Every finding on record at Stella Manor Nursing and Rehabilitation Center

Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure food was stored and prepared in sanitary conditions for one of one kitchen. The findings include: During an observation and concurrent interview with Dietary Aide (DA) #1 on 06/08/2026 at 12:15 PM, the following were observed: -Gray particles in the air under the fan and dark gray matter on the ceiling above the fan. Debris becoming dislodged from the ceiling was seen settling in the vicinity of food preparation areas. -A partially used, opened box of frozen meat patties (approximately 30) were noted to be stored without a received, or an opened date. -A box of garlic bread sticks were observed to be opened, and the plastic bag inside was not sealed, leaving the bread sticks exposed to air or contaminants. -One container of Italian seasoning with an opened date of 05/15/2025 and a use by date of 05/15/2026. DA #1 described the airborne gray particles as being dust. DA #1 indicated that the patties should have had a received date and an open date and the breadsticks should be stored in a closed bag. DA #1 also indicated that all the spices on the shelf were ready for staff to use in preparing meals for residents. During an interview on 06/10/2026 at 10:50 AM, the Dietary Manager (DM) indicated everyone who worked in the kitchen was responsible for cleaning the freezer, and sometimes tools were obtained from Maintenance to clean the fan cover. The DM revealed there was no schedule to clean the freezer. The DM also indicated that the garlic bread found opened should have been closed and sealed to help prevent freezer burn and the partially used box of hamburger meat patties should have been stored with a received date and an open date. The DM indicated that [if sealed properly] to not expose the residents to the risk of acquiring a food-borne illness the patties could have been used 30 days after the opened date, or up to one year after the received date. During an observation and concurrent interview on 06/10/2026 at 10:55 AM, this surveyor observed the [NAME] performing a temperature check on pureed lasagna. The [NAME] then put an alcohol wipe package to his mouth, tore the alcohol package open with his teeth, touched both the package and the wipe, wiped the thermometer with the alcohol pad, then performed a temperature check on pureed zucchini by placing the thermometer into the middle of the pan. This survey asked the [NAME] if he had put the wipe in his mouth to tear the package open and he answered yes. The [NAME] was not observed to perform hand hygiene after touching the wipe and package. The DM was made aware of the observation. The pureed food was served to six residents. During an interview on 06/10/2026 at 11:45 AM, the DM indicated the Italian seasoning was on the shelf ready for use, past the best by date of one year from opening. The DM also indicated that her process for ensuring compliance with food storage and preparation was randomly observing activities. During an interview on 06/10/2026 at 11:47 AM, the [NAME] indicated that he should not have torn the alcohol wipe package with his teeth and should have performed hand hygiene before obtaining temperatures on more food. During an interview on 06/11/2026 at 8:29 AM, the Infection Preventionist (IP) indicated that after the [NAME] put the alcohol wipe in his mouth, used it on the temperature probe, and put the probe into the zucchini, the zucchini should not have been served to the residents. During a follow-up interview on 06/11/2026 at 10:48 AM, the DM indicated that on 06/10/2026, during the temperature checks of the pureed foods, after putting the wipe in his mouth to tear the package open, the [NAME] should have stopped and not put the temp probe into the zucchini. In addition, the DM indicated that the zucchini should have been discarded, hand hygiene performed, and the zucchini remade. The DM indicated that a result of not performing hand hygiene and using a wipe that had been in the Cook's mouth could be exposing the residents to cross-contamination. Review of a facility policy titled, Handling, Serving, and Transporting Foods dated 05/15/2020, revealed a clean, sanitized thermometer is to be used to check the temperature of foods, and a probe wipe or a sanitizing system would be used to clean in between readings. Review of a facility policy titled, Food Storage dated 11/25/2019, revealed food storage areas are to be clean and free of dirt. Review of a facility policy titled, Receiving Foods dated 02/14/2019, revealed all food items are to be labeled with the date of delivery. Review of a facility policy titled, Handwashing and Glove Usage in Food Service dated 2016, revealed food handlers must wash their hands after touching their face. Review of a facility kitchen staff in-service titled Handling Serving food dated 03/02/2026, revealed that a clean, sanitized thermometer is to be used to check temperatures of foods and to clean the thermometer in between readings with a probe wipe or Sanitizing system.

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure that over-the-counter medications and prescribed medications required for as needed (PRN) basis were removed and not used from the medication/storage rooms and medication carts. Findings include: A review of a facility policy titled, Medication Storage in the Facility, revised January 2018, indicated, that all expired medications will be removed from the active supply and will be destroyed, regardless of the amount of medication that remains in the usual manner. During review of the [NAME] Station Medication Room on 11/06/24 at 8:40 AM, 3 bottles of Vitamin B-6 100 mg were found with the expiration date of 06/2024. During review of the East Station Medication Room, on 11/06/2024 at 8:54 AM, the medication cart used by the Medication Aide Certified (MAC) was found to have six cards of expired as needed medications. Those included: Resident #1 Cyclobenzaprine 10 milligrams (mg)-30 tablets (1 card) with an expiration date of 11/5/24; Resident #39 Benzonatate 100 mg-29 capsules (1 card) with an expiration date of 10/24/24; Resident #57 Clonidine Hydrochloride (HCl) 0.1 mg-24 tablets (1 card) with an expiration date of 10/06/24; Resident #32 Tizanidine 2 mg-16 tablets (1 card) and 7 tablets (1 card) to equal a total of 23 tablets with an expiration date of 10/24; and Resident #62 Ondansetron HCl 4 mg-29 tablets (1 card) with an expiration date of 10/23/24. During an interview on 11/06/2024 at 9:03 AM, LPN stated that the expired medications would be turned in to the Director of Nursing (DON). During an interview on 11/07/24 at 9:30 AM, DON stated that the Vitamin B-6 should have been removed and that all the other Vitamin B-6 had already been removed and those must have been missed. DON confirmed that an in-service with staff had already started regarding checking expiration dates on the over-the-counter medications and the PRN medications that are on the medication carts.

