022. Dietary Aide #1 stated, I was in the dish-washing room, and it [dish machine] was very loud. When it [dish machine] shut off, I heard a door alarm going off. When I looked out the window to the dining room, I didn't see anyone. It [door alarm] goes off often when staff go out and do not close it quick [quickly] enough. I went over and checked the door and pressed on the door but not forcefully. It didn't open. I did not see anyone outside. I guess she [Resident #1] had gone around the corner. There was no one in the dining room .[Named LPN #2], came in and asked me about if I had seen the resident [Resident #1]. This was after we had found her. LPN #2 walked over and pushed on the door, and it opened without a code . During an interview on 11/28/2022 at 1:36 PM, LPN #1 was asked about the elopement incident. LPN #1 stated, I noticed a staff member bringing her [Resident #1] inside from outside. She didn't have any complaints or perception of being outside .He [Floor Technician #1] said he had seen her between the Veterinarian Office and the facility and brought her back in .She [Resident #1] was around the 300 Nurses' Desk the last time I had seen her propelling herself in her wheelchair. I called the ADON [Assistant Director of Nursing] since she was the only number in my phone. I had seen the resident [Resident #1] about 2:35 PM, and she was brought to the desk at 2:50 PM. During an interview on 12/1/2022 at 10:12 AM, Floor Technician #1 was asked about the incident of Resident #1 exiting the facility. Floor Technician #1 stated, I was outside waiting on my ride, and I saw her [named Resident #1] in the back parking lot propelling her wheelchair . The facility's corrective action plan was verified by the surveyor on 11/28/2022 through medical record review, observations, staff interviews, in-service logs, review of audits, review of meeting minutes, and review of maintenance logs and invoices. 1. On 11/20/2022 at 2:50 PM, Resident #1 was assisted back into the facility. The surveyor made observations of Resident #1 in the facility asleep in her room. 2. On 11/20/2022 Resident #1 was assessed by LPN #1 with no injuries. This was verified by the surveyor by interview with LPN #1. 3. On 11/20/2022 a 100 percent (%) bed count conducted to ensure all residents were accounted for. This was verified by the surveyor by conducting staff interviews. 4. On 11/20/2022 Resident #1's elopement risk assessment was revised by LPN #1. This was verified by the surveyor through review of the elopement risk assessment. 5. On 11/20/2022 Resident #1's Care Plan was revised to include an intervention for elopement risk. This was verified by the surveyor through review of the Care Plan. 6. On 11/20/2022 the Responsible Party was notified of event. This was verified by the surveyor though medical record review. 7. On 11/20/2022 the Director of Nursing (DON) interviewed Resident #1, and the resident was found to have no psychological harm resulting from the event. This was verified by the surveyor through interviews. 8. On 11/28/2022 Resident #1 was scheduled to be seen by the Psychiatric Nurse Practitioner. This was verified by the surveyor though review of the medical record. 9. On 11/20/2022 the South Dining Room door was assessed by the DON, and found that the magnetic lock was not functioning appropriately. A door monitor was put in place until the door was repaired. This was verified by the surveyor through staff interviews and review of the door company invoice for repairs. 10. On 11/20/2022 the Director of Maintenance adjusted the door so it functioned properly. This was verified by the surveyor through interviews and review of the last 6 months of door checks performed by maintenance staff. 11. On 11/20/2022 at 8:00 PM, hourly checks were initiated for the South Dining Room door until the completion of repairs. This was verified by the surveyor through review of the recorded door check logs and staff interviews. 12. On 11/20/2022, every 15 minute checks were initiated for Resident #1 beginning at 11/20/2022 at 3:00 PM, until 11/22/2022 at 6:00 PM. This was verified by the surveyor through review of documented every 15 minute check logs for Resident #1 and staff interviews. 13. On 11/20/2022 all other doors were assessed by the DON, Administrator, and Director of Maintenance, and all were functioning properly. This was verified by the surveyor through review of the last 6 months door check logs completed by maintenance staff. 14. On 11/21/2022, 11/22/2022, and 11/23/2022, the Social Service Director re-evaluated Resident #1 for any psychological harm. This was verified by the surveyor through staff interviews and medical record review. 15. On 11/21/2022 the door lock company was contacted and completed appropriate repairs. This was verified by the surveyor through review of the invoice for parts and repairs. 16. On 11/21/2022 elopement risk assessments were reviewed and updated on 100% of residents. All new admissions had elopement risk assessments completed. This was verified by the surveyor through review of all new admission resident elopement risk assessments and medical records reviews for other random residents. 17. On 11/21/2022 a policy review was conducted. The Regional Director of Operations and the Regional Nurse Manager educated the facility Administrator and Nurse Managers on monitoring elopement risks and concerns. This was verified by the surveyor through review of the in-service sheet. 18. On 11/21/2022 elopement drills were completed on day and night shifts. Education was provided after each drill. Elopement drills to be conducted on each shift for 7 days. This was verified by the surveyor through staff interviews and review of the completed elopement drills. 19. On 11/21/2022 online training was assigned to staff through Relias with a due date of 11/28/2022. The online training was verified by the surveyor through review of all active staff sign-in sheets for in-services and completion of Relias training on wandering and elopement. 20. On 11/21/2022 door checks were to be completed each shift for 2 weeks, then once daily for 2 weeks. This was verified by the surveyor through review of the door checks log sheet. 21. On 11/21/2022 the Interdisciplinary Team (IDT) met with the Medical Director and conducted a Quality Assurance and Performance Improvement (QAPI) review to discuss incident and interventions put in place and preventative measures. This was verified by the surveyor through review of the sign-in sheet for the QAPI meeting. 22. On 11/20/2022 at 4:30 PM, and 11/21/2022 at 10:00 AM, the Governing Body met to discuss the incident, interventions, and preventative measures put in place. This was verified by the surveyor through interviews. 23. Audit results of the exit doors and alarms, new hire education, new admission elopement risk assessments, and elopement drills will be reviewed daily Monday through Friday by the IDT to ensure compliance. Audit results review will occur for 4 weeks or until compliance is maintained. This was verified by the surveyor through review of audits.

Based on policy review, observation, and interview, the facility failed to provide housekeeping services to maintain a sanitary interior, properly label, and store housekeeping chemicals for 3 of 3 housekeeping carts (200 Hall, 300 Hall, and 400 Hall) and 1 of 1 Laundry Room observed. The findings include: Review of the facility's policy titled, Housekeeping-Cleaning and Disinfecting, revised 7/12/2021 and effective 5/26/2022, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The facility requires the use of cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks .'Cleaning' refers to the removal of visible soil from objects and surfaces and is normal accomplished manually or mechanically using water and detergents or enzymatic products .'Disinfection' refers to a chemical destruction of pathogenic and other types of microorganisms .Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule to keep surfaces clean and dust free. Surfaces that are frequently touched by hands of health care personnel and residents, may require more frequent cleaning .Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas to include, but not limited to: Toilet flush handles, Bed rails, Tray tables, Call buttons and cords, TV [television] remote Telephones, Toilet seats, Monitor control panels, touch screens and cables, Resident chairs, Sinks and faucets, Light switches, Door knobs and leavers, Support railings, Dispensers, Door frames, Furniture in common areas. Bathroom cleaning and disinfection to include, but not limited to: Remove soiled linen and trash, clean inside and outside the sink, faucets, and mirror. Apply disinfectant to the interior of the sink and allow contact times to disinfect according to manufacturer's recommendations. Rinse and dry fixtures. Wipe plumbing under the sink .When using the disinfectant solution, it will be prepared fresh daily and changed frequently in order to ensure effectiveness if using products that must be mixed. Follow manufacturer recommendations for dilution and frequency of changing of disinfectant solution. Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection .Staff will ensure cleaning carts are checked and stocked with necessary supplies at the beginning of each shift . Observation in the 300 Hall on 9/8/2022 at 9:43 AM, revealed Floor Technician #1 mopping a resident's room and the technician's cart had a personal drinking cup with liquid sitting in the top of the cart. During an interview on 9/8/2022 at 9:43 AM, Floor Technician #1 was asked was that his personal drinking cup and is there liquid in the cup. He stated, .Yes . Observation in the 400 Hall on 9/8/2022 at 10:00 AM, revealed Housekeeper #1's housekeeping cart with a bucket of liquid with cloths soaking in the liquid. Inside the cart was a spray bottle of TruShot. During an interview on 9/8/2022 at 10:00 AM, Housekeeper #1 was asked what the solution in the bucket was. She stated, .Lysol, I take three towels [cloths from the liquid] in the room with me and clean the room including the bathroom . Housekeeper #1 was asked when the TruShot was used. She stated, .I can use both .but if I smell germs, I use Lysol .I like to use Lysol mostly . Observation in the 200 Hall on 9/8/2022 at 10:15 AM, revealed Housekeeper #2's housekeeping cart with a bucket of liquid with cloths soaking in the liquid. Inside the cart was two packages of donuts, a personal water bottle with liquid inside, and a bottle labeled Mr. Clean with a brown liquid in the bottle. During an interview on 9/8/2022 at 10:15 AM, Housekeeper #2 was asked what the liquid in the bucket was. She stated, .I get it out of the Environmental Closet . She walked to the Environmental Closet and held up a jug of solution attached to a water hose. She stated, I use this. The label read floor cleaner. When asked if she used floor cleaner to clean the surfaces in the residents' rooms. She stated, .Oh .no .I need to talk to my supervisor . During an interview in the 200 Hall on 9/8/2022 at 10:20 AM, the Environmental Services Director was asked about the Mr. Clean bottle in Housekeeper #2's cart. She looked at the bottle with the brown liquid and stated, .That is not Mr. Clean that is Pine Sol . Housekeeper #2 confirmed the chemical in the Mr. Clean bottle was not Mr. Clean. Housekeeper #2 stated, .Oh, those are my donuts and water bottle in the cart .I guess I better get them out . Observation in the Laundry Room on 9/8/2022 at 10:25 AM, revealed a cabinet with an unlabeled large white bottle with liquid inside, two unlabeled spray bottles containing liquid, one with a blue liquid and the other with a clear liquid, two-gallon size jugs of Mr. Clean labeled containers with yellow liquid in the containers. The Mr. Clean size jugs documented mix 1/4 cup with 1 gallon of water. During an interview in the Laundry Room on 9/8/2022 at 10:25 AM, the Environmental Services (ES) Director was asked about the un-labeled containers with liquid in each. She stated, .I don't know what is in this one . She opened the lid and sniffed the open container. She stated, .That is Lysol .I don't know why that is in here . She stated, . the spray bottle with the blue liquid is Virex 256 .I know because it is blue .the spray bottle with the clear liquid I think it is for odor. I don't know why it is in here . The ES Director was asked what the staff uses to measure the amount of solution to place in their housekeeping buckets for ratio to water for dilution to ensure effectiveness of the disinfectant. She stated, .Well, they have something on their carts to measure with . When the ES Director was asked what the measurement of solution was to water ratio and the product for them to use, she stated, .I'm not sure . Observation of the 200 Hall, 300 Hall, and 400 Hall housekeeping carts on 9/8/2022 at 10:30 AM, revealed no measurement tool on any of the housekeeping carts or in the Laundry Room cabinet for staff to use to measure the amount of solution to water ratio. The ES Director was present during the observation of the carts and cabinet and confirmed no such measurement tool/cup existed. She confirmed the failure to follow manufacturer recommendation for dilution of the disinfectant solution to ensure effectiveness of the disinfectant. During an interview on 9/8/2022 at 10:30 AM, Housekeepers #1, #2 and #3 were asked what the process was of cleaning a resident's room. All three housekeepers stated they use the cloths that are in the bucket of liquid to wipe all tables down, bed rails and bathrooms, including the toilet. During an interview on 9/8/2022 at 10:35 AM, the Administrator stated, .I'm not aware of using Lysol or Mr. Clean. I thought used only approved Johnson and Johnson products TruShot . During an interview on 9/8/2022 at 10:35 AM, the Regional Nurse Manager stated, .We tried to streamline our products so as not to have things like that lying around .

