Every finding on record at Star City Rehabilitation and Nursing

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the quality assurance program met the needs of the facility as evidenced by repeated deficiencies in the areas of resident rights, comprehensive resident centered care plans, food and nutrition, quality of care, and pharmacy services and failed to monitor the effects of implemented changes and make needed revisions to the action plans as needed for the prevention of further deficiencies, as evidenced by new findings (deficient practice) in the areas of quality of life, lab radiology and other diagnostic services, and administration. The findings include: On 02/13/25 at approximately 9:45 a.m., the survey team entered the facility for an abbreviated survey. This survey concluded on 02/18/25. During the survey process the surveyors identified deficient practice in the areas of resident rights, comprehensive resident centered care plans, food and nutrition, quality of care, and pharmacy services that were identified on the annual survey completed on 02/07/24-02/14/24 and/or an abbreviated survey completed on 11/06/24-11/08/24. The survey team also identified new findings (deficient practice) in the areas of quality of life, lab radiology and other diagnostic services, and administration. On 02/13/25 the administrative staff provided the survey team with a copy of their policy titled, Quality Assurance and Performance Improvement (QAPI) date implemented 11/01/20, reviewed and revised 12/01/22. This policy read in part, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .The QAA [Quality Assessment and Assurance] Committee shall be interdisciplinary and shall .Develop and implement appropriate plans of action to correct identified quality deficiencies . On 02/18/25 at 3:10 p.m., during a meeting with the Administrator, Director of Nursing, Regional Nurse Consultant, Regional Dietary Manager, and Dietary Manager the issues regarding new and repeated deficient practice were reviewed. No further information regarding the facility quality assurance program was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and/or accurate clinical record for 4 of 17 sampled residents (Resident #1, Resident #2, Resident #3, and Resident #6). The findings included: 1. For Resident #6, the facility staff failed to ensure a wound care provider progress note was included in the clinical record. Resident #6's diagnosis list indicated diagnoses, which included, but not limited to Arteriovenous Malformation of Digestive System Vessel, Gastrointestinal Hemorrhage, Pneumonitis, Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Dementia, and Malignant Neoplasm of Prostate. The minimum data set (MDS) with an assessment reference date (ARD) of 9/30/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. A review of Resident #6's clinical record revealed a nursing progress note dated 11/09/23 at 5:34 PM which read in part Wound doctor, Dr. [name omitted], was in to assess pt's [patient's] bottom, dx [diagnosed] with MASD [moisture-associated skin damage], continue with greers goo TID [three times a day] . Surveyor reviewed Resident #6's clinical record and was unable to locate the 11/09/23 wound provider assessment and/or progress note. On 2/18/25 at 11:58 AM, surveyor spoke with the Director of Nursing (DON) who stated they were also unable to locate the wound provider note. Surveyor requested and received the facility policy titled Documentation in Medical Record with a reviewed/revised date of 12/01/22 which read in part Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy . On 2/18/25 at 3:10 PM, the survey team met with the Administrator, DON, Regional Director of Clinical Services, Dietary Director, and Regional Dietary Director and discussed the concern of the missing assessment/progress note. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/18/25. 4. For Resident #3 the facility staff failed to ensure the physician's order summary was correct. Resident #3's Resident #3's clinical record listed diagnoses which included but not limited to unspecified intracranial injury with loss of consciousness, personal history of traumatic brain injury, and dysphagia. Resident #3's most recent minimum data set with an assessment reference date of 01/09/25 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section K, Swallowing/Nutrition, coded the resident as receiving 51% or more of nutrition through tube feeding. Resident #3's comprehensive care plan was reviewed and contained a care plan for At risk of malnutrition r/t (related to) need for tube feed with NPO (nothing by mouth) diet order and The resident requires tube feeding r/t dysphagia. Resident #3's clinical record was reviewed and contained a physician's order summary which read in part, Tube Feed diet. Nothing by Mouth texture, thin consistency, May crush medications and administer per GT (gastrostomy tube), NPO (nothing by mouth) diet order texture, NPO consistency, Rizatriptan Benzoate Oral Tablet 5 mg (Rizatriptan Benzoate). Give 1 tablet by mouth every 12 hours as needed for headache. Resident #3's progress notes were reviewed and contained a noted which read in part, Date of Service: 02/14/2025. HPI (history of present illness) Relating to this Visit: The patient is a *** with a notable history of traumatic brain injury (TBI) from a severe motor vehicle accident. This injury resulted in persistent aphasia and dysphagia, requiring her to rely on chronic tube feeding through a percutaneous endoscopic gastrostomy (PEG) tube . Medications Additional Text: Imitrex Oral Tablet 50 mg (Sumatriptan Succinate) Start Date: 12/16/2024 Last Modified: 12/19/2024 12:20:28 PM. Give 50 mg by mouth every 24 hours as needed for Migraines for 30 days Migraine headache: -Continue Imitrex 50 mg orally as needed every 24 hours for migraines, with a maximum use of 30 days. Surveyor spoke with the local long term care ombudsman on 02/13/25 at 12:45 pm regarding Resident #3. Ombudsman stated they have monthly meetings with the resident's family and staff regarding ongoing issues of physician's order summary listed medications as oral when resident takes nothing by mouth. Ombudsman stated family is adamant that resident receive nothing orally. Surveyor spoke with licensed practical nurse (LPN) #1 on 02/13/25 at 3:45 pm regarding Resident #3. Surveyor asked LPN #1 if resident every received any medications by mouth, and LPN #1 stated no, that resident received everything by PEG tube. The concern of the physician's order and progress note incorrectly listing medications as orally, when resident in NPO was discussed with the administrator, director of nursing, regional director of clinical services, and regional director of operations on 02/14/25 at 4:35 pm. No further information provided prior to exit. 3. For Resident #1, the facility staff failed to document in the part of the clinical record that could be accessed by the survey team that the resident had a fall that resulted in a hip fracture. Resident #1's diagnoses included, but were not limited to, anxiety disorder, abnormalities of gait and mobility, and age-related macular degeneration. Section C (cognitive patterns) of Resident #1's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/21/24 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Per the MDS manual a score of 14=cognitively intact. Section GG (functional abilities) was coded to indicate Resident #1 required set up help (5) with sit to stand and chair/bed-to-chair transfer. Walk 10 feet was coded with a (4) to indicate the resident required supervision or touching assistance for this task. The clinical record included a fall risk assessment dated [DATE] with a fall risk score of 80 per the preprinted code on this document a score of 45 and higher=high risk for falls. This document was marked to indicate Resident #1 overestimates or forgets limits. Resident #1's comprehensive care plan included the focus area at risk for falls. Interventions included be sure resident's call light is within reach and encourage the resident to use it for assistance as needed, needs prompt response to all requests for assistance, encourage to use rollator, ensure resident is wearing appropriate footwear, clutter free environment, and ensure personal items are within reach. During the clinical record review on 02/18/25 the surveyor identified a progress note transcribed on 02/16/25 at 5:53 p.m. by Licensed Practical Nurse (LPN) #2 that read, resident exited facility on stretcher with EMS [emergency medical services] at 610pm. resident transported to ______ ED [emergency department] for further evaluation. The next progress note was documented on 02/17/25 at 6:48 a.m. and read, Contacted _____ ED asking for an update on the rsd [resident], the ED nurse stated that rsd was admitted for closed left hip fracture . The surveyor was unable to find any documentation in the clinical record to indicate what had happened to this resident or an assessment. On 02/18/25 at 11:15 a.m., the surveyor and the Director of Nursing (DON) reviewed Resident #1's clinical record. After reviewing the clinical record the DON stated there was a view in risk that the survey team did not have access to. The DON stated there was a link that the staff can click and apparently the staff had not done that. On 02/18/25 the DON provided the surveyor with a copy of a document identified as being part of their risk program. This document was regarding Resident #1 and referenced an unattended fall with injury. Date of incident 02/16/25 at 5:37 p.m. indicating staff had heard a loud boom and entered the resident's room. Upon entering Resident #1 was found lying near the foot of their bed, the resident complained of pain, was unable to bear weight, the physician was notified, and an order was given to send Resident #1 to the hospital for evaluation. The DON identified the nurse that completed this form as an agency nurse there were no staff names on this form. On 02/18/25 at 3:10 p.m., during a meeting with the Administrator, DON, Regional Nurse Consultant, Regional Dietary Manager, and Dietary Manager the missing documentation regarding Resident #1's injury was reviewed. No further information regarding the missing documentation was provided to the survey team prior to the exit conference. 2. The facility staff failed to ensure that Resident #2's medical documentation was complete and/or accurate as evidence by: (a) a failure to document responsible party (RP) notification of the resident refusing an x-ray/consultation and (b) the incorrect date being included in Resident #2's nutrition/dietary care plan. Resident #2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/31/25, was signed as completed on 2/11/25. Resident #2 was assessed as usually able to make self understood and as usually able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 00 out of 15; this indicated severe cognitive impairment. Resident #2 was assessed as requiring supervision or touching assistance with personal hygiene and bathing. The following information was found in Resident #2's medical provider note dated 12/27/24: Spoke to patients RP (responsible party) (name omitted). At the time (I) spoke to her (I) did not know the patient refused his xrays [sic]. Asked staff to update her on his refusal and refusal of spine consult. No evidence was found to indicate the RP had been notified of the resident's refusal of the x-rays and the consultation. On 2/18/25 at 11:05 a.m., the Director of Nursing (DON) reported there was no policy and procedure addressing refusals and/or notifications. The DON stated, We just document refusals. On 2/18/25 at 12:08 p.m., the surveyor interviewed the medical provider (a nurse practitioner (NP)) who documented the aforementioned 12/27/24 provider note. The NP reported they had talked to Resident #2's responsible party (RP) after documenting the 12/27/24 note. The NP reported the RP was notified of the resident's refusal of the x-rays and that the RP was okay with the resident's refusal of seeing a specialist. The NP confirmed that they had not documented the RP notification of the resident's refusal of the x-rays and the consult. On 2/18/25, the surveyor noted Resident #2's nutritional care plan included the following focus dated as being initiated on 4/23/24: Resident prefers not to eat breakfast from the meal tray in the mornings. This had not been apart of Resident#2's care plan when the surveyor reviewed it on 2/14/25. On 2/18/25 12:43 p.m., the Director of Nursing (DON) confirmed they had updated Resident #2's nutritional care plan that morning. The surveyor asked about the date indicating the Resident prefers not to eat breakfast from the meal tray in the mornings focus statement had been initiated on 4/23/24 instead of 2/18/25. The DON stated they had not been aware of the dating issue. (The DON showed the surveyor that the updated interventions were correctly dated on the care plan.) The DON reported the date could be manually typed into the care plan and that they would correct the date. The following information was found in a facility policy titled Documentation in Medical Record (with a reviewed/revised date of 12/1/22): Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The survey team met with the facility's Administrator, Director of Nursing, Dietary Manager, Regional Director of Food Services, and Regional Director of Clinical Services on 2/18/25 at 3:08 p.m. During this meeting, the surveyor discussed Resident #2's incomplete and/or inaccurate clinical documentation.