Based on observation and interview, the facility failed to ensure the ice scoop holder was maintained in clean and sanitary condition, expired dairy products and food items were promptly removed / discarded on or before the expiration or used by date to prevent the growth of bacteria; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: On [DATE] at 9:33 AM, there were 4 cartons of half and half on a shelf in the walk-in refrigerator with an expiration date of [DATE]. On [DATE] at 9:40 AM, five 5-lb boxes of carrot cake mix were on a rack in the storage room with an expiration date of [DATE]. On [DATE] at 9:46 AM, a wet pink residue was on the scoop holder on the left side of the ice machine. The ice scoop was resting directly in contact with the pink residue. The Surveyor asked the Dietary Supervisor to wipe the area where the pink residue was observed, and the pink residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor how often is the ice scoop holder cleaned and who uses the ice from the machine? She stated, The CNAs used it to fill the water pitchers in the resident's rooms, and we use it to fill beverages served to the residents at mealtimes. We clean it daily. On [DATE] at 7:35 AM, Dietary Employee #1 was on the tray line assisting with the breakfast meal. He picked up condiments and cartons of supplements, and placed them on the trays. Without washing his hands, he picked up glasses by the rims and placed them on the trays to be served to the residents for lunch. On [DATE] at 10:29 AM, Dietary Employee #1 walked into the kitchen with a can of soda and placed it on the table by the door leading to the outside. He went into the walk-in refrigerator, removed a bag of bread, placed it on the counter, picked up packages of peanut butter and jelly, opened them, and placed them on the counter. He untied a bag of bread, removed gloves from the glove box, and placed them on his hands. He removed slices of bread from the bag and placed them on the pan liner. Without changing gloves or washing his hands, he spread peanut butter and jelly on the slices of bread, topped each slice with another slice of bread, and placed them on the plates. He covered them with foil and placed them on a shelf in the walk-in refrigerator to be served to the residents for the lunch meal. On [DATE] at 11:03 AM, Dietary Employee #2 removed a pan of vegetables from the oven and placed it on the counter. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for lunch. The Surveyor immediately asked Dietary Employee #2 what should you have done after touching dirty objects, and before handling clean equipment? He stated, I should have washed my hands. On [DATE] at 11:30 AM, Dietary Employee #3 picked up a menu from the counter, glanced at it and placed it on the counter. He opened the door to the walk-in refrigerator, removed a container of tuna salad and a bag of bread and placed them on the counter. He untied the bag of bread, and then removed gloves from the glove box placing them on his hands. Without washing his hands and changing gloves, he removed slices of bread from the bag and placed them on the plates. He used a scoop and scooped tuna salad, spread tuna salad on the slices of bread and topped each slice with another slice of bread to be served to residents. Review of facility policy titled, Hand washing showed staff will wash hands and exposed portions of arms to remove contamination after entering the kitchen, during food preparation, and when working with ready to eat food. Also, before donning gloves for working with food and after engaging in other activities that contaminate the hands.

Based on observation, interview and policy review, the facility failed to store controlled medications securely in 3 of 3 medication rooms. The findings are: On 10/11/2023 at 8:42 AM, the Surveyor toured the North/Northeast Medication Room with Registered Nurse (RN) #1. Inside the refrigerator, on a shelf was a red plastic tub containing what RN #1 identified as (1) unopened 30 milliliter (mL) bottle labeled as Lorazepam, (2) unopened 1 mL vials labeled as Lorazepam, and (4) unopened single-use syringes labeled as Lorazepam. The medications were not stored in a separately locked, permanently affixed compartment. The Surveyor observed the refrigerator was also being used to store nutritional supplements for the residents. On 10/11/2023 at 9:15 AM, the Surveyor toured the [NAME] Medication Room with (Licensed Practical Nurse (LPN) #2. Inside the refrigerator, there were 3 bottles sitting inside the door. LPN #2 identified the bottles as 30 mL bottles of Lorazepam, 2 unopened and 1 opened with 30mL remaining in the container. On 10/11/2023 at 9:44 AM, the Surveyor toured the East Medication Room with LPN #1. Inside the refrigerator, the Surveyor observed a metal container affixed to the roof of the refrigerator. LPN #1 opened the metal container without the use of a key. LPN #1 said they had forgotten to lock it back when they last accessed the controlled medications. LPN #1 identified the contents as 2 boxes labeled as Lorazepam in 30 mL bottles. The Surveyor asked LPN #1 to confirm controlled medications needed to be secured in a locked permanently affixed container. LPN #1 agreed. On 10/11/2023 at 12:02 PM, the Director of Nursing (DON) confirmed the controlled medications were not being stored separately as required, and the East Medication Room-controlled medications were not being stored separately in a locked container. On 10/12/2023 at 9:00 AM the Administrator said the facility had no policy on medication storage.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The findings are: On 10/11/23 at 11:05 PM, Dietary Employee (DE) #2 used 4 ounces of spoon to place 10 servings of brussels sprouts into a blender and pureed. At 1:07 AM, Dietary Employee #2 poured the pureed brussels sprouts into a pan. He covered the pan with foil and placed it on the steam table. The consistency of the pureed brussels sprouts was not smooth with pieces of brussels sprouts in the mixture. On 10/11/23 at 11:45 AM, Dietary Employee #1 placed 6 dinner rolls into a blender, added warm milk and pureed. He scooped pureed bread with milk into a pan and placed it on the steam table. The consistency was thick, with lumps and not smooth. On 10/11/23 12:00 PM, Dietary Employee #1 placed 3 servings of butter milk pies into a blender, he added milk and pureed. At 12:02 PM, Dietary Employee #1 poured the pureed dessert into a pan. The consistency of the pureed butter milk pie was not smooth or formed, and there were pieces of crumbs in the mixture. On 10/11/23 at 12:13 PM, Dietary Employee #2 placed 5 servings of pork loins into a blender, instead of 6 servings, added its juice and pureed. At 12:15 PM, DE #2 poured the pureed mixture into a pan. He placed the pan on the steam table and covered it with foil. The consistency was gritty, thick, and not smooth. On 10/11/23 at 1:54 PM, the Surveyor asked Dietary Employee #1 to describe the consistency of the pureed butter milk. Dietary Employee #1 stated, It was not smooth and was no pudding like. On 10/11/23 at 1:55 PM, the Surveyor asked Dietary Employee #2 to describe the consistency of the pureed food items served to the residents on pureed diets. He stated, Pureed meat was not smooth. It was gritty. Pureed bread was thick and lumpy.

Based on observation, record review, and interview, the facility failed to ensure that meals were prepared and served according to the planned written quantified recipe and menus meet the nutritional needs of the residents for 2 of 2 meals observed. 3 The findings are: Review on 10/11/2023, of the Spring/Summer 2023 menu for the breakfast meal showed the residents on pureed diets were to receive 6-ounces of pureed oatmeal, a #16 scoop (1/4 cup) of pureed sausage, a #16 scoop (1/4 cup) of pureed biscuit, a #8 scoop (1/2 cup) of pureed pancake. On 10/11/23 at 7:36 AM Dietary Employee (DE) #2 used a #16 scoop (1/4 cup) to serve a single portion of the following food items to the residents on pureed diet; pureed bread, pureed sausage, pureed eggs and 6-ounce spoon to serve cream of wheat. There were no pureed biscuits or pureed pancakes served to the residents on pureed diets. Review of the Spring/Summer 2023 menu noon meal showed the residents on pureed diets were to receive a #10 scoop of pureed buttermilk pie each and residents on mechanical soft diets were to receive 3 ounces of ground pork loins each. On 10/11/23 at 12:00 PM (DE) #1 placed 3 servings of butter milk pies into a blender, instead of 5 servings, added milk and pureed. At 12:06 PM, Dietary Supervisor instructed DE #1 to give pudding to 2 residents on pureed diets who did not get buttermilk pie and stated, We should have made more than 6 pies. On 10/11/23 at 12:11 PM (DE) #2 placed 11 servings of pork loins into a blender and blended. He poured the mixture into a pan and placed it on the steam table to be served to 21 residents who required mechanical soft diets. The Surveyor asked the Dietary Supervisor why is there not enough meat for all residents? She stated, We ordered enough, but they were shrunk after cooking them. I know now to do 3, instead of 2. Review on 10/12/2023 of the Spring/Summer 2023 menu for breakfast meal showed residents on pureed diets were to receive 6 -ounce of pureed oatmeal, a #16 scoop (1/4 cup) of pureed sausage, a #16 scoop (1/4 cup) of pureed biscuit, a #8 scoop (1/2 cup) of pureed pancake. On 10/12/23 at 7:50 AM DE #2 used a #16 scoop (1/4 cup) to serve a single portion of the following food items to the residents on pureed diets; pureed bread, pureed sausage, pureed eggs and 6-ounce spoon to serve cream of wheat. There were no pureed biscuits or pureed pancakes served to the residents on pureed diets. 10/12/23 7:51 AM the surveyor asked DE #2 the reason residents on pureed diets did not receive pureed biscuits and pureed pancakes. He stated, I didn't know they were supposed to have pureed biscuits and pureed pancakes.