Based on policy review, job description review, record review, observation, and interview, the facility failed to provide sufficient staff with competencies and skill sets to carry out the functions of the food and nutrition services for 8 of 8 staff members (Cook #1, Certified Nursing Assistant (CNA) #1, Laundry Staff #1, Staff #1, #2, #3, #4, and #5) working in the Kitchen. The facility had a census of 93, with 92 of those residents receiving a meal tray from the Kitchen. The findings include: Review of the facility's policy titled, Dietary: Food Safety Requirements, dated 9/15/2019 and revised 10/15/2021, revealed .Food will also be stored, prepared and served in accordance with professional standards for food service safety . Review of the facility's undated form titled, Dietary Competency and Skills Check Off, revealed .Wears hair restraint correctly .Hands are washed thoroughly using proper hand washing techniques .Employees correctly explains food rotation. Employee correctly identifies dented cans. Employee knows where chemicals are stored .Employee correctly reads thermometer in fridge [refrigerator]/freezer. Employee knows the correct temperature range for fridge: 41 degrees [Fahrenheit] or above. Employee knows the correct temperature range for freezer: 0 degrees or below. Employee correctly identifies correct location to store eggs and thawing meats .Employee correctly demonstrates how to calibrate a thermometer. Employee correctly demonstrates how to obtain a food temperature. Employee correctly demonstrates how to fill a mop bucket. Employee correctly tests the chemical concentration in the dish machine. Employee correctly tests the chemical concentration in the third compartment sink. Employee correctly tests the chemical concentration of Sanitizer solution . Review of the facility's policy titled, Dietary: Hand Washing Techniques, dated 9/19/2019 and revised 10/15/2021, revealed .Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses .Dietary employees shall keep their hands and exposed portions of their arms clean .Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.) .Before donning gloves for working with food . Review of the facility's policy titled, Dietary-Mechanical Dish Washing, dated 10/31/2020 and revised 10/15/2021, revealed .Dishes will be cleaned and sanitized after each use .Low temp machine: 120-140 [degrees] F [Fahrenheit] with chemical sanitizer If the same person is loading and unloading the racks, hands must be washed or sanitized before touching the clean surfaces of the items in the rack. Employees may use a clean utensil to remove the rack from the dish machine without washing/sanitizing hands provided the items in the rack are not touched .The temperature of the dish machine will be recorded three [3] times a day. Temperatures out of specified range will be reported .Wash and rinse temperatures will be observed and recorded at each meal service. This will be achieved while the dish machine is in operation .Low temperature machines should be between 120 [degrees] - 140 [degrees]. With the low temperature machines, the sanitizer will also be checked and recorded using a pH strip. Any temperatures recorded outside the acceptable levels should be reported to the supervisor immediately. Maintenance should be notified. Dish machine sanitizer must be tested and recorded before each mealtime when using a low temp machine: Use chemical strips recommended by chemical provider [Iodine, quaternary, or bleach]. Using the system as instructed by the chemical provider, record the appropriate sanitizing levels. If the correct parts per million are not obtained, the solution will be adjusted as needed. Record - ok if correct parts per million are obtained using the system as instructed by chemical provider. Employee should initial after completion . Review of the facility's policy titled, Dietary: Manual Ware Washing-3 Compartment Sink, dated 10/31/2020 and revised 10/15/2021, revealed .Purpose to prevent the spread of bacteria that may cause food borne illness, the 3 compartment sink is used to wash, rinse and sanitize pot, pans and other utensils .Procedure: Step 1 first sink wash, second sink rinse, third sink sanitize .Third sink sanitizing fill with hot water [171 degrees F] or use chemical sanitizer; hot water iodine @ 12.5 ppm [parts per million]; or Quat ammonia at 150-200 ppm; or detergent chlorine at 50-100 ppm. Confirm appropriate temperature or concentration prior to washing and record on log .immerse rinsed pots/utensils in sanitizer per manufacturer instructions; chlorine at least 10 seconds; iodine at least 30 thoroughly seconds or hot water for at least 30 seconds .allow pots/utensils to air dry; store pots upside down or covered . Review of the facility's undated job description titled, Dishwasher, revealed .The purpose of this position is to aid in numerous dietary functions as directed, assigned or instructed, such as upkeep of dish machine, floors, washing dishes, as well as clean up duties, all in accordance with current applicable federal, state and local standards, guidelines and regulations, as well as company policies and procedures .To perform this job, an individual must perform each essential function satisfactorily .Fill dish machine and complete at least two cycles with machine free of dishes. Record the temperature of dish machine and machine water temperatures. Use appropriate chemical test strips to determine proper sanitizing level and record results. Empty dishwasher and properly store clean dishes/utensils .Use proper procedures when working dirty to clean areas in dish room .Assist on the serving line as needed. Assist Dietary Tray Aide with necessary duties .Follow the established universal precautions, safety and infection control, and isolation procedures . Observation in the Kitchen on 6/10/2022 at 10:55 AM, revealed a three-compartment sink with sudsy liquid in the first compartment, second compartment clear water, third compartment with clear water. The surveyor requested Cook #1 to test the sanitizer water in the third compartment of the sink. Cook #1 did not use the Quat ammonia strip correctly (immersing for 10 seconds) when attempting to obtain a reading. She attempted three times without any reading of sanitizer present in the water. After being taught correctly by the Registered Dietitian (RD) how to use the strip and retesting the water, the Quat ammonia strip failed to change colors. Review of Manual Ware Washing -Three compartment Sink log dated 6/2022, revealed there was no documentation of morning, afternoon, or evening chemical strip readings or employee initials of completion for 6/7/2022, 6/8/2022, 6/9/2022 or the morning of 6/10/2022. During an interview on 6/10/2022 at 10:55 AM, Cook #1 stated, .been a couple of days got behind in recording the readings . When she was asked what the reading should be if using a Quat ammonia strip, she stated, .I don't know but it should change colors . When asked what it means if the strip does not change color or has a color not within acceptable range, she stated, .I don't know . Observations in the dishwasher room on 6/10/2022 at 2:32 PM, revealed the low temperature machine was in use and the temperature was 114 degrees F. CNA #1 was prewashing dirty dishes then once the machine completed the load, she removed the clean load and pushed a dirty load into the machine. She returned to the dirty dish side and rinsed them. The clean load completed, and she took her dirty hands, removed the clean load, and proceeded to remove the dishes from the rack and place in storage. She returned to the dirty dish side and continued rinsing dirty dishes. She never washed her hands between work areas of dirty to clean and touched clean dishes to store. Review of the Dish Machine Temperatures-Sanitation log dated 6/2022, revealed no documentation of temperature or chemical strip readings for breakfast, lunch and supper completed for 6/5/2022 - 6/9/2022 and breakfast and lunch for 6/10/2022. During an interview on 6/10/2022 at 2:32 PM, CNA #1 stated, .I don't know anything about what the temperature should be on this machine or anything about doing a test strip to check the sanitizer .No one has told me about any of that much less that I am supposed to write something down .I have received no instructions . During an interview on 6/10/2022 at 3:30 PM, the Administrator stated, .We have been very short staffed in the dietary department .The staff just quit without notice .I have had to pull in from everywhere . Observation in the Kitchen on 6/10/2022 at 6:13 PM, revealed Laundry Staff #1 took a plate with breakfast food from the refrigerator and placed it in the microwave with the plastic on the top of the food and heated the plate. The plastic melted onto the food. During an interview on 6/10/2022 at 6:13 PM, Laundry Staff #1 stated, .that is what I do at home .I didn't know it would melt into the food . During an interview on 6/13/2022 at 2:19 PM, the Administrator was asked to provide dietary competencies on all employees working in the Kitchen. Record review revealed no dietary competencies on any staff working in the Kitchen on 6/10/2022. She stated, .I only have [competencies] on three employees and that is all I can find . She confirmed there were no dietary competencies for all 8 employees (Cook #1, CNA #1, Laundry Staff #1, Staff #1, #2, #3, #4, and #5) working in the Kitchen on 6/10/2022.