Based on observations, staff interviews, and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings included: The facility staff failed to discard out of date perishable food items, failed to date and label perishable food items, failed to maintain clean dietary equipment, failed to utilize beard restraints for dietary personnel, and stored clean pans and bowls together wet. On 2/13/25 at 10:35 AM, surveyor entered facility kitchen for initial tour with dietary manager-other staff # 4 (OS#4), who stated it was his fourth day on the job. Surveyor and OS#4 observed the sandwich serving station, which he stated was unused and upon lifting the lid, multiple crumbs were observed on the station. Multiple spices were observed on a shelf directly above the sandwich serving station and surveyor observed 2 (two) bottles of ketchup with no dates, 1 (one) jar of beef base with no date, 1 bottle of lemon juice with no date, 1 old bay seasoning with no date, 1 poultry seasoning with no date, 1 garlic powder with no date, 1 can grill spray with no date, and multiple other spices without any dates to exhibit when the items would have been opened or needed to be discarded. Observation of the dry storage area revealed 5 (five) packages of soft tortillas on a shelf w/BB (best by) dates of 1/20/25 and 2 opened bottles of coriander spice with BB dates of 8/1/24. OS#4 discarded these items. The equipment in the preparation area was observed. The open grill and flat top grill were observed and a small bit, of yellow, dried, substance was noted on the area in front of the flat-top grill. OS#4 stated it appeared to be egg from breakfast services. The grate on the open grill contained a large amount of black grease build-up, approximately 1/2 an inch in thickness and OS#4 stated it probably had not been cleaned in a year. The deep fryer had a bucket located in front of it filled with oil, on the floor containing a tube coming from the deep fryer. Multiple yellowish-brown crumbs and oil were observed around the perimeter of the deep fryer. OS#4 stated we're in the process of cleaning the fryer. Grease and residue were noted upon the top of the gas cook stove. The outside top of the convection oven had a thin layer of black grease and the top of the convection oven on the bottom of the unit contained multiple bolts and grease debris lying on top of the unit. Surveyor observed the microwave, and the inside had a moderate amount of brown, dried, debris. The stacked pans and bowls were observed on storage shelves and surveyor observed pans and two large metal mixing bowls to be stacked together wet. Four steam table pans were also stacked together wet. Observation of the walk-in refrigerator revealed a large bowl, without a label or date and OS#4 stuck his finger in the bowl and tasted the substance and said it was strawberry pie filling. He agreed it should have been labeled and dated and he discarded it. A plastic square container held yellow slices of cheese, and it was not labeled or dated, and OS#4 discarded it. OS#4 stated he has been working on a cleaning schedule for dietary staff and he provided surveyor with a copy of the schedule. Surveyor observed tray-line for the lunch meal service at 12:05 PM with OS#4 and noted three male dietary employees (other staff #5 (OS#5), other staff #17 (OS#17), and other staff #19 (OS#19) without beard restraints. OS#17 was plating meatloaf. Surveyor asked what the expectation for beard restraints were, and OS#4 stated he has ordered some, but did not believe they had to wear them if the beard was short. OS#4 and lead dietary director-administrative staff # 3 (AS#3) also presented with beards and did not have beard restraints. OS#17 put a hairnet over his beard and OS#5 and OS#19 were given beard restraints that were located by one of the other dietary aides. On 2/13/25 at 2:24 PM, surveyor interviewed administrator (ADM), other staff #5 (OS#5), and other staff #6 (OS#6). OS#5 stated it was hard to keep the kitchen clean at times. OS#6 stated it depends on who is working, the previous dietary manager had a cleaning schedule. ADM stated a cleaning schedule is posted outside the dietary manager door. On 2/14/25 at 8:27AM, surveyor entered kitchen to observe breakfast service. The grate on the open grill continued to contain a large amount of black grease build-up, approximately 1/2 an inch in thickness. Multiple yellowish-brown crumbs and oil were observed around the perimeter of the deep fryer. On 2/14/25 at 1:15 PM, another surveyor observed the Juniper sub-kitchen and observed the microwave to be dirty and gnats around the ice machine. These concerns were discussed on 2/14/25 at 11:04 AM with regional director of clinical services, regional director of operations, regional dietary manager, director of nursing, and administrator and again at the pre-exit meeting on 2/18/25 at 3:08 PM with the director of nursing, administrator, regional director of clinical services, regional dietary manager, and facility dietary manager. Surveyor requested and received a facility policy titled, Dietary Employee Personal Hygiene with a revision date of 12/2/22, that read in part, .It is the policy of this facility to utilize the following guidelines for employee personal hygiene to prevent contamination of food by foodservice employees .4. Hair Restraints a. All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food . Surveyor requested and received a facility policy titled, Date Marking for Food Safety with a revision date of 12/1/22, that read in part, .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded . Surveyor requested and received a facility policy titled, Food Safety Requirements with a revision date of 12/1/22, that read in part, .6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination . Surveyor requested and received a facility policy titled, Sanitation Inspection with a revision date of 12/1/22, that read in part, .All food service areas shall be kept clean, sanitary . No further information was presented to the survey team prior to exit on 2/18/25.

Based on observation, staff interview, and facility document review, the facility staff failed to provide nourishing snacks to residents that receive snacks by oral means that wish to eat at non-traditional times. The findings included: The facility staff failed to provide snacks to residents that receive snacks by oral means that wish to eat at non-traditional times as evidenced by failing to have snacks ready and available. On 2/13/25 at 12:55 PM, surveyor spoke with dietary manager-other staff #4 (OS#4) about the locations of the unit pantries. He stated they have the sub-kitchens, and they are not currently in use, and he removed all of the outdated items and has ordered snacks for all of the sub-kitchens. On 2/13/25 at 1:56 PM, surveyor interviewed cook, other staff #3 (OS#3) and she stated they (dietary) have not had a lot of snacks available since she stopped doing the order. On 2/14/25 at 9:00 AM, surveyor interviewed certified nursing assistant #6 (CNA#6) and she stated snacks vary on the unit (3rd floor) and sometimes dietary will fill the bowl in the sub-kitchen with snacks and at other times she must go to the kitchen to get the snacks. On 2/14/25 at 9:01 AM, surveyor interviewed certified nursing assistant #5 (CNA#5) and she stated the kitchen puts snacks in the bowls in the common areas at times, but they do not have drinks available in the areas and she usually goes to the kitchen to ask for snacks if she needs them. On 2/14/25 at 9:05 AM, surveyor observed 3rd floor sub-kitchens on both units and no snacks were observed in either common area in the bowl/basket provided, or in the cabinets or refrigerators. At 9:16 AM, surveyor observed 2nd floor sub-kitchens on both units and no snacks were observed in either common area in the bowl/basket provided, or in the cabinets or the refrigerator on the Juniper unit. The refrigerator on the Emerald unit contained one can of whipped cream and one gallon of milk. At 9:25 AM, surveyor observed 1st floor sub-kitchens on both units and no snacks were observed in either common area in the bowl/basket provided, or in the cabinets or refrigerators. On 2/14/25 at 1:02 PM, surveyor interviewed Resident #10, and he stated snacks are not available. On 2/14/25 at 1:15 PM, another surveyor interviewed Resident #15's RP (resident representative) and the RP stated there are no snacks. On 2/14/25 at 1:25 PM, another surveyor spoke with Resident #14, and she stated there were no snacks and residents eat their own snacks from their room if they get hungry. These concerns were discussed at the pre-exit meeting on 2/18/25 at 3:08 PM with the director of nursing, administrator, regional director of clinical services, regional dietary manager, and facility dietary manager. Surveyor requested and received a facility policy titled, Frequency of Meals with a revision date of 12/1/22, that read in part, .1. The facility has .regular snack times .4. For those residents who desire to eat at non-traditional times .suitable, nourishing alternative meals and/or snacks will be provided .5. Nutritious snacks and convenience foods (i.e. canned soups, peanut butter, crackers, cereal, and fruit) shall be available on the nursing units for those residents who request food outside of scheduled meal and snack times . No further information was provided to the survey team prior to exit on 2/18/25.