Based on interview and record review, the facility failed to ensure 3 (Resident #25, Resident #67, and Resident # 68) of 6 (Resident #10, Resident #19, Resident #25, Resident #32, Resident #67, and Resident #68) sampled residents that were reviewed for unnecessary medication did not receive a PRN (as needed) medication past 14 days without justification, and an evaluation by the doctor. The findings are: Review of Resident #25's Order Summary Report showed a physician order dated 09/15/23 for a Haldol Injection as needed for delirium related to schizophrenia. A review of Resident #25's October 2023 Medication Administration Record revealed that Resident received an as needed injection of Haldol on 10/11/23. A review of the medical records, and the monthly pharmacy reviews did not indicate a justification of why Resident #25 should continue Haldol as needed 14 days. During interview on 10/11/23 at 3:59 PM, the Director of Nurse (DON) confirmed there was no justification for continued use of the as needed Haldol documented, and there was no evaluation by the physician for the continued use. Review of Resident #67's Order Summary Report showed a physician order dated 9/19/23 for Xanax every 6 hours as needed for anxiety for 60 Days. A review of an October 2023 Medication Administration Record revealed Resident #67 received Xanax on 10/09/23. A review of the medical records, and the monthly pharmacy reviews did not indicate a justification of why Resident #67 should continue Xanax as needed past 14 days. During interview on 10/11/23 at 3:47 PM, the Director of Nurse (DON), said it was rare to have someone on as needed antipsychotic medications, and there would be documentation. She said as needed medication should be renewed after 2 weeks, for up to 60 days. She confirmed there was no documentation in the medical record. A review of Resident #68's Order Summary Report showed a physician order for Lorazepam every 6 hours as needed for anxiety for 60 Days on 9/11/23. A review of an October 2023 Medication Administration Record revealed that Resident #68 received Lorazepam on 10/09/23. A review of the medical records and the monthly pharmacy reviews did not indicate a justification of why Resident #68 should continue Lorazepam as needed past 14 days. On 10/11/23 at 4:09 PM, the DON confirmed there was no documentation in the medical record.

Based on observation and interview the facility failed to maintain a sanitary environment during lunchtime on the secure unit. This failed practice had the potential to affect 15 residents who resided on the secure unit. The findings are. On 10/09/23 at 12:36 PM, CNA #3 opened the food cart and stepped onto the bottom shelf inside the food cart. The resident's meal trays were inside the cart. She reached on top of the cart and grabbed 3 cans of coke from the top of the cart. On 10/12 23 at 8:35 AM, the Surveyor asked the dietary manager, How are the staff supposed to get the drinks, cups and ice from top of the food carts? She stated, I have no clue. On 10/12/23 at 8:42 AM, the Surveyor asked CNA #4, How are staff supposed to get the drinks, cups and ice from top of the food carts? She stated, Reach up and get it. The Surveyor asked are staff supposed to step inside the food cart to reach the items on top of the cart? She stated, No.

Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen: expired dairy products and food items were promptly removed / discarded on or before the expiration or use by Date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination: and failed to ensure 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who receive meals from the kitchen (total census: 80) as documented on a list provided by Dietary Supervisor. The findings are: 1. On [DATE] at 11:29 AM, the following observations were made during the initial tour of the kitchen with Dietary Supervisor. a. The following cereal boxes were in a Clear rectangular container stored under the counter, there were no dates when the cereals were received or when opened. 1) Four Raisin Bran. 2) Three Rice Krispies. 3) Two Cheerios; one of which was open. b. The following dry food items in a clear rectangular container on shelf in the storage room, the dry food items had no dates were not covered or sealed and had no dates when opened or received. 1) Envelopes of Instant Whey Protein. Surveyor asked Dietary Supervisor how many were in the container. She stated, about 30. She was asked, Should they be dated? She stated, They should have a sticker with the dates on the container like the others do. 2) Plastic jar of Pro Source. 3) Box of tartar sauce packets. 4) Box of yellow cake mix dated received [DATE] and expiration date [DATE]. 5) Box of Muffin mix dated received [DATE] and manufacture date of [DATE]. No expiration date but is over a year old. 6) Open jar of Rainbow sprinkles. 7) Open jar of Sprinkle Mix. 8) Tube of Black decorative icing not dated and expired [DATE] 9) Three graham cracker crusts. 10) Spice storage shelves near walk-in freezer contained: a) Paprika with flip top lid not closed and not dated. b) Cinnamon with flip top lid not closed and not dated. The Dietary Supervisor was asked, Should these be dated like the other spices? She stated, They have expiration dates, so they don't need to be dated. 11) A bottle of vanilla dated ,d+[DATE] with old, smudged label. The Dietary Supervisor was asked, Is this March of 2021? She stated, We don't use vanilla that often, so I am not sure if it is [DATE]st or March of 2021. 2. On [DATE] at 11:40 AM, the following observations were made in the walk-in freezer shelves: a. An open box of French toast sticks bag not sealed/tied closed b. An open box of Chicken & Cheese in tortilla rolls bag not sealed/tied closed Dietary Supervisor was asked, Should these be tied or in a sealed bag? DM stated, Yes. c. An open box of Cheese, Beef, Bean Burrito bag not sealed/tied closed d. An open box of [NAME] Dean sausage patties bag not sealed/tied closed. e. An open box of Okra bag not sealed/tied closed f. Mint Chip ice cream 3- gallon tub (½ full) no open or received dates. 3. On [DATE] at 11:50 AM, the following observations were made in the walk-in refrigerator: a. Plastic container ½ full of vanilla pudding with use by date of ,d+[DATE]. Dietary Supervisor was asked, Should this be in here? She stated, No, I started to go through this but got busy. b. Five Bags of green grapes turning brown and soft and 2 bags of red grapes getting soft had use by date of ,d+[DATE]. Dietary Supervisor was asked, Does the use by date say [DATE]? She stated, I didn't know how long grapes are good for, so I made them ,d+[DATE]. She was asked, Would you eat the green grapes that are brown? DM stated, Probably not. c. One zip lock bag of shredded orange colored cheese dated use by 7/ (date not complete) and had no open date. d. Open flat of 22 banana nut muffins received date ,d+[DATE], open date ,d+[DATE], use by date ,d+[DATE]. Top of muffins covered in liquid looking film. e. Flat of 24 apple muffins received date ,d+[DATE]. Tops of muffins covered on a liquid looking film. Dietary Supervisor stated, Those should have already been used. f. One box of red bell peppers dated received ,d+[DATE]. Bell peppers were wrinkly, soft, and had patches of grayish fuzz on each pepper. g. One 11 lb. pail, ,d+[DATE] full of chocolate icing, sitting on a rectangular plastic bin on top shelf of shelving unit with black sticky build-up and brown fuzzy build-up on piece of loose tubing cover sitting on top of pail. Build-up also sticking to brown substance on lid. h. On [DATE] at 12:40 PM, the Food storage policy received from DON stated, .Procedure: Containers are to be dated and labeled with the contents .All food not in original containers will be labeled, dated, and stored in NSF approved containers . 4. On [DATE] at 10:11 AM, Dietary Employee #1 Removed celery stalks from a bag and placed them on the cutting board on the counter. She diced the celery stalks and when she was ready to put them on ham and beans in a pan on the counter. She immediately was stopped and was asked what should you have done with the celery before using them in food to be cooked and served to the residents for lunch meal? She stated, Washed them. 5. On ,d+[DATE] at 10:24 AM, Dietary Employee #1 took out a container of strawberry and a container of blackberry from the walk-in refrigerator and placed them on the counter. She removed strawberries and blackberries from their original containers and placed them in bowls to be served to the residents for lunch. She was asked what should you do before plating strawberries and blackberries to serve to the residents for lunch? She Stated, Rinse them. 6. On [DATE] at 10:34 AM, there were 3 cartons of 2 % milk stored on a shelf in the walk-in refrigerator that had an expiration date of [DATE] 7. On [DATE] at 10:37 AM, Dietary Employee #2 turned on the three-compartment sink faucet and rinsed strawberries. She then, turned off the faucet and, without washing her hands, she picked strawberries from the original container, placed them on the cutting board and sliced them in half. She then, placed slices of strawberries in bowls to be served to the residents for lunch meal. 8. On [DATE] at 11:29 AM, Dietary Employee #2 took out a box of pie crust and placed it on the counter. She removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing the gloves and washing her hands, she removed a pie crust from the box and placed it over the slices of apple in a pan and placed in the oven to bake. 9. On [DATE] At 11:34 AM, Dietary Employee #1 turned on the 3-compartment sink and washed the blender bowl and blade She then turned off the faucet and, without washing her hands, she picked up the blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets for the noon meal. At 11:37 AM, she used 4 oz spoon to place 11 servings of turnip greens into a blender. She picked up a bag of bread from the counter and untied the bag. She then removed 2 slices of bread from the bag with her bare hand and placed them on top of the turnip greens inside the blender and pureed to be served to the residents who received pureed diets. On At 11:40 AM, she poured the pureed turnip greens in a pan and placed it in the warmer. 10. On [DATE] 11:47 AM, Dietary Employee #2 was wearing gloves on her hands, she closed the door to the warmer, opened the microwave door and removed a cup of warm milk and placed it on the counter. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender, she used her contaminated gloved hand to pick up 10 servings of cornbread and placed them in the blender, added milk and pureed to be served to the residents on pureed diets. At 12:11 PM Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 11. The facility's policy on hand washing provided by the Dietary Supervisor on [DATE] at 1:47 PM documented, To remove contamination after entering the kitchen during food preparation and before donning gloves for working with food, after engaging in other activities that contaminate the hands .