Based on policy review, job description review, record review, observation, and interview, the facility failed to properly store, prepare, distribute and serve food under sanitary and safe conditions as evidenced by the failure to follow proper handwashing guidelines, low temperature dish washing machine not operating at desired temperature and sanitizer level, use of out dated leftover food, storage of leftover food not dated, failed to follow recipe and mixing guidelines during meal preparation, failed to heat and maintain food temperatures of soup, improper sanitizer level/readings in the three compartment sink, failed to record temperatures of the refrigerator and freezer as required, failed to record the cleaning of the dietary department as required per facility policy, failed to follow infection control practices during food preparation and tray line, and served/delivered the wrong diet to a resident. The facility had a census of 93, with 92 of those residents receiving a meal tray from the Kitchen. The findings include: Review of the facility's policy titled, Dietary: Food Safety Requirements, dated 9/15/2019 and revised 10/15/2021, revealed .Food will also be stored, prepared and served in accordance with professional standards for food service safety . Review of the facility's undated form titled, Dietary Competency and Skills Check Off, revealed .Wears hair restraint correctly .Hands are washed thoroughly using proper hand washing techniques .Employees correctly explains food rotation. Employee correctly identifies dented cans. Employee knows where chemicals are stored .Employee correctly reads thermometer in fridge [refrigerator]/freezer. Employee knows the correct temperature range for fridge: 41 degrees [Fahrenheit] or above. Employee knows the correct temperature range for freezer: 0 degrees or below. Employee correctly identifies correct location to store eggs and thawing meats .Employee correctly demonstrates how to calibrate a thermometer. Employee correctly demonstrates how to obtain a food temperature. Employee correctly demonstrates how to fill a mop bucket. Employee correctly tests the chemical concentration in the dish machine. Employee correctly tests the chemical concentration in the third compartment sink. Employee correctly tests the chemical concentration of Sanitizer solution . Review of the facility's policy titled, Dietary: Hand Washing Techniques, dated 9/19/2019 and revised 10/15/2021, revealed .Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses .Dietary employees shall keep their hands and exposed portions of their arms clean .Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.) .Before donning gloves for working with food . Review of the facility's policy titled, Dietary-Mechanical Dish Washing, dated 10/31/2020 and revised 10/15/2021, revealed .Dishes will be cleaned and sanitized after each use .Low temp machine: 120-140 [degrees] F [Fahrenheit] with chemical sanitizer .If the same person is loading and unloading the racks, hands must be washed or sanitized before touching the clean surfaces of the items in the rack. Employees may use a clean utensil to remove the rack from the dish machine without washing/sanitizing hands provided the items in the rack are not touched .The temperature of the dish machine will be recorded three [3] times a day. Temperatures out of specified range will be reported .Wash and rinse temperatures will be observed and recorded at each meal service. This will be achieved while the dish machine is in operation .Low temperature machines should be between 120 [degrees] - 140 [degrees]. With the low temperature machines, the sanitizer will also be checked and recorded using a pH strip. Any temperatures recorded outside the acceptable levels should be reported to the supervisor immediately. Maintenance should be notified. Dish machine sanitizer must be tested and recorded before each mealtime when using a low temp machine: Use chemical strips recommended by chemical provider [Iodine, quaternary, or bleach]. Using the system as instructed by the chemical provider, record the appropriate sanitizing levels. If the correct parts per million are not obtained, the solution will be adjusted as needed. Record - ok if correct parts per million are obtained using the system as instructed by chemical provider. Employee should initial after completion . Review of the facility's policy titled, Dietary: Manual Ware Washing-3 Compartment Sink, dated 10/31/2020 and revised 10/15/2021, revealed .Purpose to prevent the spread of bacteria that may cause food borne illness, the 3 compartment sink is used to wash, rinse and sanitize pot, pans and other utensils .Procedure: Step 1 first sink wash, second sink rinse, third sink sanitize .Third sink sanitizing fill with hot water [171 degrees F] or use chemical sanitizer; hot water iodine @ [at] 12.5 ppm [parts per million]; or Quat ammonia at 150-200 ppm; or detergent chlorine at 50-100 ppm. Confirm appropriate temperature or concentration prior to washing and record on log .immerse rinsed pots/utensils in sanitizer per manufacturer instructions; chlorine at least 10 seconds; iodine at least 30 thoroughly seconds or hot water for at least 30 seconds .allow pots/utensils to air dry; store pots upside down or covered . Review of the facility's policy titled, Dietary-Nutritive Value, Appearance and Temperatures, dated 11/1/2017 and revised 7/14/2021, revealed .Each resident receives, and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that is palatable, attractive, and at a safe and appetizing temperature .Food should be palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction. Providing palatable, attractive, and appetizing food and drink to residents can help to encourage residents to increase the amount they eat and drink. Improved nutrition and hydration status can help prevent, or aid in the recovery from, illness or injury .Food temperatures will be recorded on the daily food temperature log . Review of the facility's policy titled, Dietary: Food Service, dated 9/1/2012 and revised 7/12/2021, revealed .Leftover foods are stored in appropriate containers so that the interior temperature of the food chills quickly to [symbol less than or equal] 41 [degrees] F. They are covered, labeled and dated .Leftovers should be used within three [3] days and may be used as alternate menu items . Review of the facility's policy titled, Dietary: Cleaning, dated 7/13/2021, revealed .Adequate cleaning and sanitizing will minimize the risk of food borne illnesses. The CDM [Certified Dietary Manager]/Kitchen Supervisor is responsible for maintaining a cleaning schedule to indicate which equipment and areas are to be cleaned and at what frequency. Cleaning surfaces, equipment or utensils involve the use of hot water and detergent which removes soil, grease, food, and odors. Sanitizing can occur by applying heat and/or chemicals for a sufficient amount of time to reduce bacterial count on counters, dishware, utensils, and pots and pans. The CDM/Kitchen Supervisor will post a weekly cleaning schedule that identifies: The equipment or area to be cleaned. The frequency of cleaning. The position/staff responsible for cleaning .The weekly cleaning schedule will be used to document when a cleaning assignment is complete. The CDM/Kitchen Supervisor will audit the cleaning schedule for completeness . Review of the facility's undated job description titled, Cook, revealed .The purpose of this position is to prepare food in accordance with current, applicable federal, state and local standards, guidelines and regulations and facility policies and procedures; and to ensure that quality food service is always provided .To perform this job, an individual must perform each essential function satisfactorily .Prepare and serve meals that are palatable and appetizing and in accordance with medically appropriate portion control. Review menus prior to preparation of food and inspect special diet trays to ensure accurate preparation .Follow established Infection Control and Universal Precautions policies when performing daily tasks .Complete forms and reports to document dietary procedures .Assist in establishing food service production lines, etc. to ensure that meals are prepared on time. Assist in and/or direct scheduled cleaning duties . Review of the facility's undated job description titled, Dietary Aide, revealed .The Dietary Aide is to assist with various dietary functions as directed, assigned or instructed, such as setting up beverages, meals, utensils in preparation for and delivery of food service to patients as well as clean up duties. All tasks are expected to be performed in accordance with applicable federal and state regulations and established facility procedures and policies .Follow established safety and infection control regulations and policies .Assist in establishing food service production line to ensure that meals are prepared on time. Assist in and/or direct scheduled cleaning duties. Assist cook in preparing meals . Review of the facility's undated job description titled, Dishwasher, revealed .The purpose of this position is to aid in numerous dietary functions as directed, assigned or instructed, such as upkeep of dish machine, floors, washing dishes, as well as clean up duties, all in accordance with current applicable federal, state and local standards, guidelines and regulations, as well as company policies and procedures .To perform this job, an individual must perform each essential function satisfactorily .Fill dish machine and complete at least two cycles with machine free of dishes. Record the temperature of dish machine and machine water temperatures. Use appropriate chemical test strips to determine proper sanitizing level and record results. Empty dishwasher and properly store clean dishes/utensils .Use proper procedures when working dirty to clean areas in dish room .Assist on the serving line as needed. Assist Dietary Tray Aide with necessary duties .Follow the established universal precautions, safety and infection control, and isolation procedures . Observation in the Kitchen on 6/10/2022 at 10:40 AM, revealed the back door of the Kitchen leading outside the building propped open and remained open the entire lunch and supper shift from 10:40 AM - 7:30 PM. Three flies in the kitchen landed on food and cooking utensils. A large tray of cooked fish bites was sitting on a preparation (prep) table not covered with flies landing on the food multiple times. During an interview on 6/10/2022 at 10:40 AM, Cook #1 was asked what the uncovered tray of food sitting on the prep table was and why was it sitting out. Cook #1 stated, .I have already cooked those fish bites .I am planning on chopping them and puree them then set back on burner to warm them back up . Observation in the Kitchen on 6/10/2022 at 10:50 AM, revealed Cook #1 making corn bread. She had a dry powdered material, several eggs, cartons of liquid and began to pour and mix. She had no measurements of how much dry material, eggs, cartons of liquid and began mixing. She broke an egg on the side of the container and part of the shell fell into the mixture. She took her gloved finger and attempted multiple times to remove the broken eggshell out of the mixture until she finally succeeded. During an interview on 6/10/2022 at 10:50 AM, Cook #1 was asked what she was making, and if she knew the recipe for what she was preparing. Cook #1 stated, .I am making cornbread and I don't go by recipes. I just start mixing and go by consistency .I have no idea about a recipe book or a menu list .I just go by whatever he [Dietary Manager] types [menu] and tapes over there on the prep table . When asked how she knew the nutritional value for the large volume to make for the residents if she doesn't go by recipes or directions. She shrugged her shoulders and said, .I don't know . Observation in the Kitchen on 6/10/2022 at 11:35 AM, revealed Cook #1 making mashed potatoes. She had a clear liquid in a container and began to pour Complete Seasoned Mash Potatoes from a box into the clear liquid. She did not measure the liquid or the amount of dried mashed potatoes she was pouring. During an interview on 6/10/2022 at 11:35 AM, Cook #1 was asked what she was making and if she