Based on interviews and facility document review, facility staff failed to follow the facility menus to meet the daily nutritional and dietary needs of all residents that receive nutrition by oral means. The findings included: The facility staff failed to follow the facility menus to meet the daily nutritional and dietary needs of all residents that receive nutrition by oral means as evidenced by not following the planned facility menus on 11/30/24 and only providing two (2) meals to all residents who receive nutrition by oral means on 11/30/24. A review of facility mealtimes indicated that breakfast is served at 7:30 AM, lunch is served at 11:30 AM and dinner is served at 4:30 PM. A review of mealtimes on the rehabilitation (skilled) unit revealed breakfast is served at 8:15 AM, lunch is served at 12:15 AM, and dinner is served at 5:15 PM. Surveyor requested and received the facility meal menus for the week of 11/24/24 through 11/30/24. The menu for 11/30/24 read in part, .Breakfast .Juice of choice, Bacon, Cereal of Choice, French Toast, Milk of Choice, Coffee, Syrup/Margarine/Creamer .Lunch .Lasagna Italian Style, Zucchini, Tossed Salad w/Dressing (with dressing), Garlic Bread, Coconut Cream Pie, Beverage of Choice .Dinner .Tuna Salad Sandwich, Potato Chips, Strawberries, Tossed Salad w/Dressing, Banana Split Dessert, Beverage of Choice, Milk of Choice . On 2/13/25 at 2:24 PM, surveyor interviewed other staff #6 (OS#6) about meal service on 11/30/24. OS#6 stated she was working on 11/30/24 and recalled breakfast as being, super-late and believed it was served around 10:00 AM. She stated it was decided that lunch would be skipped, and they (dietary staff) went into dinner preparation and dinner was served as scheduled. On 2/13/25 at 3:14 PM, surveyor interviewed regional dietary manager-other staff #2 (OS#2) and he stated dietary staff made the decision to skip the lunch meal and breakfast was served around 11:00 AM. On 2/14/25 at 9:13 AM, surveyor interviewed licensed practical nurse # 4 (LPN#4) and she stated she was on-call on 11/30/24 and was called about the breakfast issue. She stated she contacted management and basically breakfast was late, lunch had not gone out and dietary staff made the decision to go into dinner service. On 2/14/25 at 12:20 PM, surveyor interviewed cook, other staff #15 (OS#15) and he recalled the 11/30/24 incident. OS#15 stated breakfast went out late and was more like brunch but could not recall the exact time breakfast was served. He stated another cook at the time, made the call to skip lunch, so they (dietary staff) went into dinner prep. He stated he did not know what was served for breakfast, he did not cook breakfast, he cooked dinner. During the course of the survey, Resident #10, Resident #15's RP (resident representative), and Resident #14 were interviewed by this surveyor and another surveyor and all parties stated on Tuesday (2/11/25) they were served half of a sweet potato and greens for lunch with no protein or meat serving. Surveyor reviewed the menu for 2/11/25 and it included chicken and dumplings for the protein portion of the meal. On 2/18/25 at 12:54 PM, surveyor interviewed other staff #8, dietary cook. She stated she did not run out of chicken and dumplings and does not know what happened with some of the residents not getting the protein on Tuesday (2/11/25). On 2/18/25 at 12:56 PM, surveyor spoke with other staff #3, dietary cook, and she denied running out of chicken and dumplings. She stated they have to serve half of a sweet potato if only one box is ordered, or they would not have enough. A half of potato is all they have to give. She denied that it was brought to her attention from any staff or residents that some residents did not get chicken and dumplings on Tuesday (2/11/25). These concerns were discussed on 2/14/25 at 11:04 AM with regional director of clinical services, regional director of operations, regional dietary manager, director of nursing, and administrator and again at the pre-exit meeting on 2/18/25 at 3:08 PM with the director of nursing, administrator, regional director of clinical services, regional dietary manager, and facility dietary manager. Surveyor requested and received a facility policy titled, Menus and Adequate Nutrition with a revision date of 12/1/22, that read in part, .The purpose of this policy is to assure menus are .prepared to meet resident choice including their nutritional .needs .3. Menus will be followed as posted .Substitutions shall comprise foods with comparable nutritive value . No further information regarding this issue was provided to the survey team prior to the exit on 2/18/25.

Based on observations, interviews, and facility document review, the facility staff failed to employ dietary staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services of the facility. The findings included: The facility staff failed to provide orientation to dietary employees and failed to implement dietary employee competency training to provide appropriate competencies and skills sets to safely and effectively carry out the meal preparation and other food and nutrition services of the facility. On 2/13/25 at 12:05 PM, surveyor entered kitchen to observe tray line with dietary manager-other staff #4 (OS#4) and noted three male dietary employees (other staff #5 (OS#5), other staff #17 (OS#17), and other staff #19 (OS#19) without beard restraints. OS#17 was plating meatloaf. Surveyor asked what the expectation for beard restraints were, and OS#4 stated he has ordered some, but did not believe they had to wear them if the beard was short. OS#4 and lead dietary director-administrative staff # 3 (AS#3) also presented with beards and did not have beard restraints. OS#17 put a hairnet over his beard and OS#5 and OS#19 were given beard restraints that were located by other staff #3 (OS#3). OS#17 and OS#19 agreed they had never received any orientation and did not know anything about beard restraints. OS#4 stated some of the aides have been here less than sixty days and have not had a dietary manager or orientation of any kind. On 2/13/25 at 2:24 PM, surveyor interviewed other staff #5 and he stated he had received orientation, but he had no knowledge of beard restraints, and he will wear them if they order them. On 2/14/25 at 8:45 AM, surveyor met with administrator (ADM) and asked the process for training dietary staff, and he explained the expectation is for them to go through orientation. They were without a dietary manager from early January until a few days ago. ADM stated the regional dietary manager is working on on-line trainings across the company that all dietary staff would take. On 2/14/25 at 9:46 AM, surveyor interviewed regional dietary manager-other staff #2 (OS#2) and ADM. ADM stated there was no policy for dietary training and in the absence of a dietary manager, dietary staff would take their training on-line. OS#2 stated he assigned staff to orientation but no one in the kitchen has completed any dietary specific orientation or competencies yet. The new dietary manager started on Monday (2/10/25) and they went through the schedule and scheduled times for orientation to dietary staff. On 2/14/25 at 12:20 PM, surveyor interviewed dietary cook-other staff #15 and he informed surveyor he had basic orientation, but did not have any dietary specific orientation. Surveyor was provided a copy of dietary staff orientation schedule, and the first orientation was scheduled to begin on 2/18/25. Surveyor was provided with a list of dietary personnel and OS#17 had a hire date of 1/1/25, other staff #18 (OS#18) had a hire date of 12/27/24, and OS#19, had hire date of 1/6/25. OS#2 provided surveyor with copies of scheduled upcoming training materials that included dietary specific competencies for dietary aides and dietary cooks. These concerns were discussed on 2/14/25 at 11:04 AM with regional director of clinical services, regional director of operations, regional dietary manager, director of nursing, and administrator and again at the pre-exit meeting on 2/18/25 at 3:08 PM with the director of nursing, administrator, regional director of clinical services, regional dietary manager, and facility dietary manager. Surveyor requested and received a facility policy titled, Dietary Services-Staffing with a revision date of 12/1/22, that read in part, .The facility employs sufficient staff with appropriate competencies and skills sets to carry out the functions of the Food and Nutrition Services .6. The facility will provide sufficient support personnel to safely and effectively carry out the supportive functions of the Food and Nutrition Services. These functions include, but are not limited to: a. Safe and timely meal preparation; b. Maintaining clean and sanitary environment; c. Providing meals and/or supplements in accordance with residents' needs . No further information was provided to the survey team prior to exit on 2/18/25.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to meet the daily nutritional and dietary needs of all residents that receive nutrition by oral means. The findings included: 1.The facility staff failed to meet the daily nutritional and dietary needs of all residents that receive nutrition by oral means as evidenced by providing only two meals on 11/30/24 and failed to develop a contingency plan in the event that food service to residents is disrupted. A review of facility mealtimes indicated that breakfast is served at 7:30 AM, lunch is served at 11:30 AM and dinner is served at 4:30 PM. A review of mealtimes on the rehabilitation (skilled) unit revealed breakfast is served at 8:15 AM, lunch is served at 12:15 AM, and dinner is served at 5:15 PM. Surveyor requested and received the facility meal menus for the week of 11/24/24 through 11/30/24. The menu for 11/30/24 read in part, .Breakfast .Juice of choice, Bacon, Cereal of Choice, French Toast, Milk of Choice, Coffee, Syrup/Margarine/Creamer .Lunch .Lasagna Italian Style, Zucchini, Tossed Salad w/Dressing (with dressing), Garlic Bread, Coconut Cream Pie, Beverage of Choice .Dinner .Tuna Salad Sandwich, Potato Chips, Strawberries, Tossed Salad w/Dressing, Banana Split Dessert, Beverage of Choice, Milk of Choice . A review of the dietary staff schedule for 11/30/24, identified five dietary employees worked on 11/30/24. On 2/13/25 at 2:24 PM, surveyor interviewed the administrator (ADM), and other staff #6 (OS#6) about meal service on 11/30/24. OS#6 stated she was working on 11/30/24 and recalled breakfast as being, super-late and believed it was served around 10:00 AM. She stated it was decided that lunch would be skipped, and they (dietary staff) went into dinner preparation and dinner was served as scheduled. ADM recalled two cooks were supposed to be working and one of the cooks was stranded due to his ride not showing up. An uber was paid for him to get to the facility and he got breakfast served late after getting here late. Surveyor asked ADM what the process was for serving meals when not having kitchen staff available and he stated that was a new issue for him, so they improvised. On 2/13/24 at 3:14 PM, surveyor interviewed regional dietary manager-other staff #2 (OS#2) and ADM. OS#2 recalled the 