UNIVERSITY PARK NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 18 residents (Resident #10) reviewed for food and nutrition services. <BR/>The facility failed to ensure Resident #10 received items listed on his lunch meal ticket on 6/05/2025. <BR/>This failure could place residents at risk of poor intake, chemical imbalance, and/or weight loss.<BR/>Findings included:<BR/>Record review of Resident #10's face sheet dated 06/19/2025 revealed [AGE] year-old male admitted on [DATE] with most recent readmission of 05/28/2025 with the following diagnoses Type 2 Diabetes, Leukemia (blood cancer that begins is bone marrow), and protein calorie malnutrition. <BR/>Record review of Resident #10's Significant Change MDS dated [DATE] indicated the following:<BR/>*Section C Cognitive Patterns revealed Resident #10 had a BIMS score of 11(meaning moderate cognitive impairment); <BR/>*Section K Swallowing/Nutritional Status-revealed Resident #10 did not have weight loss in the last 6 months. <BR/>Record review of Resident #10's lunch meal ticket dated 06/16/2025 revealed the resident was to receive the following items: <BR/>*2 Cheese Manicotti with Marinara, <BR/>*&frac12; cu Sauteed Zucchini, <BR/>*1 slice garlic bread, <BR/>*&frac12; c smooth yogurt, and <BR/>*Special Notes: fruit only for dessert (per resident request). <BR/>Observation and interview on 06/16/2025 at 4:10 PM Resident #10 was sitting on his bed in his room. Resident #10's lunch tray was sitting on the counter, by the sink, and appeared to not have been touched. The manicotti appeared to be dry and the ends were burnt ends on the manicotti. Resident #10 stated he did not attempt to eat his lunch because his food did not look appealing, the manicotti looked dry and over cooked. Resident #10 stated he did not want dessert and had requested to get fruit to replace dessert was supposed to get yogurt with his lunch meal. Resident #10's lunch tray contained 1 manicotti without marinara sauce, zucchini, garlic bread, vanilla pudding with chocolate cookie on top. Resident #10's tray did not have a serving of fruit or a serving of yogurt. Resident #10 stated the kitchen forgets to send his fruit and yogurt often. Resident #10 stated he had snacks in his room. <BR/>During an interview on 06/19/2025 at 10:29 AM the DM stated her expectation was Resident's meal tickets should have been followed. The DM stated the meal tickets reflected each resident's preference or dietary needs and was the menu for each resident. The DM stated the Dietary Aide, the cook, and the nurse were responsible to ensure meal tickets were followed. The DM stated she was responsible to monitor the kitchen staff. The DM stated she monitored by doing spot checks. The DM stated the affect on residents not getting what was on their meal ticket could have been weight loss because residents were not getting what they were supposed to get. The DM stated what led to failure was staff being nervous and not being thorough. <BR/>During an interview on 06/19/2025 at 11:13 AM the RRN stated her expectation was for staff to follow policy. The RRN stated the DM and the ADMN are responsible to ensure residents were served the appropriate meals. The RRN stated the DM and the ADMN should have been making daily rounds to ensure residents received the appropriate meals. The RRN stated the effect on residents could have been residents' dissatisfaction of food and not eating the food. The RRN stated what led to failure was lack of education or staff needed to be reeducated.<BR/>Record review of facility policy titled Resident Rights dated 2003 revealed each resident has a right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside our facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #15) reviewed for meals.<BR/>The facility failed to ensure that Resident #15 was served pureed vegetables that were the proper texture. <BR/>This deficient practice could affect residents by placing them at risk for choking and weight loss.<BR/>The findings were: <BR/>Record review of Resident #15's face sheet dated 06/19/2025 revealed [AGE] year-old female admitted on [DATE] with the following diagnoses Dementia, pulmonary embolism and heart disease. <BR/>Record review of Resident #15's Quarterly MDS dated [DATE] revealed the following:<BR/>* Section C Cognitive Patterns revealed Resident #15 had a BIMS score of 0(meaning interview was not conducted due to resident was rarely/never understood); <BR/>*Section K Swallowing/Nutritional Status revealed Resident #15 did not have weight loss in the previous 6 months and had a mechanically altered diet.<BR/>Record review of Resident #15's Dietary Profile dated 04/14/2025 revealed Resident #15 received purred texture food and honey thickened fluids. <BR/>During an observation on 06/16/2025 between 11:25 AM to 12:30 PM [NAME] C pureed the zucchini puree. [NAME] C did not add thickener to the vegetable. The zucchini appeared to be a thin liquid that did not hold shape. The ADMN came into the kitchen and told the DM the puree did not look correct. The DM then re-pureed food for the lunch meal. The re-pureed food by the DM appeared to be the correct pudding like consistency. <BR/>During an observation and interview on 06/16/2025 at 12:49 PM in the dining room Resident #15 was sitting at table with CNA D. CNA D had assisted Resident #15 with eating her meal. Resident # 15 did not appear to be choking on her meal or coughing. <BR/>During an interview on 06/16/2025 at 1:45 PM [NAME] C he stated he had his food handlers and stated DS B had trained him. [NAME] C stated he was nervous and forgot to look at recipes. <BR/>During an interview on 06/19/2025 at 10:29 AM the DM stated her expectation was food should be cooked and served according to the recipe. The DM stated puree food should be a smooth pudding like texture and not runny. The DM stated the cook was responsible to ensure recipes were followed and pureed food was the correct texture. The DM stated she was responsible to monitor the kitchen staff. The DM stated she monitored by doing spot checks. The DM stated the effect on residents could have choked because the puree was not the correct texture. The DM stated what led to failure was [NAME] C was trained by previous Dietary Manager, and he was nervous. <BR/>During an interview on 06/19/2025 at 11:13 AM the RRN stated her expectation was for staff to follow policy. The RRN stated the DM was responsible to ensure pureed food was served at the correct texture. The RRN stated the DM and the ADMN should have been making daily rounds to ensure residents received food was prepared appropriately and the correct texture. The RRN stated the effect on residents could have been residents could have choked due to food not being the correct texture. The RRN stated what led to failure was lack of education or staff needed to be reeducated.