measured the ingredients. Cook #1 stated, .No, I don't measure. I do it by thickness . When asked how she knew if the mixture was correct to give the nutritional value each resident is supposed to get with a serving of mashed potatoes, she stated, .I don't know . Observation in the Kitchen on 6/10/2022 at 11:40 AM, revealed Certified Nursing Assistant (CNA) #2 heating bowls filled with tomato soup in the microwave. There was a total of 5 bowls of tomato soup. When the soup was removed from the microwave, the temperature was never assessed, and the bowl was placed on the resident's trays. During an interview on 6/10/2022 at 11:40 AM, CNA #2 was asked how long she heated the tomato soup up for and did anyone measure the temperature of the soup. She stated, .I heated it up for about two minutes sometimes three .No, we didn't check the temperature .are we supposed to . Observation in the Kitchen of the tray service line on 6/10/2022 at 11:50 AM, revealed the serving ladle for chopped meat and puree meat was two ounces. The mechanical soft/chopped meat was not chopped good (had large chunks of food). Cook #1 took her gloved hand that she had touched utensils, equipment with and stuck it in the container and broke the mechanical soft meat up with her hand. During an interview on 6/10/2022 at 11:50 AM, Cook #1 was asked the serving size of protein/meat for chopped meat and puree meat. She stated, .It should be four ounces .my ladle is two ounces so I will just [NAME] it up on the ladle .No, I don't measure . During an interview on 6/10/2022 at 11:50 AM, the Registered Dietitian (RD) was asked what the portion size for meat/protein and she stated, .four ounces . Observation in the Kitchen on 6/10/2022 at 11:50 AM, revealed the Dietary Aide called a resident's name and stated the resident could not have fish. Cook #1 stated, .give her tomato soup . During an interview on 6/10/2022 at 11:50 AM, the RD was asked if a bowl of tomato soup was nutritionally the same as the protein portion of a meal. She stated, .No . Observation in the Kitchen during tray line on 6/10/2022 at 12:40 PM, revealed Cook #1 added water to the puree meat. CNA #2 pulled from the refrigerator a container of mixed peanut butter and jelly. The aluminum foil covering of the peanut butter and jelly mixture had no date. During an interview on 6/10/2022 at 12:40 PM, the RD was asked by the cook adding more water to the puree meat does that affect the nutritional value of the portion size when served. She stated, .Yes . The RD confirmed no date documented on the peanut butter and jelly mixture in the container. She stated, .don't know when that [peanut butter and jelly mixture] was made . Observation in the Kitchen on 6/10/2022 at 12:40 PM, revealed the RD pulled a zip lock bag of leftover cooked chicken breast from the refrigerator. The date on the bag was 6/6/2022. The RD placed several chicken breasts in the robot coupe and chopped them up to use as an alternate for residents. During an interview on 6/10/2022 at 12:40 PM, the RD confirmed the date on the bag was 6/6/2022. She stated, .Yeah, I saw you look at the bag after I had chopped it up .It is over 3 days .should be thrown out . Observation in the Kitchen on 6/10/2022 at 12:40 PM, revealed 4 plates in the plate warmer with a thin film substance on the plates. The plate warmer had a large amount of brown/black flake substances around the rims of the warmer. Six bowls were discolored and with scratch marks, and one with a red substance on the rim. Observation in the Kitchen on 6/10/2022 at 10:55 AM, revealed a three-compartment sink with sudsy liquid in the first compartment, second compartment with clear water, and the third compartment with clear water. The surveyor requested Cook #1 to test the sanitizer water in the third compartment of the sink. Cook #1 did not use the Quat ammonia strip correctly (immersing for 10 seconds) when attempting to obtain a reading. She attempted three times without any reading of sanitizer present in the water. After being taught correctly by the RD how to use the strip and retesting the water, the Quat ammonia strip failed to change colors. Review of Manual Ware Washing -Three compartment Sink log dated 6/2022, revealed there was no documentation of morning, afternoon, or evening chemical strip readings or employee initials of completion for 6/7/2022, 6/8/2022, 6/9/2022, or morning of 6/10/2022. During an interview on 6/10/2022 at 10:55 AM, Cook #1 stated, .been a couple of days got behind in recording the readings . When she was asked what the reading should be if using a Quat ammonia strip, she stated, .I don't know but it should change colors . When asked what it means if the strip does not change color or has a color not within acceptable range, she stated, .I don't know . Observation in the dishwasher room on 6/10/2022 at 2:32 PM, revealed the low temperature machine was in use and a temperature of 114 degrees F. CNA #1 was prewashing dirty dishes then once the machine completed the load, she removed the clean load and pushed a dirty load into the machine. She returned to the dirty dish side and rinsed them. The clean load completed, and she took her dirty gloved hands, removed the clean load and proceeded to remove the dishes from the rack and place in storage. She returned to the dirty dish side and continued rinsing dirty dishes. She never washed her hands between work areas of dirty to clean and touched clean dishes to store. Observation in the dishwasher room on 6/10/2022 at 2:32 PM, revealed the low temperature machine was in use and temperature never increased past 114 degrees F. The RD used the chlorine test strip to measure the sanitizer. The chlorine test strip read 10 ppm. Review of the Dish Machine Temperatures-Sanitation log dated 6/2022, revealed there was no documentation of temperature or chemical sanitizer strip readings for breakfast, lunch, and supper completed for 6/5/2022 - 6/9/2022 and breakfast and lunch for 6/10/2022. During an interview on 6/10/2022 at 2:32 PM, the RD confirmed the temperature on the low temperature dishwasher at 114 degrees F and the chlorine test strip reading of 10 ppm. She stated, .the dishwasher should be minimum 120 degrees F and the chlorine test strip should read 50 ppm .10 ppm is not the correct sanitizer level .the dish machine temperature and sanitation log are incomplete . During an interview on 6/10/2022 at 2:32 PM, CNA #1 stated, .I don't know anything about what the temperature should be on this machine or anything about doing a test strip to check the sanitizer .No one has told me about any of that much less that I am supposed to write something down .I have received no instructions . Observation in the Kitchen on 6/10/2022 at 10:40 AM, revealed Dietary Aide #1 failed to wash hands properly and touched the paper towel dispenser after washing hands which resulted in recontamination of hands. Observation in the Kitchen on 6/10/2022 at 4:05 PM, revealed Laundry Staff #1 failed to wash their hands on entry into the dietary department on five different occasions. During supper meal tray line, Cook #2 using her gloved hand, touched the front of her mask and pulled it down four different times then placed the mask back on her face and continued to place food on the plates. Observation in the Kitchen on 6/10/2022 at 5:20 PM, revealed Cook #2 picked up trash (aluminum foil) from the floor and placed it on the prep table, did not wash her hands and proceeded to the hamburger pan and transferred the hamburger patties from the pot to the flat tray. Cook #2 touched the hamburger patty with ungloved hand while placing it on the flat tray. Observation in the Kitchen on 6/10/2022 at 5:33 PM, revealed Cook #2 did not wash her hands prior to donning gloves. Observation in the Kitchen on 6/10/2022 at 5:42 PM, revealed Dietary Aide #1 dropped a straw on the floor, picked it up off the floor and placed it on a resident's tray. Cook #2 on four different occasions failed to wash her hands prior to donning gloves and after glove removal. Observation in the Kitchen on 6/10/2022 at 5:47 PM, revealed Cook #2 went to the refrigerator and touched the Cole slaw bucket, returned to the tray line, changed her gloves, and did not wash her hands. Observation in the Kitchen on 6/10/2022 at 6:13 PM, revealed Laundry Staff #1 took a plate with breakfast food from the refrigerator and placed it in the microwave with the plastic wrap on the top of the food and heated the plate. The plastic melted on the food. During an interview on 6/10/2022 at 6:13 PM, Laundry Staff #1 stated, .that is what I do at home .I didn't know it would melt into the food . Review of the Daily Food Temperatures logs revealed the following: Monday 5/23/2022 and Tuesday 5/24/2022-no documentation of temperatures taken for chopped meat for lunch and dinner meals Wednesday 5/25/2022 - Saturday 5/28/2022-no documentation of temperatures taken for chopped meat for dinner meals. Wednesday 6/1/2022-no documentation of temperatures taken for chopped meat dinner meal. Thursday 6/2/2022-no documentation of temperature taken for vegetable dinner meal or chopped meat dinner meal. Friday 6/3/2022 and Saturday 6/4/2022-no documentation of temperature taken for chopped meat dinner meals. Wednesday 6/8/2022 and Thursday 6/9/2022-no documentation of temperature taken for breakfast and lunch meals. Friday 6/10/2022-no documentation of temperature taken for breakfast meal. Wednesday 6/8/2022 and Thursday 6/9/2022-no documentation of temperature taken for chopped meat dinners and puree meat for 6/9/2022 dinner. Review of the facility's Cleaning Schedule logs revealed no documentation of daily or weekly cleaning of the dietary department for 6/2022. There was no documentation of daily cleaning for the week of 5/9/2022, 5/16/2022, 5/23/2022, and 5/30/2022. There weas no documentation of weekly cleaning for the week of 5/16/2022, 5/23/2022 and 5/30/2022. Observation in the Kitchen on 6/10/2022 at 4:15 PM, revealed Cook #1 attempting to fill out the cleaning logs from week of 4/25/2022, 5/9/2022, and 5/16/2022. During an interview on 6/10/2022 at 4:15 PM, Cook #1 stated, .They just told me to fill these out .I don't know what I am doing .Just trying to do what they asked me . The Regional Nurse Consultant stated, .No, stop we don't try to go back and document things .it wasn't done . Cook #1 confirmed the cleaning logs were blank. During an interview on 6/10/2022 at 3:30 PM, the Administrator stated, .We have been very short staffed in the dietary department .The staff just quit without notice .I have had to pull in from everywhere . Medical record review revealed, Resident #4 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)] and Dysphagia. Medical record review revealed, Resident #5 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and Alzheimer's Disease. Observation in the resident's room on 6/10/2022 at 6:31 PM, revealed Resident #4 sitting up in bed feeding self a hamburger and potato salad. She had taken at least two bites of hamburger patty and bun with lettuce, cheese, tomato, pickle and at least one bite of potato salad. CNA #3 was in the room and had set up Resident #4's tray and asked if she needed anything else. CNA #3 walked out of the room into the hallway and looked at the cart with four trays that had just arrived from the kitchen. She stated, I have already given Ms. [Resident #4] her tray, she is eating it now .why does she have another tray . She carried the second tray in and was told it was a mechanical soft/chopped diet. CNA #3 stated, .Oh, no I have given her [Resident #4] the wrong tray .It is a regular diet, and it is Ms. [Resident #5] tray .what do I do . She removed Resident #4's tray she was eating [regular diet] and gave her the physician ordered tray with diet mechanical soft/chopped. The mechanical soft/chopped diet was a chopped hot dog meat, bun, and Cole slaw. During an interview on 6/10/2022 at 6:31 PM, CNA #3 stated, .I didn't check the tray ticket .I didn't look at it .I'm used to going right on down the line in the cart order .I don't look at the names on the tickets . During an interview on 6/10/2022 at 6:40 PM, the Administrator stated, .wrong diet is not OK .staff should check the meal ticket when passing trays .and do the two identifiers .