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meal observed. The failed practice had the potential to affect 10 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 7/13/2022. The findings are: 1. On 7/11/22 at 6:28 PM, Resident # 20 was served pureed macaroni and cheese. The consistency of the pureed macaroni and cheese was clumpy. 2. On 7/13/22 at 11:27 AM, Dietary Employee #1 prepared another pan of mashed potatoes with butter and evaporated milk. The consistency of the mashed potatoes was runny. 3. On 7/13/22 at 11:58 AM, Dietary Employee #1 used a 6 ounce spoon to place 6 servings of ham and beans into a blender and pureed. She poured the pureed ham and beans in a pan and placed it on the steam table to be served to 10 residents who received pureed diets. The consistency of the pureed ham and bean was lumpy and was not smooth. 4. On 7/13/22 at 12:14 PM, the Dietary Supervisor was asked to describe the consistency of the pureed ham and beans and fortified mashed potatoes. She stated, You can see pieces of meat in the mixture and mashed potatoes was runny.

Based on observation, record review and interview, the facility failed to ensure food was prepared by methods that maintained appearance to encourage adequate nutritional intake for 1 of 2 meal observed in the kitchen. The failed practice had the potential to affect 45 residents who received regular diets, 24 residents who received mechanical soft diets and 10 residents who received pureed diets from 1 of 1 kitchen, as documented on a list provided by Dietary Supervisor on 7/13/2022 at 12:55 PM. The findings are: 1. On 7/14/22 At 7:50 PM a pan of scrambled eggs was on the steam table. The plastic pan liner used to line the pan was brown in color. The scrambled eggs were over cooked and had brown flaky substance on it. The fried eggs were over cooked and dry. The Dietary Supervisor was asked to describe the appearance of the scrambled eggs. She stated, There were brown flakes in the egg. It was yucky. 2. On 7/14/22 At 7:54 AM, Human resource (HR) Manager who was loading breakfast trays in a food cart was asked to describe the appearance of the scrambled eggs and fried eggs served to the residents for breakfast. She stated, They were brown flaky eggs in the mixture from being over cooked. The plastic liner used to line the pan has brown. Fried eggs were overcooked and dried. 3. On 7/14/22 at 8:50 PM, the Dietary Supervisor was asked to describe the appearance of pureed eggs, regular oatmeal, and cream of wheat. She stated, There were brown flaky eggs in the pureed eggs. Pureed biscuit looked like biscuit and not pureed. Oatmeal was a little thick.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 10 residents who received pureed diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 7/13/2022. The findings are: 1. On 7/13/2022 the menu for the noon meal documented residents who received pureed diets were to receive a #6 scoop (6 oz) of pureed ham and beans. 2. On 7/13/22 at 11:58 PM, Dietary Employee #1 used a 6 oz spoon to place 6 servings of ham and beans into a blender and pureed. At 11:59 PM she poured the pureed ham and beans in a pan and placed it on the steam table to be served to 10 residents who received pureed diets. 3. On 7/13/22 at 12:16 PM. the following observations were made during noon meal service. a. Dietary Employee #1 used 2 oz spoon was equivalent to ¼ cup to serve cornbread to the residents on pureed diets, instead of a #10 scoop which was equivalent 1/3 to ½ cup for each resident. b. Dietary Employee #1 used 6 oz spoon to serve half a portion of pureed ham and bean to the residents on pureed diets. The menu specified for the residents on pureed diets to receive a #6 scoop (6 ounces) of pureed ham and bean each. c. On 7/13/22 at 1:30 PM, Dietary Employee #1 was asked what spoon size did you use to serve pureed cornbread and how many servings of pureed cornbread did you serve to each resident on pureed diets? She stated, I used 2 oz spoon to give a serving of cornbread each. She was asked how much ham and beans did you prepare for the residents on pureed diets? She stated, I used 6 oz spoon to put 6 servings of ham and bean in the blender and pureed She was asked how many residents you have on pureed diets? She stated, We have 10 residents.

Based on observation, record review and interview, the facility failed to ensure the surveys conducted by Federal or State surveyors and any plans of correction for the past 3 years were readily accessible to residents, resident representatives/family, and visitors. The findings are: 1. On 07/12/22 11:20 AM, while surveyor was looking for the State survey results binder at the front entrance to the facility, Visitor #1 asked why facility was being inspected. Surveyor explained reason for current visit. He asked what surveyor was looking for and surveyor stated she was looking for a binder of the results of their last few surveys. Visitor stated he didn't realize results were available for them to see. Surveyor asked if those would be important to him. He stated, I am pretty happy with the facility, but it would be nice to know what they aren't doing. 2. On 07/12/22 11:24 AM, Surveyor checked for State survey binder at front entrance. Surveyor found thin black binder, with a plain white piece of paper in the front sleeve, sitting below Ombudsman poster on a table. Surveyor opened the binder to find a CMS-2567 from 10/11/2019 and no other surveys. 3. On 07/12/22 11:26 AM, the DON was asked who was responsible for updating the State Survey binder and the DON stated, That would be [Administrator]. Is there an issue? Surveyor asked, Should the State Survey Results be labeled and easy to find? DON stated, Yes, it was labeled. Is it not? Surveyor accompanied DON to front entrance and DON grabbed binder and stated, Well a blank piece of paper doesn't do much good. Surveyor asked, How many years should it include? DON stated, The last survey. Surveyor stated, It should contain 3 years' worth. DON stated, I will fix it now. It only needs last year's survey because we didn't have one in 2020.