<BR/>Record review of facility policy titled, Pureed Diet dated 2025 revealed, The pureed recipes are followed for regular diet items so that the consistency of pureed foods is that of a semi-solid rather that a semi-liquid, with minimal separation of the liquid from the solid. If placed on a fork, it may drip but it does not flow continuously through the prongs. Pureed food should hold its shape on the plate and be the consistency of applesauce or pudding to mashed potato consistency.<BR/>Record review of puree recipe for Zucchini dated 06/16/2025 revealed, If needed, gradually add thickener .Desired thickness should be mashed potato or pudding texture.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that:<BR/>1. The dietary staff did not operate the low temperature dish machine and check the chlorine sanitizer content to ensure it was operating correctly to clean and sanitize the dishes consistently each meal.<BR/>2. Dietary Aide C did not use disposable gloves while handling soiled dishes and did not wash or sanitize his hands before handling the clean dishes.<BR/>3. Food items in the non-perishable food storage areas were not stored in sealed containers or resealable storage bags after the manufacturer's package seal was opened.<BR/>4. Floors were soiled throughout the kitchen food preparation area.<BR/>5. The deep fryer unit was soiled with dried fried food crumbs and contained dark colored cooking oil.<BR/>6. The reach-in freezer unit #2 interior temperature was not maintained at zero degrees F or lower and foods stored in the unit were not frozen solid.<BR/>The facility's failure placed residents at risk for foodborne illness and a decline in health status.<BR/>The findings included:<BR/>Observation on 4/02/23 at 9:25 AM, during the initial tour of the facility kitchen revealed the hand washing sink was located by the door to the short hallway that led to the nurses' station. There was not another hand washing sink in the kitchen or dish washing room.<BR/>Interview and observation on 4/02/23 at 9:30 AM revealed Dietary Aide C was washing dishes in the low temperature dish machine. He was not wearing gloves when handling the soiled dishes. He stated he had worked in facility for about 1 month.<BR/>Review of the dish machine temperature log form, dated April 2023, revealed columns to document wash and rinse water temperatures and sanitizer levels 3 times daily. No entries were documented on the form for 4/01/23 or breakfast 4/02/23. <BR/>Observation on 4/02/23 at 9:35 AM revealed Dietary Aide C operated the dish machine. He started to record temperatures for breakfast on 4/01/23, then scratched them out when reminded today was 4/02/23. When Dietary Aide C checked the chlorine sanitizer content, the test strip did not react when dipped in the dish machine water. He primed the sanitizer and ran the dish machine again. No sanitizer was observed in the tube that emptied into the dish machine. Dietary Aide C checked the one-gallon sanitizer bottle, which was almost full. He removed the bottle cap which was connected to tubing and observed the siphon device was stuck down in the neck of the bottle and did not reach the cap. He stated he would go to the storage room and get another bottle of sanitizer. <BR/>In an interview and observation on 4/02/23 at 9:40 AM, after returning to the kitchen, Dietary Aide C stated he could not find another bottle of sanitizer. He stated he was not going to wash dishes by hand and stated he might as well go home. He removed the cap to the sanitizer bottle and was able to pry the siphon device to the top of the bottle neck with a knife. He replaced the bottle cap with the tubing, primed the dish machine again and ran the machine. Chlorine sanitizer was observed flowing through the tubing and emptying into the dish machine. He tested the sanitizer and measured a level of 200 ppm. Observation of the low temperature dish machine manufacturer's recommendations revealed wash and rinse water temperatures at a minimum of 120 degrees F and a sanitizer level minimum of 50 ppm. When asked about the procedure for handling soiled and clean dishes, Dietary Aide C stated he put the dirty dishes in the racks, ran them through the dish machine, and then stacked the clean dishes. Inquired if he washed or sanitized his hands between touching the soiled and clean dishes, as he was not using disposable gloves, and he stated no. A two-compartment sink for rinsing dishes was in the dish room, but there was no hand soap, paper towel dispenser, or hand sanitizer in the room. Dietary Aide C stated he would start using gloves when handling dirty dishes. He got gloves from a box in the kitchen and put them on his hands.<BR/>Observation and interview on 4/02/23 at 10:00 AM, during the initial tour of the facility kitchen revealed the following: <BR/>- The reach-in refrigerator unit contained a rectangular pan covered with foil which was not labeled or dated. [NAME] D removed the pan from refrigerator and placed the pan on the stove top. She lifted the foil and stated it looked like a roast. The piece of meat had been cooked as a whole piece of meat (not sliced) and was surrounded by white colored cold grease/fat. [NAME] D stated she did not know when it had been cooked.<BR/>- The reach-in freezer unit #2 had an interior thermometer with a temperature of 25 degrees F. The freezer was filled with unevenly stacked cardboard boxes, dated 3/29/23, which contained sweet dough and beef steak fritters (meat patties) which were not frozen solid.<BR/>- The exterior surfaces of the stainless steel reach-in refrigerator and freezer units were soiled with dried food splatters.<BR/>- The storage room for storing bread items on shelf rack had an open bag with potato chips rolled closed and dated 3/28/23. The potato chips were not in a sealed container or resealable bag.