Based on policy review, medical record review, observation, and interview, the facility failed to provide a palatable and appetizing meal to 3 of 3 sampled residents (Resident #1, #2 and #3) reviewed for appetizing and palatable meals. The findings include: Review of the facility's policy titled, Dietary-Nutritive Value, Appearance and Temperatures. dated 11/1/2017 and revised 7/14/2021, revealed .Each resident receives, and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that is palatable, attractive, and at a safe and appetizing temperature .Food should be palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction. Providing palatable, attractive, and appetizing food and drink to residents can help to encourage residents to increase the amount they eat and drink. Improved nutrition and hydration status can help prevent, or aid in the recovery from, illness or injury .Food temperatures will be recorded on the daily food temperature log . Review of the medical record revealed, Resident #1 was admitted to the facility on [DATE] with diagnoses [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and Polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), which revealed cognitively intact for daily decision making. During an interview on 6/10/2022 at 11:14 AM, Resident #1 stated, .The food here is tough and nasty .They buy cheap stuff, it is processed and anything labeled patty or fritter is a mystery meat .If you order a grilled cheese the condensation is so bad the sandwich is moist and uneatable .you can order off the grill but the food is not hot .They provide no dressing for your salad it is just lettuce and no condiments such as jelly .I have my family bring in food because the food here is so bad . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses Systemic Lupus Erythematosus, [CONDITION(S)], Severe-protein Calorie Malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed the resident scored a 9 on the BIMS, which revealed moderately cognitively impaired for daily decision making. During an interview on 6/10/2022 at 11:20 AM, Resident #2 stated, .I was really sick from Covid when I came in here. I didn't want to eat anything .They have me on an appetite stimulant now and I want to eat everything in sight. I have gained weight and doing better. However, the food is horrible, it is so tough, hard, cold not fit to eat but I eat it because I am hungry .They provide no dressing for your salad it is just a bowl of lettuce .We call the meat mystery meat because can't tell what it is. If on the menu it says a fritter or patty then it is a mystery to what it really is. That is the running joke around here . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, [CONDITION(S)], Vitamin D Deficiency and Malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed the resident scored a 9 on the BIMS, which indicated moderately cognitively impaired for daily decision making. Observation in the resident's room on 6/10/2022 at 2:53 PM, revealed Resident #3 sitting up in bed, alert and oriented to self, feeding herself a sandwich, the lunch tray had Cole slaw and mashed potatoes that were not eaten. During an interview on 6/10/2022 at 2:53 PM, Resident #3 stated, .The food is not good here .I don't like the meat they serve, half the time don't know what it is .I love vegetables like pinto, white, lima beans things like that, and cornbread .I didn't get my tomato soup as ordered .I just heard the menu today had white beans and cornbread on it. Why didn't I get that? I love that .just goes to show don't know what they are doing . Observation in the Kitchen on 6/10/2022 at 11:50 AM, revealed the lunch tray line began with a menu of fish bites, white beans, Cole slaw and corn bread, yellow cake with chocolate icing, the alternate was a sandwich, mashed potato, and tomato soup. Observation in the Kitchen on 6/10/2022 at 1:05 PM, revealed the last lunch tray was served on the 200 Hall. Observation in the Conference Room on 6/10/2022 at 1:10 PM, revealed the Test tray with fish bites cold in temperature, hard on edges and unpalatable, unappetizing, tomato soup cold in temperature and lumpy texture, unpalatable and unappetizing, unable to test dessert of yellow cake with chocolate icing due to Kitchen ran out of dessert. Observation in the Kitchen on 6/10/2022 at 5:30 PM, revealed the supper tray line began with menu hamburger patty, potato salad, condiments and lettuce, tomato, pickle, chocolate brownie with peanut butter, the alternate was a hot dog and Cole slaw. Observation on 6/10/2022 at 6:31 PM, revealed the last supper tray was served on the 200 Hall. Observation on 6/10/2022 at 6:40 PM, revealed the Test tray with hamburger patty cold in temperature unpalatable and unappetizing, hot dog cool in temperature, chocolate brownie with peanut butter very dry and unpalatable and unappetizing, requiring large drink of liquid to swallow the brownie.

Based on medical record review and interview, the facility failed to provide information regarding a resident's right to formulate an Advanced Directive for 32 of 32 sampled residents (Resident #2, #3, #8, #9, #17, #18, #20, #21, #22, #25, #31, #39, #42, #45, #47, #48, #49, #58, #60, #62, #65, #67, #72, #77, #78, #81, #82, #85, #88, #89, #245 and #246) reviewed for Advanced Directives. The findings include: Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 9, which indicated moderate cognitive impairment. Review of Resident #3's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #8 had a BIMS of 14, which indicated he was cognitively intact. Review of Resident #8's medical record revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #9 had a BIMS of 6, which indicated severe cognitive impairment. Review of Resident #9's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #17 had a BIMS of 3, which indicated severe cognitive impairment. Review of Resident #17's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #18 had a BIMS of 3, which indicated severe cognitive impairment. Review of Resident #18's medical record revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #20 had a BIMS of 6, which indicated severe cognitive impairment. Review of Resident #20's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #21 had a BIMS of 6, which indicated severe cognitive impairment. Review of Resident #21's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #22 had a BIMS of 7, which indicated severe cognitive impairment. Review of Resident #22's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #25 had a BIMS of 2, which indicated severe cognitive impairment. Review of Resident #25's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #31 had a BIMS of 10, which indicated moderate cognitive impairment. Review of Resident #31's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #39 had a BIMS of 9, which indicated moderate cognitive impairment. Review of Resident #39's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #42 had a BIMS of 2, which indicated severe cognitive impairment. Review of Resident #42's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #45 had a BIMS of 9, which indicated moderate cognitive impairment. Review of Resident #45's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #47 had a BIMS of 5, which indicated severe cognitive impairment. Review of Resident #47's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #48 had a BIMS of 0, which indicated severe cognitive impairment. Review of Resident #48's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #49 had a BIMS of 4, which indicated severe cognitive impairment. Review of Resident #49's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #58 had a BIMS of 8, which indicated moderate cognitive impairment. Review of Resident #58's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #60 had a BIMS of 13, which indicated the resident was cognitively intact. Review of Resident #60's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #62 had a BIMS of 7, which indicated severe cognitive impairment. Review of Resident #62's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #65 had a BIMS of 13, which indicated the resident was cognitively intact. Review of Resident #65's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #67 had a BIMS of 8, which indicated moderate cognitive impairment. Review of Resident #67's the medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #72 had a BIMS of 5, which indicated severe cognitive impairment. Review of Resident #72's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #77 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #77 had a BIMS of 14, which indicated the resident was cognitively intact. Review of Resident #77's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record revealed, Resident #78 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #78 had a BIMS of 15, which indicated the resident was cognitively intact. Review of Resident #78's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #81 had a BIMS of 12, which indicated moderate cognitive impairment. Review of Resident #81's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record revealed, Resident #82 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #82 had a BIMS of 11, which indicated moderate cognitive impairment. Review of Resident #82's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #85 had a BIMS of 13, which indicated the resident was cognitively intact. Review of Resident #85's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #88 had a BIMS of 15, which indicated the resident was cognitively intact. Review of Resident #88's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. Review of the medical record revealed, Resident #89 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #89 had a BIMS of 9, which indicated moderate cognitive impairment. Review of Resident #89's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #245 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #245 had a BIMS of 12, which indicated moderate cognitive impairment. Review of Resident #245's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #246 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #246 had a BIMS of 15, which indicated the resident was cognitively intact. Review of Resident #246's medical record, revealed there was no Advanced Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advanced Directive upon admission. The facility's admission packet contained an ADVANCE DIRECTIVE FOR HEALTH CARE form which the facility failed to complete on admission for the residents. During an interview on 3/14/2022 at 3:50 PM, Regional Nurse Manager #1 confirmed the residents did not have Advanced Directives, there was an admission check list sheet, a pamphlet the facility provides, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Regional Nurse Manager #1 confirmed there was no documentation the residents or representatives were informed of their right to formulate an Advanced Directive upon admission, and stated, .don't have what you asked for.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored appropriately and securely when 2 of 5 nurses (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2) left medications unattended and unsecured. The findings include: Review of the facility's policy titled, Medication Administration: Medication .Storage, revised 9/20/2021, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation .and security .All drugs and biologicals will be stored in locked compartments .during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . Random observations in the resident's room on 3/14/2022 at 10:02 AM, revealed an unlabeled, unsecured medication cup containing 3 pills on Resident #65's over bed table. Random observations in the resident's room on 3/14/2022 at 10:25 AM, revealed an unlabeled, unsecured medication cup containing 1 pill on Resident #245's over bed table. During an interview on 3/14/2022 at 10:45 AM, RN #1 was asked should unlabeled and unsecured medications be left at a resident's bedside. RN #1 stated, .No they [residents] should have taken their meds [medications] this morning before I left their rooms . Observations in a the resident's room on 3/16/2022 at 8:30 AM, during medication administration, revealed LPN #2 left oral medications unattended and unsecured at the bedside. The medication cup contained [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Potassium Chloride, Mucinex, Losartan, Iron, Cranberry Extract, [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] on Resident #7's over bed table. LPN #2 went into the bathroom to wash her hands, came back to resident's bedside, and administered Resident #7's [MEDICATION(S)] inhaler. LPN #2 then went back into the bathroom to wash her hands, while again leaving the oral medications at the bedside out of sight, unattended, and unsecured. During an interview on 3/16/2022 at 5:25 PM, the Director of Nursing confirmed medications should not be left at the residents' bedside unattended.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 4 of 32 sampled residents (Anonymous Resident #1, #2, #3, and #4) had alternative food and menu choices. The findings include: Review of the facility's policy titled, .Resident Rights and Resident Responsibilities, dated 11/2016, revealed .The right to reside and receive services in the facility with reasonable accommodation of residents needs and preferences .has the right to make choices .that are significant to the resident . Review of the annual Minimum Data Set (MDS) dated ,d+[DATE] revealed Anonymous Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. During an interview on 3/17/2022 at 3:48 PM, Anonymous Resident #1 stated, .they don't bring me what I want .don't like pimento cheese they bring me pimento cheese sandwich, don't like broccoli . Review of the admission MDS dated ,d+[DATE] revealed Anonymous Resident #2 had a BIMS score of 13, which indicated intact cognition. During an interview on 3/15/2022 at 9:04 AM, Anonymous Resident #2 was asked how she felt about the food. Resident #2 stated, .we don't get menus, and no choices of what we want to eat .I would eat better if I got what I liked . Review of the quarterly MDS dated ,d+[DATE], revealed Anonymous Resident #3 had a BIMS score of 15, which indicates intact cognition. During an interview on 3/16/2022 at 5:19 PM, Anonymous Resident #3 was asked about how she liked and enjoyed the food in the facility. Resident #3 stated, .I do not know what they have everyday, so I don't eat everything . Review of the quarterly MDS dated ,d+[DATE], revealed Anonymous Resident #4 had a BIMS score of 15, which indicated intact cognition. During an interview on 3/15/2022 at 9:34 AM, Anonymous Resident #4 was asked about how he liked and enjoyed the food in the facility. Anonymous Resident #4 stated, .I should look forward to meals .but when the meal arrives late or the food is not what I would like, I don't have an option to get anything else .I don't know what type of food is coming as far as a menu, and no options for alternative food .you settle for what they bring you, no choices and I have to depend on them . Observation in the Dining Room on 3/14/2022, 3/15/2022, 3/16/2022, and 3/17/2022, revealed on the dietary board, the dated menus did not have alternative meals. During an interview on 3/17/2022 at 1:10 PM, Certified Nurses Aide (CNA) #5 was asked, how was it known what the residents were being served everyday for meals. CNA #5 stated, I don't. CNA #5 was asked how would the residents know what they were being served everyday. CNA #5 stated, They don't, we don't have menus . CNA #5 was asked if there was an alternate meal substitute. CNA #5 stated, Not that I know of .we offer sandwiches or soup . CNA #5 was asked if the residents had a choice of what they would like to eat. CNA #5 stated, No. During an interview on 3/17/2022 at 1:15 PM, CNA #4 was asked if there was an alternate menu residents can choose from. CNA #4 stated, Yes, but not everyday. CNA #4 was asked if residents had a choice of what they would like to eat. CNA #4 stated, No, they don't have a choice. During an interview on 3/17/2022 at 7:05 PM, the Certified Dietary Manager confirmed the residents were not receiving menu choices.