Based on observation and interview, the facility failed to ensure food items stored in the dry storage areas were sealed; failed to ensure dietary staff washed their hands before handling clean equipment or food items failed to ensure expired food items were promptly removed/ discarded on or before the expiration or use by dates and failed to ensure dented cans were removed/discarded to prevent potential for bacteria growth and/or food borne illnesses for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 65 residents who meals from the kitchen. (Total Census 67), according to the list provided by the Dietary Supervisor on [DATE] at 2:10 p.m. The findings are: 1. On [DATE] at 2:17 p.m., there was one unsealed bag of flour stored on a shelf in the storage room. Dietary Supervisor was asked should the bag of flour be sealed. She stated, Yes. 2. On [DATE] at 2:19 p.m., Dietary Employee #1 picked up a can of non-stick spray and sprayed the inside of a pan. Without washing her hands, she picked up gloves and put them on her hands, contaminating the gloves. She then used the gloved hand to scrape diced meat into a pan to be used for the supper meal. 3. On [DATE] at 2:20 p.m., there was one dented can of lima beans and one dented can of dark red kidney beans stored on a shelf in the storage room. There was also one unsealed bag of nonfat dry dairy milk stored on a shelf. The Dietary Supervisor was asked should you have dented cans on the shelf. She stated, No. 4. On [DATE] at 2:26 p.m., there were 5 cartons of thickened dairy milk stored on a shelf in the storage room. The boxes had an expiration date of [DATE]. The Dietary Supervisor was asked should food be disposed of when they reach the Best if Used By date. She stated, yes. 5. On [DATE] at 2:46 p.m., Dietary Employee #1 took two bags of sweet potato patties out of the walk-in freezer and placed them on the counter. She then picked up a can of nonstick spray and sprayed the inside of two pans. She picked up a pair of scissors and opened both bags. She emptied the bags of sweet potatoes into the pans. She then went to the storage room and took out a bag of brown sugar. Without washing her hands, she removed gloves from the box and placed them on her hands, contaminating the gloves. She then put her gloved hand into a bag of brown sugar and placed brown sugar over the top of the sweet potatoes in both pans. She covered both pans with foil and put them into the oven to cook, to serve to the residents for supper. 6. On [DATE] at 2:50 p.m., Dietary Employee #2 went to the walk-in refrigerator and removed a bag of grapes and placed it on the counter. Without washing her hands, she removed gloves from the box and placed them on her hands, contaminating the gloves. She then went to the sink and sliced strawberries and placed them in bowls to be served to the residents for supper. 7. On [DATE] at 2:56 p.m., Dietary Employee #2 scratched her head. Without washing her hands, she removed gloves from the box and placed them on her hands, contaminating the gloves. She sliced up more strawberries and placed them in bowls to be served to the residents for supper. She turned off the faucet to the sink, then she picked up a bowl of strawberries, touching the strawberries with her hand, to be served to the residents. 8. On [DATE] at 3:01 p.m., Dietary Employee #2 removed one half/gallon of milk, a carton of honey thickened dairy milk, and a carton of pudding from the walk-in refrigerator and placed them on the counter. Without washing her hands, she picked up glasses by the rims and placed them on the counter. She then poured beverages into the glasses for the residents on thickened liquid to drink for supper. 9. On [DATE] at 3:07 p.m., Dietary Employee #3 used a marker to write dates on the saran wrap used to cover glasses. Without washing her hands, she picked up a stack of glasses and touched the rims. She then dispensed beverages into each glass, covered, and placed in the walk-in refrigerator to be served to residents for supper. 10. On [DATE] at 4:23 p.m., Dietary Employee #1 touched the blender motor. Without washing her hands, she removed gloves from the box and placed them on her hands contaminating the gloves. She picked up a blade and attached it to the base of the blender to be used in pureeing food items for the residents on pureed diets. 11. On [DATE] at 4:52 p.m., Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handing clean equipment? She stated, Washed my hands. 12. On [DATE] at 5:05 p.m., Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handing clean equipment? She stated, Washed my hands. 13. On [DATE] at 2:10 p.m., the Administrator provided the policy for Hand Washing. The policy documented, Staff will wash hands and exposed portions of their arms. Purpose: To remove contamination ., before donning gloves for working with food, and after engaging in other activities that contaminate the hands .