<BR/>- The non-perishable food storage room had wire rack shelf units for storing dry food items. A large plastic bag containing flake coconut, dated 3/23/22, was rolled closed and had a trombone paper clip; a 5-pound bag with pecan pieces, dated 3/08/23, was rolled closed and had a trombone paper clip. The coconut and pecans were not in sealed containers or resealable bags.<BR/>- The deep fryer unit top surface was covered with a large rectangular baking sheet and was not in use. The pan was moved to the side and dark colored cooking oil and fried food crumbs on the interior surface were observed.<BR/>- The floor was soiled with food throughout the kitchen. <BR/>In an interview on 4/02/23 at 10:10 AM, [NAME] D stated the food on the floor was from breakfast that morning and she had not yet swept the floor. She stated she sweeps the floor two times during her shift.<BR/>In an observation and interview on 4/02/23 at 3:04 PM, a chest freezer was located in a storage room located in the short hallway outside the kitchen. A thermometer was not observed inside the freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. The DSM stated the roast in the reach-in refrigerator this morning was from last Wednesday, 3/29/23. She stated it should have been labeled and dated. When asked about the supply of chlorine sanitizer for the low temperature dish machine, she stated she had more in storage. She stated the new bottle of sanitizer must have been defective. <BR/>In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake.<BR/>In an interview on 4/04/23 at 11:35 AM, the DSM stated she had worked as a dietary aide and dishwasher for the morning shift on Saturday, 4/01/23. When asked if she had changed the bottle of chlorine sanitizer for the dish machine that day, she stated no and she did not recall doing it. The DSM stated the evening shift dietary aide would have switched the sanitizer bottle with a new one. She did not recall checking the wash and rinse water temperatures and chlorine sanitizer for the Saturday 4/01/23 breakfast and lunch meals. When asked about the April 2023 dish machine temperature and sanitizer log not having any documented entries for 4/01/23, she stated she had not checked them.<BR/>Review of the facility's policy and procedure for Dishwashing Preparation and Dishwashing, included in the Dietary Services Policy and Procedure Manual 2012 , revealed the following [in part]:<BR/>The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils.<BR/>Procedure:<BR/>2. Automatic dishwasher: Low temperature machine .<BR/>d. Prior to washing the soiled dishes after a meal, the dish machine should be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be run empty for a few cycles to ensure the proper temperature is attained, and no dishes will be washed prior to achieving this standard.<BR/>e. Hands should be sanitized before touching clean items and use care in removing utensils from conveyors in order not to contaminate clean items .<BR/>Review of the facility's policy and procedure for Food Storage and Supplies, included in Dietary Services Policy and Procedure Manual 2012, revealed the following [in part]:<BR/>All facility storage areas will be maintained in and orderly manner that preserves the condition of food and supplies. Will ensure storage areas are clean, organized, dry and protected from vermin and insects.<BR/>Procedure:<BR/>4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened.<BR/>5. Storeroom floors should be swept and mopped to be maintained in a sanitary manner to prevent vermin or pest infestation .<BR/>Review of the U.S. Food and Drug Administration, 2017 Food Code, specified [in part]:<BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days.<BR/>6-501.12 Cleaning, Frequency and Restrictions. <BR/>Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices.<BR/>CNA C and CNA D failed to perform hand hygiene and change their gloves at the appropriate times while providing incontinence care for Resident #1.<BR/>These failures placed residents at risk for the spread of infection. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 01/30/24, revealed the resident was a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infections, constipation, and benign prostatic hyperplasia (enlarged prostate).<BR/>Review of Resident #1's MDS assessment, dated 01/17/24, revealed Resident #1 required extensive assistance with most ADLs and one person assist. Resident #1 was always incontinent of bowel and bladder.<BR/>Review of Resident #1's care plan, dated 12/27/23, revealed the resident was care planned for bowel but not bladder incontinence.<BR/>Observation of incontinence care for Resident #1 on 01/29/24 at 2:38 p.m. revealed CNA C and CNA D did not wash their hands or perform hand hygiene before the start of care. Both CNAs donned gloves. CNA C wiped Resident #1 from front to back making 5 strokes of clean with same soiled wipe. Resident #1's brief was soiled with urine and fecal matter. CNA C picked up the clean brief and placed it on the trash bag where the dirty wipes were kept. Her gloves were visibly soiled but she continued to clean the resident with it. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves while repositioning and putting back the resident clean sheets and pillows. She also walked out of the room without washing hands and returned without performing hand hygiene and assisted in putting Resident #1 clothes on. CNA C and CNA D doffed their gloves, picked up the trash and left the room without washing their hands or performing hand hygiene. <BR/>In an interview on 01/29/24 at 2:54p.m. with CNA C she stated she had been employed at the facility for about 1 month. She worked for the facility previously for 7 months. CNA C said she did not receive infection control training during her orientation. She stated cross contamination meant mixing clean with dirty. CNA C noted she should have washed hands and changed gloves at the appropriate times while providing care. She stated Resident #1 could get an infection for not using good infection control practice. <BR/>Interview with CNA D on 01/30/24 at 1:42 p.m. revealed she had been employed at the facility for about 7 months. She stated she received infection control training from the facility 2 months ago. She stated cross contamination was transferring germs from one place to another. CNA D noted she should have changed her gloves and washed her hands after repositioning resident and changing her clean sheets.