Based on medical record review and interview, the facility failed to notify the Ombudsman of emergency transfers for 1 of 2 sampled residents (Resident #8) reviewed for hospitalization s. The findings include: Review of the medical record, revealed Resident #8 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurses' Note dated 1/7/2022 at 11:03 PM, revealed .BP [blood pressure] 210/110 HR [heart rate/pulse] 72 RR [respiratory rate] 22 T [temperature] 97.4 ORAL O2 SAT [oxygen saturation] 80% [percent] 3L/MIN [liters per minute] BNC [by nasal cannula] .SEND TO ER [emergency room ] FOR EVAL [evaluation] . Review of a Nurses' Note dated 1/7/2022 at 11:10 PM, revealed to send Resident #8 to the local Emergency Department. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital for Resident #8 on 1/7/2022. During an interview on 3/17/22 at 4:02 PM, Regional Nurse Manager #1 confirmed the facility should have notified the Ombudsman of the emergency transfer to the hospital.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to shaving, nail care, and grooming for 2 of 2 sampled residents (Resident #2 and #67) reviewed for ADLs. The findings included: Review of the facility's policy titled, Resident Rights and Responsibilities dated 11/2018, revealed .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Review of the CNA [Certified Nursing Assistant] ASSIGNMENT SHEET dated 5/28/2014, revealed .Complete appropriate documentation .Routine patient care-nail care, hair care, dentures and mouth care .Men shaved daily .Full bath/Shower .Sponge bath offered on non-bath days .Bed linens changed on shower/bath days & as needed .Make sure patients are kept clean & dry . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Baseline Care Plan dated 3/9/2022, revealed .Self care deficit related to [CONDITION(S)] and due to his inability to independently perform his activities of daily living staff to assist with ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers .will be assisted with ADLs .Bathing-Bath/Shower .3x [times] week/prn [as needed] as tolerated alternating days with bed baths .Assist with hygiene as needed .Dressing-Assist with clothing that is clean .Assist with dressing as needed . Observation in the resident's room on 3/14/2022 at 9:22 AM, 11:34 AM, and 5:15 PM, revealed Resident #2 was unshaven with whiskers growing out of both sides of his face and neck, his mouth was drooling, he was wearing a gray shirt with a brown spot on the front of his shirt and a blue pair of plaid pants with a dried black spot on the right leg of his pants. Observation in the resident's room on 3/15/2022 at 7:40 AM, 11:45 AM, and 4:00 PM revealed Resident #2 was unshaven with whiskers growing out of both sides of his face and neck, had a body odor, he was wearing a gray shirt with a brown spot on the front of his shirt and blue pair of plaid pants with a dried black spot on the right leg of his pants. During an interview on 3/14/2022 at 5:30 PM, Registered Nurse #1 confirmed Resident #2 needed to be shaved and his clothes needed to be changed. During an interview on 3/15/2022 at 4:30 PM, CNA #3 confirmed Resident #2 did not receive a bath today. CNA #3 also confirmed that Resident #3 needed to be shaved and his clothes needed to be changed. CNA #3 was asked how often Resident #2 should receive a bath. CNA #3 stated, .men should be shaved daily and should have a sponge bath or shower with a change of clothes daily . Observation in the resident's room on 3/16/2022 at 7:25 AM, revealed Resident #2 returned from having a shower accompanied by CNA #4 and by the resident's son. Resident #2 and his son confirmed today was the first day he had received a bath, had been shaved, or had his clothes changed in several days. During an interview on 3/16/2022 at 7:40 AM, CNA #4 stated, .I'm not sure if he [Resident #2] had a bath since Saturday [3/12/2022] 4 days ago .I knew he hasn't been shaved in a while I don't think they even changed his clothes .I gave him a shower today and a shave .he is supposed to get showers 3 times a week, and a bed bath on the other days .we document the ADL's each shift .he wasn't charted for baths . During an interview on 3/16/2022 at 1:59 PM, Licensed Practical Nurse (LPN) #1 stated, .his ADL and care documentation appears that he [Resident #2] doesn't have documentation for bathing on 3/13 [2022], 3/14 [2022], or 3/15 [2022], or for his ADLs . During an interview on 3/16/2022 at 2:30 PM, the Director of Nursing confirmed Resident #2 should have had a bath, been shaved, and had his clothes changed daily. Review of the medical record, revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. She required extensive assist with personal hygiene and bathing. Review of the Care Plan dated 2/28/2022, revealed Resident #67 .Requires extensive assist with .hygiene .grooming .Clean and manicure fingernails as needed . Observation in resident's room on 3/14/2022 at 10:17 AM and 5:15 PM, and on 3/15/2022 at 8:17 AM, and 5:40 PM, revealed Resident #67 had fingernails with black/brown sediment underneath the nails to both hands. During an interview on 3/15/2022, LPN #3 confirmed Resident 67's fingernails on both hands were dirty and needed to be cleaned.