11/30/24 incident and stated one of the cooks had car issues, so he (OS#2) paid for an uber and kept in contact with the kitchen and ordered snacks for the residents. OS#2 stated dietary staff made the decision to skip the lunch meal and breakfast was served around 11:00 AM. On 2/14/25 at 9:13 AM, surveyor interviewed licensed practical nurse # 4 (LPN#4) and she stated she was on-call on 11/30/24 and was called about the breakfast issue. She stated she contacted management and basically breakfast was late, lunch had not gone out and dietary staff made the decision to go into dinner service. On 2/14/25 at 12:20 PM, surveyor interviewed cook, other staff #15 (OS#15) and he recalled the 11/30/24 incident. OS#15 stated breakfast went out late and was more like brunch but could not recall the exact time breakfast was served. He stated another cook at the time, made the call to skip lunch, so they (dietary staff) went into dinner prep. This concern was discussed on 2/14/25 at 11:04 AM with regional director of clinical services, regional director of operations, regional dietary manager, director of nursing, and administrator and again at the pre-exit meeting on 2/18/25 at 3:08 PM with the director of nursing, administrator, regional director of clinical services, regional dietary manager, and facility dietary manager. Surveyor requested and received a facility policy titled, Frequency of Meals, with a revision date of 12/1/22, that read in part, .The facility will ensure that each resident receives at least three meals daily . Surveyor requested a facility policy to address disruption in normal meal service/delivery and was informed by the ADM, there was none. No further information regarding this issue was provided to the survey team prior to the exit on 2/18/25. 2. The facility staff failed to provide the correct amounts of food on three (3) residents' breakfast trays on the morning of 2/14/25 (Resident #2, Resident #16, and Resident #17). On the morning of 2/14/25 at 8:51 a.m., the surveyor noted Resident #17's breakfast tray did not include Large Portions which was noted under Food Likes on the resident's meal slip. The breakfast tray was noted to contain one (1) folded egg omelet, two (2) link sausages, and (2) half slices of toasted bread. On the morning of 2/14/25 at 8:54 a.m., the surveyor noted Resident #16's breakfast tray did not include Large Portions which was noted under Food Likes on the resident's meal slip. Resident #16 was ordered a mechanical soft diet. The breakfast tray was noted to contain one (1) folded egg omelet and one (1) scoop of ground sausage. On the morning of 2/14/25 at 8:58 a.m., the surveyor noted Resident #2's breakfast tray did not include Double Portions which was noted as part of the diet order on the resident's meal slip. The breakfast tray was noted to contain one (1) folded egg omelet, two (2) link sausages, and (2) half slices of toasted bread. On 2/14/25 at 9:05 a.m., Staff Member (SM) #8 (a dietary employee) reported large portions and double portions are the same. SM #8 reported that two (2) folded egg omelets should have been provided instead of only one (1) folded egg omelet. SM #8 reported that four (4) sausage links should have been provided instead of two (2) sausage links. SM #8 stated the bread/toast would not have been doubled. On 2/14/25 at 10:04 a.m., the facility's consultant Registered Dietitian (RD) reported they would not consider large portions to mean double portions but stated it is not incorrect if the facility was providing double portions when large portions were ordered/requested. The facility's Regional Director of Food Services (RDFS) reported that there was not a policy addressing double portions and/or large portions. On 2/18/25 at 12:56 p.m., the aforementioned observations of three (3) breakfast trays on the morning of 2/14/25 not having double portions and/or large portions was discussed with the RDFS and Administrator. The RDFS confirmed the large portions and double portions should both have been double portions. It was discussed that double portions would have been two (2) folded egg omelets and four (4) sausage links. The survey team met with the facility's Administrator, Director of Nursing, Dietary Manager, Regional Director of Food Services, and Regional Director of Clinical Services on 2/18/25 at 3:08 p.m. During this meeting, the surveyor discussed the observations of the failure of facility staff to provide the requested and/or ordered food portion sizes.

Based on observation, staff interview, and facility document review the facility staff failed to ensure a clean, comfortable, homelike environment for 2 of 17 residents, Resident #3 and Resident #11. The findings included: 1. For Resident #3 the facility staff failed to ensure the feeding pump pole was clean. Resident #3's clinical record listed diagnoses which included but not limited to unspecified intracranial injury with loss of consciousness, personal history of traumatic brain injury, and dysphagia. Resident #3's most recent minimum data set with an assessment reference date of 01/09/25 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section K, Swallowing/Nutrition, coded the resident as receiving 51% or more of nutrition through tube feeding. Surveyor observed Resident #3 on 02/13/25 at 10:30 am. Surveyor observed a dried, tan-colored substance on the base of the feeding pump pole at this time. Surveyor, along with the director of nursing (DON) observed Resident #3 again on 02/13/25 at 2:30 pm. DON stated to surveyor that the dried, tan-colored substance was dried tube feeding formula, and they would have someone clean the pole. Surveyor requested and was provided with a facility policy entitled, Safe and Homelike Environment which read in part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible .Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The concern of not providing a clean and sanitary environment was discussed with the administrator, DON, regional director of operations, and regional director of clinical services on 02/13/25 at 4:35 pm. No further information was provided prior to exit. 2. For Resident #11 the facility staff failed to ensure a clean and sanitary environment. Resident #11's clinical record listed diagnoses which included but not limited to unspecified dementia and benign prostatic hyperplasia with lower urinary tract symptoms. Resident #11's most recent minimum data set with an assessment reference date of 01/02/25 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section H, Bladder and Bowel, coded the resident as always incontinent of urine. Surveyor observed Resident #11 on 02/13/25 at 11:15 am. Resident was resting in bed. Surveyor observed stained reusable pad under resident. Surveyor observed yellowish substance on wall under window in room, with run marks down to floor. Floor observed to have a sticky residue under window and beside bed. surveyor observed a folding chair against the wall with a yellowish substance on the seat. Surveyor detected a transient odor of urine in the room. Surveyor spoke with registered nurse (RN) #1 on 02/13/25 at 11:25 am. Surveyor asked RN #1 if they noticed an odor in Resident #11's room, and RN #1 stated that resident sometimes takes their brief off and urinates in the floor. Surveyor pointed out the stain on the wall, residue in the floor, and yellowish substance on the chair. RN #1 removed the chair from the room, and stated they would get housekeeping to come clean the room. Surveyor, along with director of nursing (DON) observed Resident #11 on 02/13/25 at 2:40 pm. Surveyor pointed out stain on wall and residue in floor, and informed DON that RN #1 had stated they would get housekeeping to clean room earlier in the day. DON confirmed that room had not been cleaned. Surveyor requested and was provided with a facility policy entitled, Safe and Homelike Environment which read in part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible .Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The concern of not providing a clean and sanitary environment was discussed with the administrator, DON, regional director of operations, and regional director of clinical services on 02/13/25 at 4:35 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to address lab test recommendations for one (1) of 17 sampled residents (Resident #2). The findings include: The facility staff failed to ensure laboratory recommendations from a consulting medical provider was addressed by Resident #2's primary medical providers. Resident #2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/31/25, was signed as completed on 2/11/25. Resident #2 was assessed as usually able to make self understood and as usually able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 00 out of 15; this indicated severe cognitive impairment. Resident #2 was assessed as requiring supervision or touching assistance with personal hygiene and bathing. Resident #2's clinical record contained communication from a brain injury center; this communication was dated 10/31/24 and was faxed to the facility on [DATE]. This communication included the following information: Your thyroid function tests, including TSH and Free T4, are within normal range, which is good news. However, your FSH level is elevated at 25.7 mIU/mL, where the normal range is between 1.4 and 12.8. Additionally, your testosterone level is slightly below the normal range at 237 mg/dL, with a reference range being 250 to 1100ng/dL. Given these findings, I recommend repeating the testosterone, FSH, and LH tests. It's important to do this before 9 AM and while fasting, as hormone levels can vary throughout the day. If your FSH remains high and your testosterone remains low, it would be advisable to consult with an endocrinologist, a specialist who can provide further insights and guidance. Resident #2's medical documentation failed to provide evidence of the facility staff obtaining the aforementioned recommended laboratory tests. On 2/18/25 at 11:58 a.m., the Director of Nursing (DON) reported they were unable to find evidence of the recommended laboratory test being obtained and/or addressed by a medical provider. On 2/18/25 at 12:08 p.m., the surveyor interviewed the nurse practitioner (NP) that had reviewed the aforementioned communication from the brain injury center. The NP reported she was unable to remember if clarification had been obtained from the brain injury center related to the laboratory test recommendations. The NP stated that she would not have repeated them immediately. The NP stated she would get clarification from the recommending provider. The following progress note was dated 2/18/25 at 1:22 p.m.: Called (doctor's name omitted) office to get clarification on the labs mentioned in his office note on 10/31/24. Nurse will get with the physician and call nurse at facility. The survey team met with the facility's Administrator, Director of Nursing, Dietary Manager, Regional Director of Food Services, and Regional Director of Clinical Services on 2/18/25 at 3:08 p.m. During this meeting, the surveyor discussed the failure of the facility's medical providers to address Resident #2's laboratory recommendations from a brain injury center.

Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised to address the resident's dietary breakfast request for one (1) of 17 sampled residents (Resident #2). The findings include: Resident #2's care plan did not include specific interventions to address Resident #2's breakfast request and/or breakfast routine. Resident #2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/31/25, was signed as completed on 2/11/25. Resident #2 was assessed as usually able to make self understood and as usually able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 00 out of 15; this indicated severe cognitive impairment. Resident #2 was assessed as requiring supervision or touching assistance with personal hygiene and bathing. On the morning of 2/14/25, the surveyor observed facility staff members providing resident breakfast trays on Resident #2's unit. The facility staff failed to provide Resident #2 with a breakfast tray. On 2/14/25 at 8:58 a.m., Certified Nurse Aide (CNA) #2 stated the resident was asleep and never wants breakfast so they do not wake him up. CNA #2 stated the breakfast tray is left on the cart which brought the unit's residents' trays. On 2/14/25 at 9:00 a.m., CNA #3 confirmed that Resident #2's breakfast tray was left on the cart due to the resident sleeping and routinely not wanting breakfast. Resident #2's comprehensive care plan did not address Resident #2's breakfast request/routine observed by the surveyor and reported by CNA #2 and CNA #3. On 2/14/25 at 9:35 a.m., the surveyor asked the Director of Nursing (DON) about Resident #2's breakfast request not being addressed in the resident's care plan. On 2/18/25 at 11:35 a.m., the DON reported Resident #2's care plan had been updated to address the resident's breakfast request. The DON reported the CNAs were aware of the resident's wishes and provided appropriate care. The following updated information was found documented on Resident #2's care plan: - 2/18/25: Resident noted to prefer not to eat breakfast from the meal tray in the mornings. - (Resident name omitted) has snacks in his room provided by family. (W)ill notify nursing if he needs an alternate meal option at meal times. Date Initiated: 2/18/2025 . The following information was found in a facility policy titled Care Plan Revisions Upon Status Change (with a reviewed/revised date of 12/1/22): The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The survey team met with the facility's Administrator, Director of Nursing, Dietary Manager, Regional Director of Food Services, and Regional Director of Clinical Services on 2/18/25 at 3:08 p.m. During this meeting, the surveyor discussed the failure of Resident #2's care plan to address the resident's specific breakfast needs/desires.

Based on staff interviews, clinical record review and facility document review, the facility staff failed to implement an effective discharge planning process that focuses on the residents discharge goals and effectively transitions them to post discharge care for 1 of 17 residents in the survey sample, Resident #5 (R5). The findings included: For R5 the facility failed to ensure prescriptions for medications that included antibiotics and pain medications, were ready and available upon discharge from the facility. R5s diagnoses all stemmed from a motor vehicle accident and included abdominal injury requiring a colostomy, multiple pelvic and nasal bone fractures, a fractured left arm and post traumatic urethral stricture that required a suprapubic catheter. The discharge minimum data set (MDS) assessment for R5 was reviewed. The brief interview for mental status (BIMS) score was assessed at 15 out of 15 indicating the resident had intact cognition at the time of discharge. In Section J Health Conditions R5 was coded as having had frequent pain or hurting over the last five days that limited their participation in therapy and their day-to-day activities. Their pain was rated as high as 8 out of 10. On 2/2/25 at 5:39 PM a nurse progress note read, Patient was discharged . Left the facility with his mom via car with all belongs. Discharge instructions reviewed. MD to call in all prescriptions to the pharmacy. The physician's orders and medication administration record (MAR) were reviewed. R5 had an order for levofloxacin (an antibiotic) 750 mg by mouth daily for 6 months for prevention r/t injuries and wounds. The MAR indicated that resident had been given the daily dose prior to leaving the facility on the day of discharge. R5 was also noted to have orders for Gabapentin 300 mg 2 (two) capsules by mouth three times daily for neuropathic pain, flagyl 500 mg 1 tablet every 8 (eight) hours for prevention for injuries and wounds for 6 (six) months. The MAR indicated resident received morning and afternoon doses of these medications but not the evening/night doses. R5s orders included Oxycodone-Acetaminophen 7.5-325 mg as needed (PRN) for pain which was signed off as given almost daily and sometimes multiple times daily during his stay. On 2/13/25 at 3:40 PM this surveyor interviewed the Social Services Director. When asked about R5s discharge and medications they stated, He was cut by insurance on a Saturday. I had to call the family from home and let them know, and (POA) decided to go ahead with the Sunday discharge because they had done several appeals and this was the final one. Nursing was supposed to print the prescriptions and have the NP (Nurse Practitioner) sign them, the NP was here both days and I don't know why they didn't do that. I had the medical director call them in on Monday as soon as I could. On 2/18/25 at 11:40 AM this surveyor interviewed Licensed Practical Nurse (LPN) # 8. They stated that they did assist with R5s discharge. When asked about the plan for medications they stated, There were supposed to be paper prescriptions but they weren't there so the doctor was going to call in the meds so they could just pick them up on their way home. LPN # 8 could not recall who had said that the doctor was calling them in, I think the lady that picked him up had talked to the social worker and got that worked out but I'm not sure. When asked if any medications were sent with resident at discharge LPN # 8 stated, Not that I'm aware of. On 2/18/25 at 3:09 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services and the Regional Director of Operations. This concern was reviewed at that time. No additional information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a shower/bath was offered twice a week to one (1) of 17 residents (Resident #2). The findings include: The facility staff failed to ensure Resident #2 was offered a shower and/or full bath at least twice a week. Resident #2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/31/25, was signed as completed on 2/11/25. Resident #2 was assessed as usually able to make self understood and as usually able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 00 out of 15; this indicated severe cognitive impairment. Resident #2 was assessed as requiring supervision or touching assistance with personal hygiene and bathing. Resident #2's clinical documentation indicated for the following five (5) weeks the resident only received one (1) shower/bath per week: (a) 10/20/24 - 10/26/24; (b) 11/10/24- 11/16/24; (c) 12/15/24 - 12/21/24; (d) 1/19/25 - 1/25/25; and (e) 1/26/25 - 2/1/25. The facility's policy addressing resident bathing did not provide information on the frequency of which baths should be offered to residents. On 2/18/25 at 11:53 a.m., the Administrator reported the facility did not have a written policy detailing the frequency of shower and/or baths; the Administrator confirmed that two (2) showers/baths should be offered weekly. On 2/18/25 at 11:58 a.m., the Director of Nursing (DON) reported that residents should be provided/offered showers/baths twice a week and as needed. On 2/18/25 at 12:28 p.m., the DON reported that Resident #2's documentation failed to indicate the resident had been offered two (2) showers each week for the weeks in question. The survey team met with the facility's Administrator, Director of Nursing, Dietary Manager, Regional Director of Food Services, and Regional Director of Clinical Services on 2/18/25 at 3:08 p.m. During this meeting, the surveyor discussed the failure of the facility staff to offer Resident #2 two (2) baths per week.