<BR/>During an interview with the DON on 01/30/24 at 4:17 p.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the aides were expected to follow standard precautions to include appropriate hand washing and hand hygiene when providing incontinent care. <BR/>The facility's infection control policy manual 2019 revealed, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.<BR/>1) <BR/>Hand Hygiene:<BR/>Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.:<BR/>a) <BR/>When coming on duty:<BR/>b) <BR/>When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .<BR/>c) <BR/>Before and after assisting a resident with personal care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide advance notice of change in services and charges not covered under Medicare for 1 of 3 residents (Residents #45) reviewed for Medicaid and Medicare Coverage Liability Notices. <BR/>The facility failed to ensure Resident #45's representative was given a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN Form CMS-10055) when he was discharged from skilled services.<BR/>This failure could place residents and their representatives at risk of not being fully informed about services covered by Medicare.<BR/>The findings included:<BR/>Record review of Resident #45's admission Record, dated 5/17/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included: congestive heart failure (impairment in the heart's ability to fill with and pump blood); hypertension (high blood pressure); polycythemia vera (rare blood cancer with increased red blood cells that thicken the blood and increase risk for blood clots); anemia; hyperlipidemia (high cholesterol); cerebrovascular disease (condition affecting blood flow and blood vessels in the brain); neuropathy (nerve damage causing weakness, numbness, and pain in hands and feet); chronic atrial fibrillation (irregular heartbeat); hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness following a stroke); and joint pain. <BR/>Record review of Resident #45's electronic health record census report reflected he was hospitalized from [DATE] to 1/31/2024.<BR/>Record review of the SNF Beneficiary Protection Notification Review worksheet for Resident #45 revealed he received Medicare Part A Services from 1/31/2024 through 2/19/2024. The resident remained in the facility. The form documented the resident's discharge from Medicare Part A services when benefit days were not exhausted had been voluntary. A SNF ABN, Form CMS-1005 was not provided. A hand-written note documented Resident is private pay and didn't want to go into co-pay days.<BR/>In an interview on 5/15/24 at 9:51 AM, MDS Coordinator C stated she used the NOMNC and SNF ABN forms for notifying the residents and their responsible parties when skilled care services would end. She stated an IDT meeting was held to determine if skilled care was still needed and a resident's discharge from skilled services needed to be approved by the corporate office. She stated sometimes residents chose to be discharged from skilled services or chose hospice.<BR/>In an interview on 5/17/24 at 10:57 AM, MDS Coordinator C stated Resident #45 was private pay and had used 20 days of Medicare Part A for skilled nursing care. She stated Resident #45's family member did not want to pay the copay for continued skilled care. She stated she did not have documentation from the conversation with Resident #45's family member. MDS Coordinator C stated she used the beneficiary notice guidelines from AAPACN decision tree. She stated the guidelines did not specify the use of the SNF ABN form when the resident initiated discharge from services and chose to remain in the facility. MDS Coordinator C stated she did not provide a SNF ABN to Resident #45 or his family member. She stated she would contact the corporate regional reimbursement nurse and ask if there was a policy and procedure for determining when and which notification form should be used.<BR/>During an interview and record review on 5/17/24 at 2:13 PM, MDS Coordinator C stated her corporate regional reimbursement nurse said there was not a policy and procedure for use of the SNF ABN form, just the NOMNC form. She provided a company policy and procedure for NOMNC, which was not dated. The policy and procedure did not include information regarding the SNF ABN form.<BR/>In an interview on 5/17/24 at 3:18 PM, MDS Coordinator B provided a copy of a policy and procedure for Advanced Beneficiary Notice NOMNC. She stated she was told to give it to the State Surveyor to review.<BR/>In an interview on 5/17/24 at 3:21 PM, Resident #45 stated he received therapy services earlier this year. He stated the money ran out and he was told he had to stop services. Resident #45 stated he did not really want to stop therapy at that time. <BR/> Record review of the facility's policy and procedure Advance Beneficiary Notice NOMNC, dated as revised 05/2024, reflected [in part]:<BR/>ABN Notices are issued under the following circumstances: <BR/>Part A only CMS 10055<BR/>1. On admission to SNF, the beneficiary has a 3-day hospital stay but does not require skilled care.<BR/>2. Part A stay will end because, SNF determines the beneficiary no longer requires daily skilled services. Resident has days remaining in benefit period. Resident will remain in facility (custodial care) .<BR/>The above notices are to be delivered in writing far enough in advance to enable residents to make an informed decision.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 7 residents (Residents #5, #15 and #50) reviewed for accuracy of assessments.<BR/>1. The facility failed to ensure Resident # 5's MDS accurately reflected the resident's weight gain.<BR/>2. The facility failed to ensure Resident # 15's MDS accurately reflected her weight loss or that she received hemo dialysis 3 times a week.<BR/>3. The facility failed to ensure Resident #50's MDS accurately reflected her weight loss.<BR/>These failures could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life.<BR/>The findings include:<BR/>1. Record review of Resident #5's admission profile, dated 5/17/24, reflected a [AGE] year-old female who's most recent admission date was 06/16/21. Resident #5 had diagnoses which included: abnormal weight loss, edema (a condition in which fluid collects in the tissues of the body), and hypertension (high blood pressure). <BR/>Record review of Resident #5's Quarterly MDS, dated [DATE], Section K reflected Resident #5 did not have a significant weight loss or gain of 5% in the last 30 days, or a 10% weight loss of gain within the last 180 days.