Based on observation, record review and interview, the facility failed to ensure a nebulizer mask was labeled and in a container, when not in use to prevent respiratory complications for one (Resident #45) of 3 (Residents #5, #9, and #45) sampled residents; Failed to ensure the oxygen rate was administered as ordered to prevent respiratory complications for 1 (Resident #5) of 4 (Residents #5, #9, #42, and #45) sampled residents; and Failed to ensure oxygen tubing was changed weekly as ordered to prevent respiratory complications for 1 (Resident #25) of 9 (Residents #5, #9, #15, #25, #42, #45, #53, #59, and #67) sampled residents. These failed practices had the potential to affect 15 residents who received oxygen and or used a nebulizer, according to lists provided by the Administrator on 5/7/21. The findings are: 1. Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) dated [DATE] documented the resident scored 4 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS) and used oxygen in the past 14 days. a. The Comprehensive Plan of Care documented, .The resident has oxygen therapy r/t COVID Pneumonia Date Initiated: 01/29/2021 . Give medications as ordered by physician. Monitor/document side effects and effectiveness . b. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 1-2L/min [liters per minute] via NC [nasal cannula] every 8 hours as needed . Change and date oxygen tubing when in use every day shift every Tue [Tuesday] . c. The April Treatment Administration Record (TAR) documented 5 for Tuesday 4/27/21. The Chart Codes at the bottom of the page documented, .5=Hold/See Progress Notes . There was no documentation in the electronic health record as to why the oxygen tubing was not changed as ordered. d. On 05/03/21 at 01:47 PM and 05/04/21 at 8:57 AM, Resident #25 was lying in bed with oxygen on per nasal cannula at 1.5 liters per minute via an oxygen concentrator. The nasal cannula oxygen tubing that was attached to the oxygen concentrator was dated 4/20. e. On 05/05/21 at 11:59 AM, after being asked if she could provide the oxygen administration policy and procedure, the DON stated the Policy titled, Oxygen Safety was what the facility used. She was asked if the nurses where instructed on tubing and humidifiers for oxygen administration. She stated, We don't have that. That is in the order . f. On 5/6/21 at 3:21 PM, Licensed Practical Nurse (LPN) #1 was asked, Who is responsible for changing the oxygen tubing? She stated, The treatment nurse usually or a nurse can. She was asked when oxygen tubing is changed. She stated, Weekly and PRN [as needed] . She was asked, If a TAR documented 5=hold/see progress notes, what would you expect to find in the progress notes? She stated, Why it was held. She was asked, Should a resident's oxygen tubing be in use for 12-14 days without changing? She stated, No. She was asked, What would be the possible outcome? She stated, They could hold germs and get you sick. g. On 5/6/21 at 3:26 PM, LPN #2 (the Treatment Nurse) was asked who is responsible for changing the oxygen tubing. She stated, I do it every Tuesday. She was asked if the TAR documented 5=hold/see progress notes what would you expect to find in the progress notes. She stated, That the oxygen is not in use. She was asked, Should a resident's oxygen tubing be in use over 7 days? She stated, No. She was asked, What would be the possible outcome? She stated, High risk of infection, moisture backing up into the respiratory tract. 2. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date (ARD) of 4/26/21 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, required extensive assist for bed mobility, transfer, and dressing, and required oxygen therapy. a. A Care Plan with an initiated date of 1/26/21 documented, .The resident is at risk for respiratory infection r/t [related to] SOB [Shortness of Breath] . O2 [Oxygen] as ordered . b. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen @ [at] 2L/M via nc [liters per minute/nasal cannula] as needed for SOB if less than 90 . c. On 05/03/21 at 12:31 PM, Resident #5 with oxygen on and running at 2.5-3 liters per minute via nasal cannula. The oxygen tubing is dated 4/27/21. Resident #5 was asked, Do you use the oxygen every day? Resident #5 stated, Yes, every day. (A photo was taken). d. On 05/03/21 at 01:32 PM and 05/03/21 at 8:35 AM, Resident #5 with oxygen on and running at 2.5-3 liters per minute via nasal cannula. (A photo was taken). e. On 05/06/21 at 02:41 PM, the Director of Nursing (DON) was asked, Why is oxygen administered per the physician orders? The DON replied, Because someone has respiratory compromise and requires supplemental oxygen. f. On 05/06/21 at 04:08 PM, LPN #1 was asked, How do you know what the resident's oxygen is supposed to be on? LPN stated, Based on the orders in their chart. LPN was asked, Do you ever check the resident's oxygen settings? LPN stated, Every time I walk in the room. LPN was asked, What do you do if the oxygen is not correct? LPN stated, Check the chart and clarify and adjust it. g. A policy on Oxygen Safety provided by the DON documented, .The facility will properly handle oxygen . oxygen therapy is administered to the resident only upon the written order of a licensed physician . 3. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 4/5/21 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS and was independent with activity of daily living (ADL's). a. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) mg/3ml [milligram/milliliter] 3 ml inhale orally four times a day related to chronic obstructive pulmonary disease . b. A Care Plan with a revision date of 3/30/21 documented, .Resident has shortness of breath r/t [CONDITION(S)] with hx [history] of respiratory failure . increase updrafts . c. On 05/03/21 at 11:57 AM, Resident #45 was in bed with oxygen on and running at 2 liters per minute via nasal cannula. A nebulizer mask and tubing were lying on Resident #45 nightstand with no label and was not bagged. (Photo was taken). Resident #45 was asked, Do you take breathing treatments? Resident #45 stated, Yes, three times a day. d. On 05/07/21 at 09:15 AM, LPN #3 was asked, How are nebulizer masks and tubing stored when not in use? LPN #3 stated, Should be in a bag. LPN #3 was asked, What are some side effects of leaving nebulizer masks and tubing out in the open and not contained when not in use? LPN #3 stated, Infection control is the biggest thing. e. On 05/07/21 at 09:18 AM, LPN #1 was asked, How are nebulizer masks and tubing stored when not in use? LPN #1 stated, After cleaned and dried, it should be stored in a bag. LPN #1 was asked, What are some side effects of leaving nebulizer masks and tubing out in the open and not contained when not in use? LPN #1 stated, Increased risk of infection.