2. For Resident #5 (R5) the facility staff failed to provide wound care daily per provider orders. The clinical record was reviewed. R5 was admitted with an order that read, Cleanse perineal wounds with wound wash, pat dry, pack wound with iodoform packing strips, cover with ABD pads (abdominal pads- a thick, absorbent nonadhesive dressing). Every shift. On 11/18/24, 11/20/24 night shift, there were blanks on the TAR indicating the treatments were not done. This order was discontinued on 11/23/24. On 11/23/24 an order was put in that read, Cleanse perineal wounds with wound wash, pat dry, pack wound with iodoform packing strips, cover with ABD pads. Two times a day for wound care. There were holes on the TAR for 12/9/25, 12/10/25, 12/12/25 all on day shift, 12/22/25 day shift and 12/23/25 day and night shift. This order was discontinued 12/27/25. An order dated 12/17/24 read, Clean surgical incision to lower ABD (abdomen) with wound cleanser and apply antifungal powder followed by dry gauze and ABD pads one time a day for wound treatment. There were blanks on the TAR for 12/22/24, 12/23/24 and 12/25/24. An order dated 11/13/24 that read, nystatin external ointment 100,000 units/gm (Nystatin topical) apply to affected area for skin topically two times a day for skin infection apply BID (twice daily) to skin infection due to the fungus candida. There were holes on the TAR for 12/22/24 and 12/23/24 day shift, 1/11/25 night shift, 1/17/25 day shift, 1/19/25 night shift and 1/31/25 night shift. An order dated 12/19/24 read, Scrotum- cleanse with wound cleanser and pack with iodoform packing strip. Change if soiled and after showers one time a day for wound management. There were blanks noted on the TAR for 12/22/24, 12/23/24. This order was discontinued on 12/25/24. On 12/25/24 an order was put in that read, Scrotum- cleanse with wound wash, pat dry, pack with iodoform packing strip cover with ABD pad. Change if soiled and after showers. Two times a day for wound management. There was a hole on 12/30/24 and the order was discontinued that same day. In addition to these holes on the TAR, there were multiple holes noted for emptying JP drains (A Jackson Pratt drain is a surgical suction drain that draws fluid from a wound after surgery) that resident initially had, and holes for the care of his suprapubic catheter for the duration of his stay. On 2/18/25 at 12:15 this surveyor interviewed the Director of Nursing (DON). When asked what holes in TARs for various wound treatments might indicate, she stated, the nurse didn't sign off or complete their documentation. When asked if the wound care was done and just not signed off she said, Well, if it isn't signed, I don't know for sure it was done. This surveyor requested, received and reviewed the policy entitled, Documentation of Wound Treatment with a review/revised date of 12/1/22 that read in part, 3. Wound treatments are documented at the time of each treatment on the Treatment Administration Record in PCC (EMR). If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact.) There was no indication in the record that R5's wounds worsened. A Nurse Practitioner (NP) specializing in wound care documented weekly notes that specifically stated wounds were improving. On 2/18/25 at 3:09 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional Director of Operations and this concern was discussed. No further information was presented to the survey team prior to the exit conference. 3. For Resident #6, the facility staff failed to apply topical Greer's [NAME] ointment to the sacrum/buttocks as ordered by the medical provider to treat moisture-associated skin damage (MASD). Resident #6's diagnosis list indicated diagnoses, which included, but not limited to Arteriovenous Malformation of Digestive System Vessel, Gastrointestinal Hemorrhage, Pneumonitis, Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Dementia, and Malignant Neoplasm of Prostate. The minimum data set (MDS) with an assessment reference date (ARD) of 9/30/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #6's comprehensive person-centered care plan included a focus area stating, Pressure Ulcer/Impaired Skin Integrity Potential for/impaired skin integrity r/t [related to] fragile skin with an intervention to Provide treatment as ordered - see TAR [treatment administration record] for specifics. Resident #6's medical provider orders included an order dated 11/23/23 and 12/07/23 for Greer's [NAME] to bilateral buttocks every shift. A review of the resident's December 2023 Treatment Administration Record (TAR) revealed treatment omissions for 12/05/23 night shift, 12/06/23 night shift, 12/07/23 day and night shift, 12/10/23 night shift, and 12/14/23 night shift. Resident #6's clinical record also included a medical provider order dated 1/05/24 for Greer's [NAME] to the sacrum/buttocks topically three times a day for excoriation. The order was transcribed to be administered only twice a day instead of the ordered three times a day. According to the resident's January 2024 TAR, the Greer's [NAME] was only applied twice a day from 1/05/24 through 1/15/24. On 2/18/25 at 1:42 PM, surveyor spoke with the Director of Nursing (DON) who stated the order for Greer's [NAME] was entered incorrectly. Surveyor requested and received the facility policy titled Documentation of Wound Treatments with a reviewed/revised date of 12/01/22 which read in part .3. Wound treatments are documented at the time of each treatment on the Treatment Administration Record . On 2/18/25 at 3:10 PM, the survey team met with the Administrator, DON, Regional Director of Clinical Services, Dietary Director, and Regional Dietary Director and discussed the concern of Resident #6's treatment omissions and Greer's [NAME] order. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/18/25. Based on staff interview and clinical record review, the facility staff failed to complete provider ordered treatments for 3 of 17 residents in the survey sample, Residents #3, #5, and #6. The findings include: 1. For Resident #3, the facility staff failed to provide evidence that the nursing staff had completed a provider ordered treatment of zinc oxide twice a day. Resident #3's diagnoses included, but were not limited to, traumatic brain injury, aphasia, epilepsy, and cognitive communication deficit. Section C (cognitive patterns) of Resident #3's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/09/25 was coded to indicate this Resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. Resident #3's comprehensive care plan included the focus area has potential impairment to skin integrity related to decreased mobility, thin fragile skin with easy bruising and tearing related to disease process, incontinence of bowel and bladder. Resident #3's clinical record included a provider order for zinc oxide left buttock twice a day until healed. The order date was documented as 12/09/24 the treatment was discontinued on 01/11/25. A review of Resident #'3's treatment administration records (TARs) for 12/2024 and 01/2025 revealed that for 12/25/24 and 01/02/25 for the evening shift no nurse had documented that this treatment had been completed. During the record review the surveyor identified two nurses that would have been working on the dates and times in question. The Director of Nursing (DON) was notified of the issue with the zinc oxide treatment on 02/18/25 at 10:20 a.m., the DON stated neither of these nurses were currently employed at the facility. On 02/18/25 the DON provided the surveyor with a copy of their policy titled Documentation in Medical Record. Date implemented 11/01/20 this policy read in part, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident .Licensed staff .shall document all assessments, observations, and services provided in the resident's medical record .Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred . On 02/18/25 at 12:15 surveyor #2 interviewed the DON. When asked what holes in TARs for various wound treatments might indicate, she stated, the nurse didn't sign off or complete their documentation. When asked if the wound care was done and just not signed off she said, Well, if it isn't signed, I don't know for sure it was done. On 02/18/25 at 3:10 p.m., during a meeting with the Administrator, Director of Nursing, Regional Nurse Consultant, Regional Dietary Manager, and Dietary Manager the issue regarding Resident #3's provider ordered zinc oxide treatment was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interviews, clinical record review, and facility document review the facility staff failed to provide treatment in accordance with provider orders to promote pressure area healing for 1 of 17 residents, Resident #9. The findings were: For Resident #9, facility staff failed to consistently provide pressure wound care as ordered by the provider. Resident #9's Minimum Data Set Assessment with an Assessment Reference Date of 12/26/24, assessed the resident should not have a brief interview for mental status conducted due to the resident was rarely/never understood. Section C (cognitive patterns) coded Resident #9 to have short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. Section M (skin conditions) assessed the resident for having 6 (six) Stage 3 pressure ulcers present upon admission and 1 (one) unstageable pressure ulcer present upon admission. Resident #9's clinical record contained wound care orders which included but not limited to: 1a. Right heel stage Right heel stage 3 pressure wound - cleanse daily with wound cleanser. Apply calcium alginate and wrap with Kurlix [sic] every shift for wound treatment. Start date: 01/09/25 with discontinue date: 01/27/25. Resident #9's treatment administration record (TAR) for January 2025 indicated wound treatment to this area was not documented for: 01/10/25 night shift, 01/11/25 night shift, 01/13/25 day shift, 01/16/25 night shift, 01/18/25 day shift, and 01/25/25 night shift. 1b. Right heel stage 3 pressure wound - cleanse daily with wound cleanser, apply medihoney and wrap with kerlix every shift for wound treatment. Start date: 01/28/25. Resident #9's TAR for January and February 2025 indicated wound treatment to this area was not documented for: 02/05/25 night shift, 02/10/25 night shift, and 02/13/25 night shift. 2. Right chest pressure wound - cleanse with wound cleanser and apply calcium alginate and cover with boarded gauze, one time a day for wound treatment. Start date: 01/09/25. Resident #9's TAR for January and February 2025 indicated wound treatment to this area was not documented for: 01/17/25, 01/18/25, and 02/05/25. 3. Stage 3 pressure wound left shoulder - cleanse with wound cleanser and apply medical grade honey fiber and cover with bordered gauze, one time a day for wound treatment. Start date: 01/09/25. Resident #9's TAR for January and February 2025 indicated wound treatment to this area was not documented for: 01/17/25, 01/18/25, 01/23/25, and 02/05/25. 4. Unstageable left upper buttock pressure wound - cleanse with Dakins Solution. Apply Dakins moistened fluffed gauze and cover with border gauze, one time a day for wound treatment. Start date: 01/09/25. Resident #9's TAR for January and February 2025 indicated wound treatment to this area was not documented for: 01/17/25, 01/18/25, 01/23/25, and 02/05/25. On 02/18/25 at 12:45 p.m., one surveyor visited Resident #9 in his room. The resident was observed lying in bed with eyes closed. The resident did not respond to questions and was therefore not interviewed. The director of nursing (DON) was interviewed on 02/18/25 with the concern regarding the dates of Resident #9's wound care treatments not being documented discussed. The DON reported at 1:40 p.m. there was no evidence Resident #9's wound care was completed for those areas on the dates left blank on the TAR. The DON acknowledged the nursing staff schedules were separated into two shifts every day; Day shift and night shift. The facility's policy titled, Documentation of Wound Treatments with an implementation date of 11/01/2020 and a reviewed/revised date of 12/01/2022 was reviewed. The document read in part, Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: 3. Wound treatments are documented at the time of each treatment on the Treatment Administration Record in PCC (Point Click Care - facility's documentation software program) . The most recent Wound Assessment Report was dated 02/10/25 and electronically signed by the wound nurse practitioner (WNP) described the wounds' status as follows: 1. Right heel Stage 3 pressure wound: Improving without complications 2. Right chest pressure wound: Stalled 3. Left shoulder Stage 3 pressure wound: Stalled 4. Left upper buttock pressure wound: Stalled and unstageable. On 02/18/25 at 3:10 p.m. during a summary meeting with the administrator, regional director of clinical services, DON, regional dietary manager, and dietary manager the concern regarding wound care not being consistently provided to Resident #9 according to provider orders was discussed. No further information was provided prior to the exit conference.