<BR/>Record review of Resident #5's care plan reflected the resident had the potential for unplanned weight loss or gain. The problem start date was 3/3/21, and a revision date of 9/6/23. Interventions included: monitor weight per facility protocol.<BR/>Record review of Resident #5's weights reflected: On 10/03/2023, the resident weighed 134.6 lbs. On 04/01/2024, the resident weighed 147.4 pounds which was a 9.51 % Gain. <BR/>Record review of nurse's progress notes dated 5/1/24 at 4:43 PM, reflected the following: Resident has weight gain since receiving dental work, resident currently on Lasix 40 mg of Lasix daily with 2+ edema noted to BLE. (Bilateral lower extremities) MD (physician) notified. No new orders. <BR/>In an interview on 5/17/24 at 12:27 PM, MDS Coordinator B stated she did a Significant Change MDS on 5/16/24 for a weight gain of 13.8 pounds. She stated she must have made an error on the 4/1/24 Quarterly MDS because she just missed the weight change. MDS LVN B stated weight loss or change was communicated to her weekly by the Unit Manager and the DON through a written summary of the Standards Of Care Meeting. She stated she attended the Standards of Care meetings, but normally left the meeting after about 30 minutes into it because she had to go and supervise the smokers. She stated she did not feel her leaving the meeting had anything to do with the failure. She stated failure to document a weight loss or gain could result in the resident not receiving care.<BR/>2. Record review of Resident # 15's physician orders dated 5/16/24reflected a [AGE] year-old female who's most recent admission date was 6/9/23. Resident #15 had diagnoses which included: chronic kidney disease, end stage renal disease (condition in which the kidneys are not functioning properly and fail to filter waste and excess fluid from the body), and hypertensive heart disease (high blood pressure). <BR/>Record review of Resident # 15's Quarterly MDS, dated [DATE], Section K reflected Resident # 15 did not have a significant weight loss or gain of 5% in the last 30 days, or a 10% weight loss of gain within the last 180 days. Section O reflected the resident did not receive hemodialysis or peritoneal dialysis.<BR/>Record review reflected on 2/2/24, the resident weighed 179.8 lbs. On 3/5/24, the resident weighed 163.8 pounds which is a -8.90 % Loss. <BR/>Record review of Resident #15's physician orders, dated 4/1/24, reflected: dialysis 3 times a week (3/5/24) and check shunt to left arm for signs and symptoms of infection, bleeding, bruising pulsation, or aneurysm (start date 3/1/24), weekly weight for weight loss (start date 2/29/24).<BR/>Record review of Resident #15's care plan reflected the following: hemodialysis. Problem initiated 6/27/23. Intervention encourage resident to go for scheduled dialysis treatments.<BR/>In an interview on 05/17/24 at 03:51 PM, MDS Coordinator B stated I cannot capture dialysis on the MDS without proof from dialysis center, and they will not provide documentation. She stated, We send a binder but 9 times out of 10 there is nothing there. She stated a Significant Change MDS was completed on 3/12/24 for Resident #15 for weight loss, but she should have caught the weight loss on 3/6/24.<BR/>3. Record review of Resident #50's admission profile, dated 5/17/24, reflected a [AGE] year-old female who's most recent admission date was 06/16/21. Resident # 5 had diagnoses which included: hypertension (high blood pressure), Protein calorie malnutrition and liver transplant. <BR/>Record review of Resident #50's Quarterly MDS, dated [DATE], Section K reflected Resident #50 did not have a significant weight loss or gain of 5% in the last 30 days or a 10% weight loss of gain within the last 180 days.<BR/>Record review of Resident #50's weights reflected: On 11/01/2023, the resident weighed 127.8 lbs. On 05/01/2024, the resident weighed 113.6 pounds which is a -11.11 % loss.<BR/>Record review of Resident 50's physician orders, dated 5/17/24, reflected an order for Med Pass 2.0 (dietary caloric supplement) 60 cc three times a day. Order 12/29/23. Regular pureed diet pudding consistency 3 times a day. <BR/>Record review of Resident #50's care plan reflected the following: potential nutritional problem related to dysphagia( difficulty swallowing) initiated 3/18/24. Problem initiated 6/27/23. Intervention monitor resident for signs and symptoms malnutrition, report weight loss or gain of more than 5 percent in one month, 7.5 percent in 3 months, and 10 percent in 6 months (initiated 3/18/24 . Last revised 3/18/24).<BR/>In an interview on 5/16/24 at 1:00 PM Resident #50's family member stated she had trouble swallowing and was going to see the physician this week to see about getting a peg tube for nutrition. He stated she lost a lot of weight.<BR/>Record review of the facility's, undated, policy titled MDS Data Accuracy Policy, reflected the following [in part]:<BR/>The MDS coordinator will receive training to ensure competence in completing the assessment. Federal law requires the assessment accurately reflects the resident's status. Each individual responsible for a portion of the MDS must sign and certify their section of the assessment is accurate and complete.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that:<BR/>1. The dietary staff did not operate the low temperature dish machine and check the chlorine sanitizer content to ensure it was operating correctly to clean and sanitize the dishes consistently each meal.<BR/>2. Dietary Aide C did not use disposable gloves while handling soiled dishes and did not wash or sanitize his hands before handling the clean dishes.<BR/>3. Food items in the non-perishable food storage areas were not stored in sealed containers or resealable storage bags after the manufacturer's package seal was opened.<BR/>4. Floors were soiled throughout the kitchen food preparation area.<BR/>5. The deep fryer unit was soiled with dried fried food crumbs and contained dark colored cooking oil.<BR/>6. The reach-in freezer unit #2 interior temperature was not maintained at zero degrees F or lower and foods stored in the unit were not frozen solid.<BR/>The facility's failure placed residents at risk for foodborne illness and a decline in health status.