Based on policy review, medical record review, observation, and interview, the facility failed to monitor meal percentages and failed to implement nutritional interventions for 3 of 5 sampled residents (Resident #9, #18, and #31) reviewed for nutrition. The finding included: Review of the facility's policy titled, .Physician Verbal Order ., revised 9/1/2017, revealed .Follow through with orders . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of the Care Plan revealed, .risk for weight loss .Interventions .Diet as ordered .monitor meal intake and offer substitute if resident eats less than 75% [percent] of meal . Review of the Activities of Daily Living (ADL) Verification Worksheet revealed meal percentages were not documented on the following days: a. 1/1/2022 at dinner b. 1/2/2022 at breakfast, lunch, and dinner c. 1/3/2022 at dinner d. 1/4/2022 at breakfast and lunch e. 1/5/2022 at breakfast, lunch, and dinner f. 1/6/2022 at dinner g. 1/8/2022 at dinner h. 1/12/2022 at breakfast and lunch i. 1/13/2022 at dinner j. 1/15/2022 at dinner k. 1/16/2022 at breakfast and lunch l. 1/17/2022 at breakfast and lunch m. 1/20/2022 at lunch n. 1/23/2022 at dinner o. 1/24/2022 at breakfast and lunch p. 1/25/2022 at breakfast and lunch q. 1/26/2022 at breakfast and lunch r. 1/27/2022 at breakfast and lunch s. 1/28/2022 at lunch and dinner t. 1/30/2022 at dinner u. 1/31/2022 at lunch and dinner v. 2/1/2022 at lunch and dinner w. 2/2/2022 at dinner x. 2/3/2022 at dinner y. 2/4/2022 at dinner z. 2/11/2022 at breakfast, lunch, and dinner aa. 2/12/2022 at dinner bb. 2/14/2022 at dinner cc. 2/15/2022 at dinner dd. 2/18/2022 at dinner ee. 2/19/2022 at breakfast, lunch, and dinner ff. 2/20/2022 at dinner gg. 2/22/2022 at dinner hh. 2/23/2022 at dinner ii. 2/25/2022 at breakfast, lunch, and dinner jj. 2/26/2022 at dinner kk. 2/27/2022 at dinner ll. 2/28/2022 at dinner mm. 3/2/2022 at dinner nn. 3/3/2022 at dinner oo. 3/5/2022 at lunch pp. 3/6/2022 at breakfast and lunch qq. 3/7/2022 at dinner rr. 3/8/2022 at dinner ss. 3/10/2022 at breakfast and lunch tt. 3/11/2022 at breakfast and lunch uu. 3/15/2022 at breakfast, lunch and dinner Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #18 had a BIMS score of 3, indicated severe cognitive impairment. Review of the Care Plan for Resident #18 dated 2/13/2022, revealed .At risk for weight loss .Interventions .Monitor meal intake .Diet as ordered .Dietary supplements . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Soup with lunch and supper . Review of the meal ticket dated 3/14/2022, revealed .ICE CREAM .ADD SOUP W [with] .MEAL . Review of the ADL Verification Worksheet revealed meal percentages were not documented on the following days: a. 1/1/2022 at dinner b. 1/2/2022 at dinner c. 1/3/2022 at dinner d. 1/4/2022 at dinner e. 1/6/2022 at dinner f. 1/8/2022 at lunch and dinner g. 1/10/2022 at breakfast and lunch h. 1/12/2022 at breakfast and lunch i. 1/14/2022 at dinner j. 1/15/2022 at dinner k. 1/16/2022 at breakfast and lunch l. 1/17/2022 at breakfast and lunch m. 1/20/2022 at lunch n. 1/23/2022 at dinner o. 1/28/2022 at lunch and dinner p. 1/29/2022 at dinner q. 1/30/2022 at dinner r. 2/1/2022 at lunch s. 2/2/2022 at dinner t. 2/3/2022 at dinner u. 2/4/2022 at dinner v. 2/11/2022 at breakfast and lunch w. 2/12/2022 at dinner x. 2/14/2022 at dinner y. 2/16/2022 at dinner z. 2/25/2022 at dinner aa. 2/26/2022 at dinner bb. 2/27/2022 at dinner cc. 2/28/2022 at dinner dd. 3/2/2022 at dinner ee. 3/3/2022 at dinner ff. 3/5/2022 at lunch gg. 3/6/2022 at breakfast and lunch hh. 3/7/2022 at dinner ii. 3/8/2022 at dinner jj. 3/12/2022 at dinner Observation in the resident's room on 3/14/2022 at 12:36 PM, revealed there was no ice cream or soup on Resident #18's meal tray. During an interview on 3/14/2022 at 12:38 PM, Certified Nursing Assistance (CNA) #1 confirmed there was no ice cream or soup on Resident #18's meal tray. Observation in the resident's room on 3/15/2022 at 12:40 PM, revealed there was no ice cream on Resident #18's meal tray. Observation in the resident's room on 3/15/2022 at 5:21 PM, revealed there was no soup or ice cream on Resident #18's meal tray. During an interview on 3/16/2022 at 3:55 PM, the Regional Registered Dietician confirmed Resident #18 should have received ice cream and soup twice a day for lunch and dinner as ordered and stated, .would have definitely made a difference .think it would have helped . Review of the medical record, revealed Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan for Resident #31 revised 3/5/2022, revealed .At risk for weight loss .Therapeutic diet .Monitor meal intake .Dietary supplements . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] &J] sandwich with breakfast and lunch . Review of the meal ticket dated 3/15/2022, revealed .ADD PB&J [peanut butter and jelly] SANDWICH . Review of the ADL Verification Worksheet revealed meal percentages were not documented on the following days: a. 1/1/2022 at dinner b. 1/2/2022 at dinner c. 1/3/2022 at dinner d. 1/4/2022 at lunch e. 1/6/2022 at dinner f. 1/8/2022 at dinner g. 1/14/2022 at lunch h. 1/16/2022 at breakfast and lunch i. 1/23/2022 at dinner j. 1/28/2022 at breakfast and lunch k. 1/30/2022 at lunch and dinner l. 2/1/2022 at breakfast and lunch m. 2/2/2022 at dinner n. 2/3/2022 at dinner o. 2/13/2022 at dinner p. 2/14/2022 at lunch and dinner q. 2/25/2022 at dinner r. 2/26/2022 at dinner s. 2/27/2022 at dinner t. 2/28/2022 at dinner u. 3/2/2022 at dinner v. 3/3/2022 at dinner w. 3/7/2022 at dinner x. 3/8/ at dinner y. 3/11/2022 at lunch z. 3/12/2022 at dinner aa. 3/13/2022 at dinner Observation in the resident's room on 3/14/2022 at 12:40 PM, revealed Resident #31's lunch tray did not contain a peanut butter and jelly sandwich. Observation on 3/15/22 at 5:26 PM, revealed Resident #31's meal tray contained a meal ticket with instructions to add PB&J sandwich and the meal tray did not contain a peanut butter and jelly sandwich. During an interview on 3/17/2022 at 5:40 PM, the Certified Dietary Manager (CDM) was asked should residents receive what is ordered on their meal ticket. The CDM stated, Absolutely . During an interview on 3/17/2022 at 6:21 PM, the Assistant Director of Nursing (ADON) was asked should Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON was asked should meal percentages be documented. The ADON stated, Yes .

Based on policy review, medical record review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care while providing personal care for 3 of 15 (Resident #63, #81 and #34) sampled residents reviewed and failed to provide a dignity bag for 2 of 2 (Resident #37 and #308) sampled residents reviewed with indwelling urinary catheters. The findings include: 1. The facility's .Promoting/Maintaining Resident Dignity policy revised 11/17 documented, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .When interacting with a resident, pay attention to the resident as an individual .Maintain resident privacy . 2. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in the shower room across from the 300 Hall Nurses' Station on 5/6/19 at 9:12 AM, revealed Resident #63 and 81 were receiving showers. Resident #63 was in a shower stall, fully exposed, and the shower curtain was not pulled. Resident #81 was in the adjacent shower stall, fully exposed, and the shower curtain was not pulled. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in the shower room across from the 300 Hall Nurses' Station on 5/7/19 at 9:40 AM, revealed Resident #34 was seated in a shower chair outside the shower stall. Resident #34 was completely unclothed, uncovered and exposed. Certified Nursing Assistant (CNA) #1 and CNA #2 were standing in the shower room talking. Interview with CNA #1 on 5/7/19 at 1:45 PM, in the 300 Hall, CNA #1 was asked if CNA #2 was assisting with Resident #34's personal care in the shower room. CNA #1 stated, No, she was just in there to get a brief out of the cabinet. Interview with the Director of Nursing (DON) on 5/8/19 at 5:47 PM, in the Conference Room, the DON was asked how staff should provide personal care in the shower room. The DON stated, .Not having the resident openly exposed, behind the curtain, covered with a towel . The DON was asked if a resident should be completely naked sitting in a shower chair in the middle of the shower room. The DON stated, No, I would think she would have something over her . 3. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Maintain indwelling catheter . Observations in Resident #37's room on 5/6/19 at 2:40 PM and 4:40 PM, and on 5/8/19 at 8:40 AM, revealed Resident #37's catheter was not in a dignity bag. Medical record review revealed Resident #308 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observations in Resident #308's room on 5/6/19 at 2:50 PM and 4:25 PM, revealed Resident #308's catheter was not in a dignity bag. Interview with the DON on 5/8/19 at 6:30 PM, the DON was asked if a catheter bag should have a dignity bag. The DON stated,Yeah .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 2 of 6 (Licensed Practical Nurse (LPN) #1 and #2) nurses failed to perform proper hand hygiene during medication pass observations and when 1 of 1(Registered Nurse (RN) #1) nurses failed to clean a medication container during wound care observations. The findings include: 1. The facility's Hand Hygiene policy with a revision date of 4/2018 documented, .Staff involved in direct resident contact will perform proper hand hygiene .Use clean/ dry towel to turn off the faucet . 2. Observations in Resident #45's room on 5/7/19 at 8:00 AM, revealed LPN #1 administered medications to Resident #45. LPN #1 performed hand hygiene and turned off the water faucet with the same paper towel that she had used to dry her hands. Observations in Resident #100's room on 5/7/19 at 8:58 AM, revealed LPN #2 administered medications to Resident #100. LPN #2 performed hand hygiene twice during medication pass and turned off the water faucet with the same paper towel that was used to dry her hands. Interview with the Director of Nursing (DON) on 5/8/19 at 4:29 PM, in the DON Office, the DON was asked how did she expect staff to turn off the water after they washed their hands. The DON stated, .a clean paper towel . The DON was asked if it was acceptable to turn off the water faucet with the same paper towel that had been used to dry their hands. The DON stated, That is not the expectation . 3. Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Wound Care .CLEAN PRESSURE INJURY TO RT (Right) ELBOW WITH NORMAL SALINE OR WOUND CLEANSER SPRAY C (WITH) SANARA .X (times) 1 SPRAY COVER WITH [MEDICATION NAME] AND ABSORBENT DRESSING DAILY . Observations in Resident #84's room on 5/7/19 at 3:30 PM, revealed wound care had been completed and RN #1 placed a spray bottle of Sanara on the overbed table without a barrier, left the room, and placed the bottle of Sanara in the medication cart without cleaning the bottle. Interview with the DON on 5/7/19 at 4:00 PM, in the 400 Hall, the DON was asked if the container of Sanara should have been cleaned before placing it back into the medication cart. The DON confirmed the container of Sanara should have been cleaned.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure staff followed physician's orders for fluid restriction for 1 of 1 (Resident #143) sampled residents reviewed for [MEDICAL TREATMENT]. The findings included: 1. The facility's FLUID RESTRICTION policy documented, .Fluid restriction will be followed according to the physician's order. The Food Service Supervisor and the nursing department will determine the amount of fluid needed for med (medication) pass, bedtime snack and hydration cart. The remainder will be divided between the three (3) meal trays . 2. Medical record review revealed Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, required limited to extensive staff assistance for all activities of daily living, and received [MEDICAL TREATMENT] services. The care plan dated 5/25/17 documented, .At risk for complications of [MEDICAL CONDITION] .has [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] .Interventions .Fluid Restriction as ordered . The physician orders signed on 6/15/17 documented, .Intake and Output .Two Times Daily Starting 05/30/2017 . A [MEDICAL TREATMENT] Reassessment Nutrition Profile Report dated 6/12/17 documented, .32 ounce fluid Restriction Q (every) 24 hours . A physician's telephone order dated 6/15/17 documented, .960 ML (milliliters) FLUID RESTRICTION . Observations in Resident #143's room on 6/28/17 at 2:24 PM, revealed Resident #143 seated in a wheelchair at the bedside with a cup of ice and a cup of coffee on the overbed table in front of her. Interview with Certified Nursing Assistant (CNA) #3 on 6/28/17 at 2:30 PM in Resident #143's room, CNA #3 was asked whether she knew if Resident #143 had any restrictions with eating or any fluid restrictions. CNA #3 stated, I do not, but I can find out. CNA #3 was asked whether she knew the capacity of the ice cup. CNA stated, No. Interview with Registered Nurse (RN) #1 on 6/28/17 at 2:37 PM, at the 300/400 nurses' desk, RN #1 confirmed Resident #143 was on a fluid restriction. RN #1 was asked how she knew how much fluid to give Resident #143. RN #1 stated, .it's 960 (milliliters) fluid restriction .kitchen would also have that information, and it would be divided up . RN #1 was asked whether Resident #143 should have water or ice at bedside. RN stated, I'll have to check . Interview with Licensed Practical Nurse (LPN) #3 on 6/28/17 at 2:41 PM, at the 300/400 nurses' desk, LPN #3 was asked whether Resident #143 was allowed to have a cup of ice at bedside. LPN #3 stated, She's not supposed to . LPN #3 was asked what the capacity for the cup of ice on Resident #143's overbed table was and LPN #3 stated, I don't know. It's probably 12 to 16 ounces . LPN #3 was asked how intake could be measured to ensure fluid restrictions were followed unless the cup capacity was known. LPN #3 gave no response. Interview with RN #1 on 6/28/17 at 2:45 PM, at the 300/400 nurses' desk, RN #1 returned to the nurses' desk and stated, I have an answer for you. She (Resident #143) should not have that cup at bedside. Interview with the Director of Nursing (DON) on 6/28/17 at 3:27 PM, in the conference room, the DON was asked whether Resident #143 should have the cup of ice at bedside. The DON stated, We took that away .