Based on staff interview and clinical record review the facility staff failed to ensure medications and biologicals were stored and labeled correctly for 2 of 17 residents, Resident #3 and Resident #13. The findings included: For Resident #3 the facility staff failed to label/date tube feeding solution and placed a treatment belonging to Resident #13 in Resident #3's room. Resident #3's Resident #3's clinical record listed diagnoses which included but not limited to unspecified intracranial injury with loss of consciousness, personal history of traumatic brain injury, and dysphagia. Resident #3's most recent minimum data set with an assessment reference date of 01/09/25 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section K, Swallowing/Nutrition, coded the resident as receiving 51% or more of nutrition through tube feeding. Resident #3's comprehensive care plan was reviewed and contained a care plan for At risk of malnutrition r/t (related to) need for tube feed with NPO (nothing by mouth) diet order and The resident requires tube feeding r/t dysphagia. Resident #3's clinical record was reviewed and contained a physician's order summary which read in part, Enteral Feed Order-Promote 1.0 @ 120 ml/hr x 12 hours start at 1800 complete at 0600. Run for total of 12 hours or until total volume of 1440 ml is infused. Document amount at 0600 every 24 hours for nutrition. Tube feeding to start at 1800 and Nystatin External Powder 100000 Unit/GM (Nystatin (Topical)). Apply to both under breast topically three times a day for rash for 3 weeks. Surveyor observed Resident #3 on 02/13/25 at 10:30 am. Resident was resting in bed. Container of tube feeding solution of Promote 1.0 was hanging on feeding pump pole. This contained was not labeled with name, date/time opened, or rate of feeding. Surveyor spoke with director of nursing (DON) on 02/13/25 at 2:30 pm. DON stated that tube feeding formula should be labeled with name/date/rate. During a complaint investigation, it was alleged that a medication belonging to Resident #13 was administered to Resident #3. Surveyor spoke with the local long-term care ombudsman on 02/13/25 at 12:45 pm and asked ombudsman if they had received any complaints for Resident #3 related to this issue. Ombudsman stated that the medication in question was Nystatin, and it was found in Resident #3's room and was unclear as to whether it had been administered to Resident #3. Resident #13's clinical record was reviewed and contained a physician's order summary which read in part Nystatin External Powder 100000 Unit/GM (Nystatin (Topical)). Apply to under breasts topically two times a day for rash for 10 days. This order was discontinued on 01/04/25. Surveyor spoke with the DON on 02/13/25 regarding a treatment belonging to Resident #13 being found in Resident #3's room. DON confirmed that this had happened and that the medications for both residents were discarded and replacement ordered for Resident #3. The concern on not labeling tube feeding solution and placing a treatment belonging to another resident in Resident #3's room was discussed with the administrator, DON, regional director of operations, and regional director of clinical services on 02/13/25 at 4:35 pm. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to maintain an effective pest control program for 1 of 6 resident care units (Juniper). The findings included: On the Juniper resident care unit, the facility staff failed to maintain an effective pest control program to address the presence of small, black, gnat-sized flying insects. On 11/06/24 at 11:45 AM, surveyor entered the Juniper resident care unit's kitchen. The kitchen area was separated from the resident dining and living areas by a counter and waist-high gate. Surveyor immediately observed a minimum of 20 small, black, gnat-sized flying insects flying about the kitchen area and present on the walls and cabinets. The shelf under the unit microwave was soiled with food crumbs and debris. On 11/06/24 at 1:16 PM, surveyor spoke with Resident #7 who stated there were gnats in the kitchen and it needed a thorough cleaning. On 11/06/24 at 1:19 PM, surveyor spoke with Resident #2 who stated for the past two weeks there had been a bunch of gnats on the unit. On 11/07/24 at 6:55 AM, surveyor spoke with Licensed Practical Nurse (LPN) #4 who stated recently the gnats had gotten worse and had never been this bad. On 11/07/24 at 9:00 AM during the breakfast meal service, surveyor observed a meal cart on the Juniper unit hall with an open gallon of milk with the lid removed sitting on top. A small, black, gnat-sized flying insect was observed near the meal cart in the hall. On 11/07/24 at 9:22 AM, while speaking with Resident #2 in their room, surveyor observed a small, black, gnat-sized insect flying over their breakfast tray. Resident #2 stated it was that time of year and there was not much you could do about it. Resident #2 also stated people had been complaining about the gnats. On 11/07/24 at 10:28 AM, surveyor spoke with the facility Maintenance Director (MD) who stated they were aware of the gnat issue on the Juniper unit. MD stated there was a hole for the water machine beside the under the counter trash can and if trash inadvertently misses the can and goes into the hole it caused gnats. To address the gnats, MD stated they were focusing on cleaning and recently placed a gnat trap in the kitchen sink but had to remove it due to a visitor concern, but it was effective when it was in use. MD stated the pest control company comes monthly but they have not discussed the gnat concern with them. Surveyor requested and received the Resident Council Minutes for October 2024 which included discussion of fruit flies. The 10/10/24 minutes read in part, .Fruit Flies - Extermination and Cleaning of trash in the areas - situation is helping . On 11/07/24 during the end of day meeting with the Administrator, Director of Nursing, Regional Director of Food Services, and the Regional Director of Clinical Services, surveyor discussed the concern of the flying insects observed on the Juniper care unit. On 11/08/24, the Administrator provided pest control service invoices dated 8/01/24, 9/01/24, and 10/01/24. On 11/08/24 at 10:23 AM, surveyor spoke with the Regional Director of Operations (RDO) who stated this was the first they had heard of the gnats and pest control came weekly and with the next visit they would be placing a special chemical in the drain to address the gnats. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/08/24.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to store, prepare, and serve food in accordance with professional standards for food service safety for 4 of 6 resident care units and the facility kitchen. The findings included: On the Juniper resident care unit, the facility staff failed to maintain a clean and sanitary refrigerator and microwave, failed to store foods under sanitary conditions, failed to discard out of date foods, and failed to label and date perishable food items. On 11/06/24 at 11:45 AM, surveyor entered the Juniper resident care unit kitchen. The kitchen area was separated from the resident dining and living area by only a counter and a half gate. Surveyor observed a minimum of 20 small, black, gnat-sized, flying insects flying about the kitchen area and present on the walls and cabinets. The exterior of the refrigerator was soiled with dried, sticky splattered substances and debris particles. The inside of the refrigerator was also soiled with a substantial number of crumbs on the bottom shelf and around the door seals. The refrigerator contained a small block of yellow cheese wrapped in plastic wrap with no label or date present. The cheese had four small black circles resembling mold present on the surface. Also present in the refrigerator was a unlabeled, undated, container with a piece of grayish meat, an unlabeled, undated large container of applesauce loosely covered with tin foil, an open 12 ounce bottle of mayonnaise with a Best When Used By date of 21 [DATE], a half full gallon of milk with a date of [DATE] printed on the jug, and an unlabeled, undated bowl of beans covered with plastic wrap. A Temperature Equipment Log dated 10/01/24 was affixed to the refrigerator door and the last recorded refrigerator temperature was documented on 10/14/24. The pantry included a 32-ounce bag of toasted oats cereal which was open leaving cereal exposed to the air. The shelf under the unit microwave was soiled with food crumbs and debris, the outside of the microwave had dried smeared substances present. The interior of the microwave was heavily soiled with wet and dried splattered substances on the bottom, top, sides, and door. On 11/06/24 at 1:16 PM, surveyor spoke with Resident #7 who stated there were gnats in the kitchen and it needed a thorough cleaning. On 11/06/24 at 1:30 PM, surveyor spoke with Housekeeper #1 who stated the dietary department was responsible for cleaning the unit kitchen as Housekeeping did not go behind the kitchen counter. On 11/07/24 at 9:00 AM during the breakfast meal service, surveyor observed a meal cart on the Juniper unit hall with an open gallon of milk with the lid removed sitting on top. A small black, gnat-sized flying insect was observed near the meal cart in the hall. On 11/07/24 at 10:46 AM, surveyor spoke with the Regional Director of Food Services (RDFS) who stated the facility stopped serving meals out of the unit kitchens and brought all food preparation back into the main kitchen on 10/23/24. RDFS stated since that time, the cleaning of the kitchens became the responsibility of housekeeping, and the refrigerators remained the responsibility of dietary personnel. On 11/07/24 at 3:43 PM, surveyor spoke with the Director of Housekeeping who stated their department was responsible for cleaning the dining area but not the unit kitchens as they did not go behind the kitchen counters. On the Emerald resident care unit, the facility staff failed to maintain a clean and sanitary microwave, stored a half full container of Ranch salad dressing in a non-operational refrigerator, and failed to properly store a container of prepared food. On 11/06/24 at 11:42 AM, surveyor entered the Emerald resident care unit kitchen and observed the microwave with food debris and crumbs on the shelf under the microwave. The inside of the microwave was heavily soiled with food crumbs on the glass turntable and bottom and dried splattered substances present on the top, sides, and interior door. The refrigerator was unplugged and pulled out into the floor and only contained a half full one-gallon container of Ranch salad dressing. At 12:01 PM, surveyor spoke with an outside vendor who was repairing the refrigerator. The vendor stated the refrigerator had not been working for approximately one month and it was unplugged when they arrived today. Upon arrival to the Emerald Unit on 11/06/24 at 11:42 AM, surveyor observed a plastic container filled with sauced noodles and shrimp sitting on the edge of the counter entering the unit kitchen. Surveyor returned to the unit on 11/06/24 at 6:00 PM and the container with the sauced noodles and shrimp remained on the kitchen counter and accessible to residents as the kitchen half gate was open. An ambulatory resident was walking near the counter asking when dinner would be served. Surveyor notified a staff member, and they picked up the container. On 11/07/24 during the end of day meeting with the Administrator, Director of Nursing, RDFS, and Regional Director of Clinical Services, surveyor discussed the concerns with the Juniper and Emerald kitchen observations. On 11/08/24 at 11:10 AM, surveyor spoke with the RDFS who stated they had no Juniper refrigerator temperature log for the month of November and October was only partially completed. On 11/08/24 at 12:28 PM, surveyor spoke with a Dietary Aide who stated when the unit kitchens were closed, cleaning was turned over to housekeeping and they were not sure who's responsibility it was to check the refrigerators and refrigerator temperatures. Surveyor requested and received the facility policy titled Monitoring of Cooler/Freezer Temperature with a revised date of 12/01/22 which read in part, .1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least twice per day by designated personnel. b. Logs will be changed out and filed each month . Surveyor requested and received the facility policy titled Date Marking for Food Safety with a revised date of 12/01/22 which read in part, .