<BR/>The findings included:<BR/>Observation on 4/02/23 at 9:25 AM, during the initial tour of the facility kitchen revealed the hand washing sink was located by the door to the short hallway that led to the nurses' station. There was not another hand washing sink in the kitchen or dish washing room.<BR/>Interview and observation on 4/02/23 at 9:30 AM revealed Dietary Aide C was washing dishes in the low temperature dish machine. He was not wearing gloves when handling the soiled dishes. He stated he had worked in facility for about 1 month.<BR/>Review of the dish machine temperature log form, dated April 2023, revealed columns to document wash and rinse water temperatures and sanitizer levels 3 times daily. No entries were documented on the form for 4/01/23 or breakfast 4/02/23. <BR/>Observation on 4/02/23 at 9:35 AM revealed Dietary Aide C operated the dish machine. He started to record temperatures for breakfast on 4/01/23, then scratched them out when reminded today was 4/02/23. When Dietary Aide C checked the chlorine sanitizer content, the test strip did not react when dipped in the dish machine water. He primed the sanitizer and ran the dish machine again. No sanitizer was observed in the tube that emptied into the dish machine. Dietary Aide C checked the one-gallon sanitizer bottle, which was almost full. He removed the bottle cap which was connected to tubing and observed the siphon device was stuck down in the neck of the bottle and did not reach the cap. He stated he would go to the storage room and get another bottle of sanitizer. <BR/>In an interview and observation on 4/02/23 at 9:40 AM, after returning to the kitchen, Dietary Aide C stated he could not find another bottle of sanitizer. He stated he was not going to wash dishes by hand and stated he might as well go home. He removed the cap to the sanitizer bottle and was able to pry the siphon device to the top of the bottle neck with a knife. He replaced the bottle cap with the tubing, primed the dish machine again and ran the machine. Chlorine sanitizer was observed flowing through the tubing and emptying into the dish machine. He tested the sanitizer and measured a level of 200 ppm. Observation of the low temperature dish machine manufacturer's recommendations revealed wash and rinse water temperatures at a minimum of 120 degrees F and a sanitizer level minimum of 50 ppm. When asked about the procedure for handling soiled and clean dishes, Dietary Aide C stated he put the dirty dishes in the racks, ran them through the dish machine, and then stacked the clean dishes. Inquired if he washed or sanitized his hands between touching the soiled and clean dishes, as he was not using disposable gloves, and he stated no. A two-compartment sink for rinsing dishes was in the dish room, but there was no hand soap, paper towel dispenser, or hand sanitizer in the room. Dietary Aide C stated he would start using gloves when handling dirty dishes. He got gloves from a box in the kitchen and put them on his hands.<BR/>Observation and interview on 4/02/23 at 10:00 AM, during the initial tour of the facility kitchen revealed the following: <BR/>- The reach-in refrigerator unit contained a rectangular pan covered with foil which was not labeled or dated. [NAME] D removed the pan from refrigerator and placed the pan on the stove top. She lifted the foil and stated it looked like a roast. The piece of meat had been cooked as a whole piece of meat (not sliced) and was surrounded by white colored cold grease/fat. [NAME] D stated she did not know when it had been cooked.<BR/>- The reach-in freezer unit #2 had an interior thermometer with a temperature of 25 degrees F. The freezer was filled with unevenly stacked cardboard boxes, dated 3/29/23, which contained sweet dough and beef steak fritters (meat patties) which were not frozen solid.<BR/>- The exterior surfaces of the stainless steel reach-in refrigerator and freezer units were soiled with dried food splatters.<BR/>- The storage room for storing bread items on shelf rack had an open bag with potato chips rolled closed and dated 3/28/23. The potato chips were not in a sealed container or resealable bag.<BR/>- The non-perishable food storage room had wire rack shelf units for storing dry food items. A large plastic bag containing flake coconut, dated 3/23/22, was rolled closed and had a trombone paper clip; a 5-pound bag with pecan pieces, dated 3/08/23, was rolled closed and had a trombone paper clip. The coconut and pecans were not in sealed containers or resealable bags.<BR/>- The deep fryer unit top surface was covered with a large rectangular baking sheet and was not in use. The pan was moved to the side and dark colored cooking oil and fried food crumbs on the interior surface were observed.<BR/>- The floor was soiled with food throughout the kitchen. <BR/>In an interview on 4/02/23 at 10:10 AM, [NAME] D stated the food on the floor was from breakfast that morning and she had not yet swept the floor. She stated she sweeps the floor two times during her shift.<BR/>In an observation and interview on 4/02/23 at 3:04 PM, a chest freezer was located in a storage room located in the short hallway outside the kitchen. A thermometer was not observed inside the freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. The DSM stated the roast in the reach-in refrigerator this morning was from last Wednesday, 3/29/23. She stated it should have been labeled and dated. When asked about the supply of chlorine sanitizer for the low temperature dish machine, she stated she had more in storage. She stated the new bottle of sanitizer must have been defective. <BR/>In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake.<BR/>In an interview on 4/04/23 at 11:35 AM, the DSM stated she had worked as a dietary aide and dishwasher for the morning shift on Saturday, 4/01/23. When asked if she had changed the bottle of chlorine sanitizer for the dish machine that day, she stated no and she did not recall doing it. The DSM stated the evening shift dietary aide would have switched the sanitizer bottle with a new one. She did not recall checking the wash and rinse water temperatures and chlorine sanitizer for the Saturday 4/01/23 breakfast and lunch meals. When asked about the April 2023 dish machine temperature and sanitizer log not having any documented entries for 4/01/23, she stated she had not checked them.