Based on observation, record review and interview, the facility failed to ensure staff changed gloves / washed hands / performed hand hygiene when contaminated, before, during, and after incontinent care to prevent the potential spread of infection for a resident who had a UTI for 1 (Resident #9) of 3 (Residents #5, #9, and #42) sampled residents who required assistance for incontinent care. This failed practice had the potential to affect 3 residents who resided on Hall 400 and shared staff with Resident #9, as documented on the Census by hall and a list provided by the Administrator; and Failed to ensure staff handled the indwelling catheter bag and tubing in accordance to infection control standards of practice to prevent the further potential of urinary tract infections and other complications for 1 (Resident #9) of 2 (Residents #9, and #18) sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date (ARD) of 2/1/21 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assist for transfer, bed mobility, dressing, toilet use, and personal hygiene, was frequently incontinent of bowel and had a suprapubic indwelling catheter. a. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Foley catheter 22FR/30CC [French/cubic centimeter] balloon change every day shift starting on the 15th and ending on the 16th every month . b. The Care Plan with a revision date of 4/27/21 documented, .The resident has Suprapubic Catheter r/t [related to] [CONDITION(S)], urinary retention, and personal history of UTI . (Suprapubic Catheter) .Position catheter bag and tubing below the level of the bladder and away from entrance room door . c. On 05/03/21 at 12:10 PM, CNA #6 and Nursing Assistant (NA) #1 provided peri-care to the resident who had a bowel movement. CNA #6 used her left gloved hand to wipe bowel movement from Resident #9 buttocks with an adult wipe and disposed of the wipe in a clear plastic bag at the end of Resident #9's bed. CNA #6 then used her left gloved hand to wipe bowel movement between Resident #9 buttocks and dispose of the used wipe into the clear plastic bag. CNA #6 did not change gloves and did not perform hand hygiene. NA #1 went around the bed and removed a tube of Aloe Vista Protective Ointment from Resident #9's nightstand and expelled ointment into CNA #6 left gloved hand that was just used to wipe bowel movement from Resident #9 buttocks. CNA #6 applied the protective ointment to Resident #9 buttocks with the left gloved hand. CNA #6 did not change gloves or perform hand hygiene. CNA #6 then removed gloves and applied a new pair of gloves without washing her hands. CNA #6 then secured Resident #9 brief, removed her gloves and without washing her hands, went to the closet and removed a pair of pants. d. On 05/03/21 at 12:15 PM, NA #1 removed Resident #9 foley catheter from the privacy bag with her bare hands and placed the foley catheter bag through the resident's right pant leg. e. On 05/03/21 at 12:19 PM, CNA #6 and NA #1 placed a lift pad under the resident and hooked the pad to the lift. NA #1, with bare hands, lifted the resident above the bed using the lift. and removed the resident's foley catheter bag from the privacy bag and hooked it to the lift bar/handle. (A photo was taken). NA #1 then dropped the foley catheter bag in the floor under the resident's wheelchair. NA #1 then picked up the foley bag and placed it back on the lift bar/handle. f. On 05/03/21 at 12:23 PM, NA#1 with bare hands, rolled Resident #9 bed linen, and placed in a clear bag. NA #1 did not perform hand hygiene. CNA #6 with bare hands, removed the lift pad from under the resident, and hung it on the resident's closet door, placed foot pedals x 2 to the resident's wheel chair, and then went through the resident's drawers looking for a hairbrush. CNA #6 did not perform hand hygiene. CNA #6 exited Resident #9's room and did not perform hand hygiene. g. On 05/03/21 at 12:27 PM, CNA #6 re-entered Resident #9 room with a hairbrush. CNA #6 did not perform hand hygiene after entering the resident's room. CNA #6 brushed Resident #9's hair with bare hands, placed the brush in Resident #9 drawer, and then pushed the resident out of the room in a wheelchair. The CNA did not perform hand hygiene before exiting the room. h. On 05/03/21 at 12:30 PM, NA #1 removed the lift from Resident #9's room and parked it in the hallway. NA #1 did not clean the lift prior to parking it in the hallway. NA #1 did not perform hand hygiene prior to exiting the resident's room. (Photo was taken) i. On 05/06/21 at 02:16 PM, CNA #3 was asked, When should hand hygiene be performed? CNA #3 stated, When you enter the room, before you leave the room, and between residents. CNA #3 was asked, How should foley catheter bags be handled during a lift transfer? CNA #3 stated, The staff that supports resident during the transfer holds it. CNA #3 was asked, Where do they hold it? CNA #3 replied, In their hand. CNA #3 was asked, Why should you change gloves and or perform hand hygiene after cleaning a resident with bowel movement? CNA #3 stated, The same germs are on the gloves and are contaminated. CNA #3 was asked, Why should the foley catheter bag not be placed in the floor? CNA #3 stated, Because that's contamination too. CNA #3 was asked, What type of training did you receive on how to handle catheters, tubing, and drainage bags during care? CNA #3 stated, They taught us how to clean it during CNA class, and don't hang the bag on your pants. CNA #3 was asked, Would you hang the foley catheter bag on the handlebars of the lift during a transfer? CNA #3 stated, No, plus it would pull the catheter and contaminate the handle. CNA #3 was asked, Does Resident #9 have a urinary tract infection? CNA #3 stated, Yes, I think he does. j. On 05/06/21 at 02:33 PM, LPN #1 was asked, When should hand hygiene be performed? LPN #1 stated, Every time you do anything; before and after care. LPN #1 was asked, How should foley catheter bags be handled during a lift transfer? LPN #1 stated, Carry with the resident so it doesn't get hung on anything. LPN #1 was asked, Why should you change gloves and or perform hand hygiene after cleaning a resident with bowel movement? LPN #1 stated, It's cross contamination. LPN #1 was asked, Why should the foley catheter bag not be placed in the floor? LPN #1 stated, Possible contamination. LPN #1 was asked, Would you hang the foley catheter bag on the handlebars of the lift during a transfer? LPN #1 stated, No, it's too high up. k. On 05/06/21 at 02:41 PM, the Director of Nursing (DON) was asked, When should hand hygiene be performed? The DON stated, All the time, between tasks, between glove changes. The DON was asked, How should foley catheter bags be handled during a lift transfer? The DON stated, They need to be with whoever is moving with the resident. The DON was asked, Why should you change gloves and or perform hand hygiene after cleaning a resident with bowel movement? The DON stated, Because you're performing peri-care and you should perform hand hygiene. The DON was asked, Why should the foley catheter bag not be placed in the floor? The DON stated, Because it's an infection control issue. The DON was asked, Would you hang the foley catheter bag on the handlebars of the lift during a transfer? The DON stated, No. The DON was asked, Does Resident #9 have a UTI? The DON stated, Yes, since 4/27/21, and he's on antibiotics. l. A Catheter policy provided by the DON on 5/5/21 documented, .Catheter Indwelling . secure urinary drainage bag below the level of the bladder and keep off the floor at all times . m. A policy on Handwashing/Hand Hygiene provided by the DON on 5/5/21 documented, .This facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . an alcohol-based hand rub may be used if no visible soiling . hand hygiene is the final step after removing and disposing of personal protective equipment . the use of gloves does not replace hand washing/hand hygiene . integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on observations, record review and interviews, the facility failed to ensure staff wore masks covering their mouth and nose while in the facility to prevent the possible spread of respiratory infections and possible COVID-19 for 1 (Resident #3) of 1 resident who required assistance with transfers. This failed practice had the potential to affect 67 residents, according to the Resident Census and condition of Residents form dated 5/3/21; and Failed to ensure staff followed contact and droplet isolation precautions, including the consistent, appropriate use of personal protective equipment (PPE), and adherence to proper hand hygiene when entering the isolation room, to prevent the potential spread of infection to other residents for 1 (Resident #119) of 1 sampled resident who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) documented the resident was moderately impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status (SAMS), required extensive assist from staff for bed mobility, transfer, dressing, toilet use, and personal hygiene, was frequently incontinent of bowel and bladder, and had functional limitations in an upper extremity and a lower extremity on one side. a. The Care Plan with a revision date of 6/23/2020 documented, .Resident is at risk for s/sx [signs and symptoms] of COVID-19 .follow facility protocol for COVID-19 Screening/Precautions . b. On 05/03/21 at 12:02 PM, Certified Nursing Assistant (CNA) #5 was in Resident #3's room with a face mask not covering the nose. (A photo was taken). CNA #5 raised the bed with her bare hands, using the electric controller. CNA #5 then applied gloves and checked the resident for incontinence. CNA #5 did not perform hand hygiene prior to applying the gloves. At 12:04 PM, CNA #5, with bare hands, removed the left arm/rest of the wheelchair, and placed a sliding board on Resident #3's wheelchair and on the edge of the bed. CNA applied a boot to Resident #3's left foot, then applied a shoe to Resident #3 right foot. CNA #5 did not perform hand hygiene. She then pulled the mask over her nose and assisted Resident #3 to a sitting position on the side of the bed. c. On 05/06/21 at 02:16 PM, CNA #3 was asked, Why should face masks be worn while in the facility? CNA #3 replied, To protect yourself and the residents, especially with COVID going on. d. On 05/06/21 at 02:26 PM, CNA #5 was asked, Why should face masks be worn while in the facility? CNA #5 replied, To protect our residents. e. On 05/06/21 at 02:41 PM, the Director of Nursing (DON) was asked, Why should face masks be worn while in the facility? The DON stated, To protect and prevent the spread of infections. f. On 05/07/21 at 10:26 AM, CNA #1 was asked, Have you been shown how to properly wear a mask? CNA #1 stated, Yes, we have all been shown how to wear them, from cloth masks to N95s. CNA#1 was asked, What's the proper way to wear a mask? CNA #1 stated, Make sure it's arched across the bridge of your nose, and it should cover your mouth and nose. g. A policy on .Guidelines for Suspected or Confirmed COVID-19 provided by the DON on 5/5/21 documented, .Facility will follow the current CMS (Centers for Medicare & Medicaid Services . hand hygiene . face covering or mask (covering mouth and nose) . 2. Resident (R) #119 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. The Physicians Orders dated 04/30/21 documented, Resident is in droplet isolation. Every shift. b. The Care Plan dated 04/30/21 documented, Resident is at risk for signs and symptoms of COVID-19. Resident is in droplet isolation. c. On 05/04/21 at 11:30 am., CNA #1 entered R #119 room without sanitizing hands, wearing a N95 type mask only. Signage on resident's door documented, Droplet Contact Precautions, hand hygiene, gown, gloves, face shield/goggles and mask on all room entries, regardless of anticipated contact. d. On 05/06/21 at 1:45pm., CNA #1 was asked, What should you do before entering a resident's room that is on droplet contact precautions? CNA #1 stated, Gown up, put on mask, face shield, sanitize your hands, and put on gloves before entering the room. Everything should be on the door. CNA #1 was asked, How are you made aware of protocols for Transmission Based Precautions? CNA #1 stated, There's a sign on the door that tells what to put on before you go in, and we are told in report who is on isolation. e. On 05/06/21 at 2:35 pm., the DON was asked, What should you do before entering a resident's room that is on droplet contact precautions? DON stated, Wash your hands, put on PPE and wash your hands again before leaving the room. DON was asked, How are staff made aware of protocols for Transmission Based Precautions? DON stated, There is a sign outside the resident's room, usually on the door. It tells them what to put on before they go in. DON was asked, How do you monitor staff to ensure they are following infection control and transmission-based practices? DON stated, I make rounds on the halls. DON was asked, If you see a staff member not practicing infection control or transmission-based practices what do you do? DON stated, I will correct them immediately. DON was asked, Are staff in-serviced on infection control and transmission-based precautions? DON stated, Yes, we have in-services at least quarterly and as often as needed. 3. On 05/03/21 at 11:42 AM, CNA #4 entered Resident #1's room and asked the resident if she was ready to transfer to her wheelchair. CNA #4 wore a KN95 facial mask with her mouth covered and her nose exposed.