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest . Surveyor requested and received the facility policy titled Food Safety Requirements with a revised date of 12/01/22 which read in part, . 3 .c .Practices to maintain safe refrigerated storage include .v. Keeping foods covered or in tight containers .5. Foods and beverages shall be delivered to residents in a manner to prevent contamination. Strategies include, but are not limited to: a. Covering all foods with lids .6. All equipment used in the handling of food shall be cleaned and sanitized . No further information regarding this concern was presented to the survey team prior to the exit conference on 11/08/24. 21227 On 11/8/24 at 9:55 a.m., the surveyor observed with Licensed Practical Nurse (LPN) #2, the small refrigerator in the common area where resident food items were stored on Rehab A Unit. A red/pink liquid had pooled on the bottom level of the inside of this refrigerator. LPN #2 disposed of the following items this refrigerator was observed to contain: - An opened gallon jug of water with a best by date of 8/31/24. This jug of water had less than a fourth of the water remaining in the jug. - An opened multi-serving plastic container of cranberry juice with approximately a quarter of the juice missing. This container of cranberry juice was not dated to indicate when it had been opened. - A plastic bag containing a slice of pizza wrapped in foil was not labeled with a date and was not labeled to indicate whose food the pizza was. The plastic bag containing the pizza had been soiled with a red/pink liquid. - A plastic bag containing a foam clam shell container was not dated and not labeled to indicate whose food was in the foam clam shell container. The foam clam shell container contained partially eaten chicken wings and French fries. On 11/8/24 at 10:05 a.m., the surveyor observed with Licensed Practical Nurse (LPN) #7, the small refrigerator in the common area where resident food items were stored on Rehab B Unit. LPN #7 disposed of the following items this refrigerator was observed to contain: - A block of butter that had been opened and partially rewrapped in its paper covering/wrapping. The butter had not been completely covered resulting in part of the block of butter being left exposed. - A single serving cup of chocolate pudding with a whipped topping was not dated. This item had been repackaged by the facility staff from multi-serving containers. - An opened multi-serving plastic container of apple juice with greater than half the juice missing had not been dated to indicate when opened. - A bag containing a partially eaten sandwich from a local restaurant. This item was not labeled with a date and was not labeled to indicate to whom it belonged. The following information was found in a facility policy titled Date Marking for Food Safety (with a reviewed/revised date of 12/1/22): - Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 F or less for a maximum of 7 days. - The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. - The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. - The marking system shall consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded. - The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. On 11/8/24 at 11:09 a.m., the Regional Director of Food Services (RDFS) stated the opened containers of water, milk, and juice should have been labeled with a date to indicate when they had been opened. On 11/6/24 at 12:10 p.m., Staff Member (MR) #7 (a dietary aide) was observed, working in the facility's kitchen during the midday meal service, without wearing a beard restraint. Dietary Manager #2 confirmed SM #7 should have been wearing a beard restraint. The following information was found in a facility policy titled Dietary Employee Personal Hygiene (with a reviewed/revised date of 12/2/22): All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. On 11/8/24 at 9:25 a.m., the surveyor discussed the observations of SM #7 not wearing a beard cover while working in the dietary department with the Administrator and the Regional Director of Food Services (RDFS). On the afternoon of 11/6/24, two (2) of the three (3) handwashing sinks located in the dietary department was noted to be dispensing only cool water. On 11/6/24 at 6:10 p.m., the Maintenance Director, with the surveyor and the Administrator present, checked the water temperature in the handwashing sinks in the dietary department. One (1) sink's water temperature was 81.6 degrees Fahrenheit and a second sink's water temperature was 85 degrees Fahrenheit. The Maintenance Director adjusted the flow of the cold water to these sinks and the water temperature promptly increased. The following information was found in a facility policy titled Handwashing Guidelines - Dietary Employees (with a reviewed/revised date of 12/1/22): - Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink . - Handwashing Procedure: a. Turn on water to a comfortable warm temperature . On 11/7/24 at 4:05 p.m., the survey team met with the facility's Administrator, Director of Nursing, Regional Director of Food Services, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the failure of two (2) of the three (3) hand washing sinks located in the dietary department to dispense warm water for handwashing.

Based on observations, staff interviews, and facility document review, the facility staff failed to ensure that food was served at a safe and/or appetizing temperature. The findings include: On 11/6/24 at 11:54, the surveyor observed dietary staff plating food from the steam table. The plated food was being placed on carts to be provided to the facility's residents. Food temperatures had not been documented for this meal. Dietary Manager #1 confirmed the food temperatures had not been documented for this meal. Dietary Manager #1 reported they were responsible for making sure the temperatures were checked. Dietary Manager #1 had the food temperatures checked. The pureed peas were 93 degrees Fahrenheit and the pureed chicken was 96 degrees Fahrenheit. Dietary Manager #1 had the food items that were below the desired temperatures reheated. On 11/6/24, the surveyor reviewed the food temperature logs with Dietary Manager #1. No food temperatures had yet to be documented for the month of November 2024. The food temperature binder included the following entries: - An undated page with only hot food temperatures entered for breakfast and lunch; no dinner food temperatures were entered. - An undated page with only one (1) food temperature entered for lunch (Swedish meatballs); no breakfast and dinner food temperatures were entered. - An undated page with only hot food temperatures entered for breakfast; no lunch and/or dinner food temperatures were entered. - An undated page with only hot food temperatures entered for lunch; no breakfast and/or dinner food temperatures were entered. - The only food temperature logs for October 2024 found by and/or provided to the surveyor were for the following dates: 10/2/24, 10/3/24, 10/4/24, 10/7/24, 10/8/24, 10/9/24, 10/11/24, 10/25/24, and 10/28/24. The following information was found in a facility policy titled Record of Food Temperatures (with a reviewed/revised date of 12/1/22): - It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. - Food temperatures will be checked on all items prepared in the dietary department. - Hot foods will be held at 135 degrees Fahrenheit or greater. - Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log. - When holding hot foods for service, food temperature should be measured when placing it on the steam table line. - Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy. On 11/7/24 at 4:05 p.m., the survey team met with the facility's Administrator, Director of Nursing, Regional Director of Food Services, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the failure of the facility staff to check, document, and/or maintain food temperatures.

Based on observations, staff interviews, and facility document review, the facility staff failed to consistently follow menus for resident meals. The findings include: On 11/6/24 at 12:03 p.m., during the midday meal, the surveyor observed the dietary staff to be plating food for the residents. It was noted the menu included a dinner roll which was not being placed on the food trays sent to the resident units. Staff Member (SM) #6 (a dietary aide) reported that three (3) carts of food trays had been sent to the resident units without the dinner rolls. Dietary Manager #1 reported the trays should have included a dinner roll. Dietary Manager #1 obtained the dinner rolls from the freezer and had them baked for the rest of the meal trays. The menu for this meal also included for the residents to be provided oriental vegetables. The surveyor observed that peas and carrots were being served to the residents. Dietary Manager #1 confirmed the facility had mixed vegetables that should have been used for the 11/6/24 midday meal. Dietary Manager #1 reported the cook decided to cook peas and carrots; Dietary Manager #1 reported the cook did not get the substitutions approved prior to cooking them. The facility staff failed to ensure the correct serving size of the pudding provided as part of the facility's evening meal on 11/6/24. On 11/6/24 at approximately 5:40 p.m., Staff Member (SM) #8 (a dietary aide) was observed to use a scoop with a blue handle to plate pudding. According to the menu, the pudding was to be a four (4) ounce serving. SM #8 was unable to identify the size of the scoop used to serve the pudding. On 11/6/24 at 5:55 p.m., Dietary Manager #1, after looking up the scoop information on the internet, reported the scoop used in the aforementioned observation of SM #8 plating the pudding was a 2.75-ounce scoop. Dietary Manager #1 confirmed the size of the scoop by measuring the amount the scoop held and comparing it with another measuring device. The following information was found in a facility policy titled Menus and Adequate Nutrition (with a reviewed/revised date of 12/1/22): - The facility will ensure that menus meet the nutritional needs of residents in accordance with established national guidelines. - Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value. - The facility's dietician or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus. On 11/7/24 at 4:05 p.m., the survey team met with the facility's Administrator, Director of Nursing, Regional Director of Food Services, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the failure of facility staff to provide resident food according to the menu.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to complete a comprehensive admission assessment for one (1) of eight (8) sampled residents (Resident #1). The findings include: Review of Resident #1's clinical record, on the morning of 11/7/24, indicated the facility staff failed to complete an admission/comprehensive Minimum Data Set (MDS) assessment for Resident #1 when the resident was readmitted to the facility after being discharged with a return not anticipated. Resident #1's MDS assessment, with an Assessment Reference Date (ARD) of 10/18/24, was signed as completed on 11/6/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. On 11/7/24 at 10:30 a.m., Registered Nurse (RN) #1 confirmed Resident #1 had been discharged return not anticipated therefore resulting in the need to have had an admission/comprehensive assessment completed when readmitted . On 11/7/24 at 10:41 a.m., RN #1 stated Resident #1 had an admission/comprehensive assessment started when readmitted to the facility. RN #1 stated this assessment had been struck out. This struck out assessment had not been completed. RN #1 reported they could reopen the assessment and complete it today. RN #1 confirmed this admission/comprehensive MDS assessment would be completed late. On 11/7/24 at 4:05 p.m., the survey team met with the facility's Administrator, Director of Nursing, Regional Director of Food Services, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the failure of the facility staff to complete the admission/comprehensive MDS assessment when Resident #1 was readmitted to the facility after being discharged with a return not anticipated.