<BR/>Review of the facility's policy and procedure for Dishwashing Preparation and Dishwashing, included in the Dietary Services Policy and Procedure Manual 2012 , revealed the following [in part]:<BR/>The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils.<BR/>Procedure:<BR/>2. Automatic dishwasher: Low temperature machine .<BR/>d. Prior to washing the soiled dishes after a meal, the dish machine should be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be run empty for a few cycles to ensure the proper temperature is attained, and no dishes will be washed prior to achieving this standard.<BR/>e. Hands should be sanitized before touching clean items and use care in removing utensils from conveyors in order not to contaminate clean items .<BR/>Review of the facility's policy and procedure for Food Storage and Supplies, included in Dietary Services Policy and Procedure Manual 2012, revealed the following [in part]:<BR/>All facility storage areas will be maintained in and orderly manner that preserves the condition of food and supplies. Will ensure storage areas are clean, organized, dry and protected from vermin and insects.<BR/>Procedure:<BR/>4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened.<BR/>5. Storeroom floors should be swept and mopped to be maintained in a sanitary manner to prevent vermin or pest infestation .<BR/>Review of the U.S. Food and Drug Administration, 2017 Food Code, specified [in part]:<BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days.<BR/>6-501.12 Cleaning, Frequency and Restrictions. <BR/>Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices.<BR/>CNA C and CNA D failed to perform hand hygiene and change their gloves at the appropriate times while providing incontinence care for Resident #1.<BR/>These failures placed residents at risk for the spread of infection. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 01/30/24, revealed the resident was a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infections, constipation, and benign prostatic hyperplasia (enlarged prostate).<BR/>Review of Resident #1's MDS assessment, dated 01/17/24, revealed Resident #1 required extensive assistance with most ADLs and one person assist. Resident #1 was always incontinent of bowel and bladder.<BR/>Review of Resident #1's care plan, dated 12/27/23, revealed the resident was care planned for bowel but not bladder incontinence.<BR/>Observation of incontinence care for Resident #1 on 01/29/24 at 2:38 p.m. revealed CNA C and CNA D did not wash their hands or perform hand hygiene before the start of care. Both CNAs donned gloves. CNA C wiped Resident #1 from front to back making 5 strokes of clean with same soiled wipe. Resident #1's brief was soiled with urine and fecal matter. CNA C picked up the clean brief and placed it on the trash bag where the dirty wipes were kept. Her gloves were visibly soiled but she continued to clean the resident with it. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves while repositioning and putting back the resident clean sheets and pillows. She also walked out of the room without washing hands and returned without performing hand hygiene and assisted in putting Resident #1 clothes on. CNA C and CNA D doffed their gloves, picked up the trash and left the room without washing their hands or performing hand hygiene. <BR/>In an interview on 01/29/24 at 2:54p.m. with CNA C she stated she had been employed at the facility for about 1 month. She worked for the facility previously for 7 months. CNA C said she did not receive infection control training during her orientation. She stated cross contamination meant mixing clean with dirty. CNA C noted she should have washed hands and changed gloves at the appropriate times while providing care. She stated Resident #1 could get an infection for not using good infection control practice. <BR/>Interview with CNA D on 01/30/24 at 1:42 p.m. revealed she had been employed at the facility for about 7 months. She stated she received infection control training from the facility 2 months ago. She stated cross contamination was transferring germs from one place to another. CNA D noted she should have changed her gloves and washed her hands after repositioning resident and changing her clean sheets.<BR/>During an interview with the DON on 01/30/24 at 4:17 p.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the aides were expected to follow standard precautions to include appropriate hand washing and hand hygiene when providing incontinent care. <BR/>The facility's infection control policy manual 2019 revealed, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.<BR/>1) <BR/>Hand Hygiene:<BR/>Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.:<BR/>a) <BR/>When coming on duty:<BR/>b) <BR/>When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .<BR/>c) <BR/>Before and after assisting a resident with personal care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 4 residents (Residents #39) whose records were reviewed for assessments.<BR/>1) The facility failed to recognize and assess Resident #39's weight loss, IV medications while in the facility, decline in ADL's and a decline in Bowel and Bladder function. <BR/>This failure placed residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments.<BR/>The findings included:<BR/>Review of Resident #39's Face Sheet, dated 04/04/2023, reflected Resident #39 was a [AGE] year-old female re-admitted to the facility on [DATE]. The resident had Acute Respiratory Failure with Hypoxia (impaired gas exchange between the lungs and blood), Bacterial Infection (infection by microorganisms that invade the tissue), and malnutrition (lack of proper nutrition). <BR/>Review of Resident #39's MDS assessments showed significant changes from her Quarterly MDS Assessment 10/09/2022 to her Quarterly MDS Assessment 11/29/2022 as follow:<BR/>1) The Quarterly MDS dated [DATE] section G revealed the resident had extensive assistance in dressing and was not steady but able to stabilize with staff assistance while moving from seated to standing position, was not steady but able to stabilize with staff assistance in walking, was not steady but able to stabilize with staff assistance in turning around, was not steady but able to stabilize with staff assistance in moving on and off toilet and was not steady but able to stabilize with staff