Based on medical record review, observation, and interview, the facility failed to ensure staff followed care plan interventions related to fluid restrictions and fall prevention for 2 of 22 (Resident #143 and 156) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 5/25/17 documented, .At risk for complications of [MEDICAL CONDITION] .has [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] .Interventions .Fluid Restriction as ordered . Observations in Resident #143's room on 6/28/17 at 2:24 PM, revealed Resident #143 seated in a wheelchair at the bedside with a cup of ice and a cup of coffee on the overbed table in front of her. Interview with Certified Nursing Assistant (CNA) #3 on 6/28/17 at 2:30 PM, in Resident #143's room, CNA #3 was asked whether she knew if Resident #143 has any restrictions with eating or any fluid restrictions. CNA #3 stated, I do not, but I can find out. CNA #3 was asked whether she knew the capacity of the ice cup. CNA stated, No. Interview with Registered Nurse (RN) #1 on 6/28/17 at 2:37 PM, at the 300/400 nurses' desk, RN #1 confirmed Resident #143 was on a fluid restriction. RN #1 was asked how she knew how much fluid to give Resident #143. RN #1 stated, .it's 960 (milliliters) fluid restriction .kitchen would also have that information, and it would be divided up . RN #1 was asked whether Resident #143 should have water or ice at bedside. RN stated, I'll have to check . Interview with Licensed Practical Nurse (LPN) #3 on 6/28/17 at 2:41 PM, at the 300/400 nurses' desk, LPN #3 was asked whether Resident #143 was allowed to have a cup of ice at bedside. LPN #3 stated, She's not supposed to . LPN #3 was asked what the capacity was for the cup of ice on Resident #143's overbed table. LPN #3 stated, I don't know. It's probably 12 to 16 ounces . LPN #3 was asked how intake could be measured to ensure fluid restrictions were followed unless the cup capacity was known. LPN #3 gave no response. Interview with RN #1 on 6/28/17 at 2:45 PM, at the 300/400 nurses' desk, RN #1 returned to the nurses' desk and stated, I have an answer for you. She (Resident #143) should not have that cup at bedside. Interview with the Director of Nursing (DON) on 6/28/17 at 3:27 PM, in the conference room, the DON was asked whether Resident #143 should have the cup of ice at bedside. The DON stated, We took that away . 2. Medical record review revealed Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan documented Resident #156 was at risk for falls. Falls were noted on the care plan on 4/20, 4/27, 4/29, 5/8, 5/18 (twice), 5/21 and 6/8/17. Interventions included, Resident is to have urinal at bedside PRN (as needed) related to a fall on 5/21/17 .only be outside with supervision of staff/family r/t (related to) fall on 6/08/17. A review of the Resident Care Summary Assessment used by Certified Nursing Assistants (CNAs) in provision of care specified Resident #156 was to have a urinal at his bedside at all times and resident is only to be outside with supervision of staff/family. Observations in Resident #156's room on 6/27/17 at 3:05 PM, 6/28/17 at 8:00 AM, and 6/28/2017 at 1:00 PM, revealed no urinal near the bedside. On 6/27/17 at 3:05 PM and 6/28/17 at 8:00 PM Resident #156 was observed on the front porch of the facility. There was no staff outside with the resident nor within eyesight of the front porch. Interview with the Assistant Director of Nursing (ADON) on 6/28/17 at 1:03 PM at the 100 Hall nurse's station, the ADON stated, After (Resident #156) fell the last time, he wasn't to be outside without staff being present or being able to see him. The ADON confirmed Resident #156 was outside with no supervision. The ADON stated Resident #156 can let himself out the front door. At that time, the ADON instructed staff to bring Resident #156 back inside the facility. Interview with Licensed Practical Nurse (LPN) #4 on 6/28/17 at 1:10 PM at the 100 Hall nurse's station. LPN #4 said, Resident #156 is on my assignment every morning and he can go out. The family says he can. LPN #4 said she was not aware of the intervention to not allow Resident #156 outside unsupervised. Interview with Certified Nursing Assistant (CNA) #4 on 6/28/17 at 4:06 PM in the hallway near Resident #156's room. CNA #4 stated she was familiar with Resident #156 and confirmed he did not have a urinal. She wasn't sure if he would be able to use it because there were times he would ask for assistance to the bathroom and times he would be incontinent

Based on medical record review, observation, and interview, the facility failed to ensure an assessment accurately documented the use of a self-releasing seat belt as a physical restraint for 1 of 22 (Resident #111) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: Medical review for Resident #111 revealed [DIAGNOSES REDACTED]. Review of the care plan dated 3/15/17 revealed the problem of, Is up to a positioning recliner. Staff assists resident out of chair when agitated or resident tries to get up unassisted. An additional problem added on 4/13/17 documented, Resident has trunk restraint - seatbelt added to positioning recliner r/t (related to) excessive falls. The goal was Resident #111 would be out of bed as tolerated. The interventions included to educate the family regarding the risk of restraint use, remove the restraints and provide range of motion every 2 hours. Review of a Clinical Note dated 4/13/17 revealed Resident has had two falls the previous two nights .MD (medical doctor) called about medications and will place a seat belt on her position recliner and monitor. Will attempt to remove when able to do so. Review of Restraint Consent form dated 4/13/17 signed by the resident's son and facility representative documented the seatbelt as a restraint. The most recent comprehensive Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 did not have physical restraints in place. Review of the Physical Restraint/Side Rail assessment dated [DATE] documented the recommendations the physical restraint (seatbelt) was for a positioning recliner with a seatbelt. Observation on 6/26/17 at 2:26 PM, 6/26/17 at 3:25 PM, and 6/27/17 at 11:13 AM , revealed Resident #111 by the 100 hall nurses station seated in a positioning recliner with a seatbelt fastened across the waist/hip area. Interview with Certified Nursing Assistant (CNA) #1 in the 100 Hallway on 6/27/17 at 2:01 PM, CNA #1 stated Resident #111 cannot self-release the seatbelt but the resident could independently exit the positioning chair when the seatbelt was not in use. At that time, CNA #1 asked Resident #111 to unfasten the seatbelt. Resident #111 made multiple attempts to unfasten the seat belt and was unable to do so on command. Interview with Minimum Data Set (MDS) Nurse #1 on 6/27/17 at 2:56 PM in the MDS office, MDS Nurse #1 verified the resident's seatbelt was assessed as a physical restraint and the significant change MDS dated [DATE] was not coded correctly to identify the assessed use of a trunk restraint.

Based on policy review, medical record review and interview, the facility failed to notify the physician of a significant change in condition and that the resident refused all medications necessary to treat cardiac conditions for 1 of 22 (Resident #124) sampled residents reviewed during the stage 2 review. The findings included: Review of the Documentation of Med (Medication) Pass policy dated July 2014 revealed, The physician should be consulted and made aware if the patient is frequently refusing any or all of their meds. Medical record review revealed Resident #124 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. These medications included Aspirin 81 milligrams (mg), [MEDICATION NAME] 125 micrograms (mcg), [MEDICATION NAME] Sodium 100 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] ER(Extended Release) 50 mg, Multivitamin, and Potassium Chloride 20 milliequivalents (mEq). The Nurse's Notes dated 4/27/17 at 10:45 AM documented by Licensed Practical Nurse (LPN) #1 revealed Resident #124 spit out medications and breakfast stating that's enough. The Nurse's Notes dated 5/2/17 at 2:22 AM indicated nursing staff had difficulty administering meds (medications) this shift. Appetite poor. Increased weakness noted. There was no documentation on 4/27/17 or 5/2/17 that the physician had been notified of Resident #124 refusing to take the medications or the change in condition of a poor appetite and increased weakness. Interview with Licensed Practical Nurse (LPN) #1 on 6/27/17 at 3:55 PM in the conference room. LPN #1 stated she was familiar with Resident #124. She stated, (Resident #124) didn't take her medication that day. She would do that with food and fluids too. I would normally write it down in the doctor's book. I wouldn't call him. He comes in almost every day. We have a communication book we write things in for him. He looks at the book and then removes the paper. LPN #1 could not find any documentation from the physician acknowledging he was notified that Resident #124 did not take her medication on 4/27 and 5/2/17 or had a change in condition on 5/2/17. Interview with the Assistant Director of Nursing (ADON) on 6/27/17 at 4:25 PM, in the conference room, the ADON stated the physician should be notified that a resident refuses medications. That doctor is here every day. He has a communication book that they write things in for him. They can call him if there is something that needs to be called. He doesn't keep the papers we communicate with him on. Interview with the Director of Nurses (DON) on 6/28/17 at 8:15 AM in the conference room, the DON stated, Our policy says you don't have to report refusals unless they are frequent. Frequent to me would be almost daily.