Based on observation, interview, and record review, the facility failed to ensure staff implemented gait belts to aid in transfer of 1 (Resident #3) of 3 (Residents #9, #3 and #42) sampled residents who required assistance with transfers to prevent the potential for further fall accidents and or injury. This failed practice had the potential to affect 6 residents who required assistance for transfers according to a list provided by the Administrator on 5/7/21. The findings are: Resident #3 had diagnoses of [CONDITION(S)] affecting left nondominant side, contracture left hand, and history of falling. The Quarterly Minimum Data Set (MDS) documented the resident was moderately impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status (SAMS), required extensive assist from staff for bed mobility, transfer, dressing, toilet use, and personal hygiene, was frequently incontinent of bowel and bladder, and had functional limitations in an upper extremity and a lower extremity on one side. a. A Care Plan with a revision date of 4/26/21 documented, .the resident has an ADL [activity of daily living] self-care performance deficit r/t [related to] CVA [Cerebral Vascular Accident] .the resident requires extensive assistance by 1 staff to move between surfaces as necessary using slide board . the resident uses a slide board to maximize independence with transferring . b. On 05/03/21 at 12:05 PM, Certified Nursing Assistant (CNA) #5 was assisted Resident #3 to a sitting position on the side of the bed facing the door. CNA #5 slid the sliding board under Resident #3 right upper leg, grasped Resident #3 under the left arm pit, and assisted resident to the wheelchair. CNA #5 did not use a gait belt to transfer Resident #3. A gait belt was visible around CNA #5 waist during the transfer. c. On 05/06/21 at 02:16 PM, CNA #3 was asked, When should gait belts be used? CNA #3 replied, All the time, unless they are a lift. d. On 05/06/21 at 02:26 PM, CNA #5 was asked, When should gait belts be used? CNA #5 replied, At all times with stand or slide board, any transfer that is not a lift. e. On 05/06/21 at 02:33, PM, Licensed Practical Nurse (LPN) #1 was asked, When should gait belts be used? LPN #1 replied, Every time you transfer a resident. f. On 05/06/21 at 02:41 PM, the Director of Nursing (DON) was asked, When should gait belts be used? The DON replied, When a patient requires assistance with transfer and ambulation, unless care planned otherwise. g. A Gait Belts, Use of policy provided by the DON on 5/5/21 documented, .Gait belts will be utilized for any resident transfers (sit to stand; stand to sit; sit to sit) or for resident ambulation that requires assistance .

Based on observation, record review, and interview, the facility failed to report an allegation of neglect in accordance with the facility Abuse Investigation and Reporting Policy for 1 (Resident #1) of 3 (Residents #1, #2, and #3) case mix residents who were receiving comfort care. This failed practice had the potential to affect 5 residents who were receiving comfort care, according to a list provided by the Administrator on 5/11/2020 at 2:36 p.m. The findings are: 1. On 5/11/2020 at 10:16 a.m., the Administrator was notified per telephone and was asked for a copy of the Division of Medical Services (DMS) form 7734 regarding the allegation of neglect involving Resident #1. He stated, Reportable? He was reminded of the phone call from the Office of Long-Term Care on 5/5/2020. He stated, I did get a call, but I explained to them it was an end of life situation. I guess I didn't see it as that. I took it as them asking me some questions. So no, I don't have a reportable. 2. On 8/12/20 at 11:15 a.m., the Administrator was asked, When OLTC (Office of Long-Term Care) called and told you about the allegation of neglect, why did you not start the reportable then? He stated, The lady that called me was asking me a lot of questions about the resident. He was 97 (years old), on comfort care, and I knew the son was okay with his care. I didn't look at it as neglect. But I have learned my lesson. 3. The facility policy titled Abuse Investigation and Reporting provided by the Administrator on 8/12/2020 documented, .The Facility will endeavor to protect residents from maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents . All facility personnel, including all employees and any physician, the owner and the Administrator, must immediately report all incidents of alleged, witnessed or suspected resident maltreatment, including abuse, sexual abuse, neglect, misappropriation of resident property and exploitation of residents to the Administrator or Administrator's Designee who will report events as required by State law or regulation . ALL alleged, witnessed or suspected incidents must be reported according to State and federal law, according to the time restrictions required by law. All alleged violations will be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse .The following persons or entities will be notified, as required by State law, by facility personnel (Administrator or Administrator Designee) . Administrator, State Survey Agency, local law enforcement .

Based on observation, record review, and interview, the facility failed to ensure Physician's Orders for the resident's Immediate Plan of Care at the time of admission or readmission contained orders for [MEDICAL TREATMENT] and isolation / quarantine for the prevention of potential transmission of COVID-19 for 2 (Residents #3 and #4 ) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who were admitted since 5/28/2020. This failed practice had the potential to affect 1 (Resident #3) who required [MEDICAL TREATMENT] services, and 18 residents who were admitted since 5/28/2020, according to a list provided by the Administrator on 6/22/2020 at 2:42 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Significant Change of Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required [MEDICAL TREATMENT]. a. A Physician's Order dated 6/22/2020 documented, .Monitor Tunneled [MEDICAL TREATMENT] Catheter Dressing . Report Abnormal Findings to ([MEDICAL TREATMENT] Center) at (Telephone Number) . every shift related to Dependence on [MEDICAL TREATMENT] . The Physician's Order Listing dated June 2020 contained no documentation related to isolation precautions. b. On 6/22/2020 at 11:59 a.m., a Contact / Droplet Isolation sign was on the door of the resident's room, and an isolation supply container was outside of the resident's room. The resident was sitting on his bed watching television. 2. Resident #4 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 6/17/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, and currently used tobacco. a. As of 6/22/2020 at 3:25 p.m., the Physician's Orders Listing dated June 2020 contained no documentation related to isolation. b. On 6/22/2020 at 11:45 a.m., was lying in bed. A Contact / Droplet isolation sign was on the resident's room door and an isolation supply container was outside of the resident's room. The resident was admitted from an acute care setting on 6/10/2020. 3. On 6/22/2020 at 3:53 p.m., the Director of Nursing (DON) was notified via telephone and was asked about the resident's [MEDICAL TREATMENT] orders. She stated, We normally don't have orders. They are on the hospital Discharge Orders. 4. On 6/23/2020 at 8:37 a.m., the DON was notified via telephone and was asked, Should a resident in Contact / Droplet Isolation have a Physician's Order for isolation? She stated, Yes. I'm assuming we are missing some.