assistance in surface to surface transfers. A wheelchair was used for mobility devices. <BR/>The Quarterly MDS dated [DATE] section G revealed the resident had total dependance in dressing, activity did not occur in transfers, activity did not occur while moving from seated to standing position, activity did not occur in walking, activity did not occur in turning around, activity did not occur in moving on and off toilet and activity did not occur in surface-to-surface transfers. None of the above was used for mobility devices. <BR/>2) Resident had a significant weight loss from 10/09/2022 to 11/29/2022. The Quarterly MDS dated [DATE] section K revealed the resident weighed 195 with no significant weight loss or weigh gain coded. The Quarterly MDS dated [DATE] section K revealed the resident weighed 171 with no significant weight loss or weight gain coded. <BR/>3) Review of the MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident was not receiving IV Medications while in the facility and was receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 0 days of Antibiotics, 7 days of Antidepressants and 7 days of Antianxiety. <BR/>The MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident received IV Medications while in the facility and was not receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 7 days of Antibiotics, 0 days of Antidepressants and 0 days of Antianxiety. <BR/>Observation and interview on 04/02/2023 at 10:30 AM revealed Resident #39 was alone in her room lying in her bed. She stated that she had been doing much better after her recent hospitalization. <BR/>In an interview on 04/02/2023 at 3:15 PM, the MDS Coordinator said that Resident #39 had a significant change and that a significant change assessment should have been completed within 14 days after the change. She said failure to do a significant change assessment could result in inadequate care areas and an appropriate care plan not being established. She said she did not know that she needed to complete a Significant Change Assessment with some of these areas and she had not realized she had more than one care area where the resident declined. She stated she knew the resident had a weight loss and she forgot to code it. She said that she was the one responsible for completing and the assessment and ensuring it was done accurately. <BR/>Review of the facility's policy and procedure for Resident Assessment, dated 2003, revealed the following [in part]:<BR/>A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument in (RAI). <BR/>The assessment will include at least the following:<BR/>Medically defined conditions and prior medical history<BR/>Medical status measurement<BR/>Physical and mental functional status <BR/>Nutritional status and requirements<BR/>Special treatments or procedures<BR/>Drug therapy<BR/>RAI assessments must be conducted within 14 days after the date of admission, probably after a significant change in the residence physical or mental condition as soon as the resident stabilizes at a new functional are cognitive level or within two weeks, whichever is earlier<BR/>The results of the assessment are used to develop, review, and revise the residence comprehensive plan of care.<BR/>Any individual who willing play knowingly certifies or causes another individual to certify immaterial and false statement in a resident assessment will be terminated in a septic to civil many penalties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 7 residents (Residents #5, #15 and #50) reviewed for accuracy of assessments.<BR/>1. The facility failed to ensure Resident # 5's MDS accurately reflected the resident's weight gain.<BR/>2. The facility failed to ensure Resident # 15's MDS accurately reflected her weight loss or that she received hemo dialysis 3 times a week.<BR/>3. The facility failed to ensure Resident #50's MDS accurately reflected her weight loss.<BR/>These failures could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life.<BR/>The findings include:<BR/>1. Record review of Resident #5's admission profile, dated 5/17/24, reflected a [AGE] year-old female who's most recent admission date was 06/16/21. Resident #5 had diagnoses which included: abnormal weight loss, edema (a condition in which fluid collects in the tissues of the body), and hypertension (high blood pressure). <BR/>Record review of Resident #5's Quarterly MDS, dated [DATE], Section K reflected Resident #5 did not have a significant weight loss or gain of 5% in the last 30 days, or a 10% weight loss of gain within the last 180 days.<BR/>Record review of Resident #5's care plan reflected the resident had the potential for unplanned weight loss or gain. The problem start date was 3/3/21, and a revision date of 9/6/23. Interventions included: monitor weight per facility protocol.<BR/>Record review of Resident #5's weights reflected: On 10/03/2023, the resident weighed 134.6 lbs. On 04/01/2024, the resident weighed 147.4 pounds which was a 9.51 % Gain. <BR/>Record review of nurse's progress notes dated 5/1/24 at 4:43 PM, reflected the following: Resident has weight gain since receiving dental work, resident currently on Lasix 40 mg of Lasix daily with 2+ edema noted to BLE. (Bilateral lower extremities) MD (physician) notified. No new orders. <BR/>In an interview on 5/17/24 at 12:27 PM, MDS Coordinator B stated she did a Significant Change MDS on 5/16/24 for a weight gain of 13.8 pounds. She stated she must have made an error on the 4/1/24 Quarterly MDS because she just missed the weight change. MDS LVN B stated weight loss or change was communicated to her weekly by the Unit Manager and the DON through a written summary of the Standards Of Care Meeting. She stated she attended the Standards of Care meetings, but normally left the meeting after about 30 minutes into it because she had to go and supervise the smokers. She stated she did not feel her leaving the meeting had anything to do with the failure. She stated failure to document a weight loss or gain could result in the resident not receiving care.<BR/>2. Record review of Resident # 15's physician orders dated 5/16/24reflected a [AGE] year-old female who's most recent admission date was 6/9/23. Resident #15 had diagnoses which included: chronic kidney disease, end stage renal disease (condition in which the kidneys are not functioning properly and fail to filter waste and excess fluid from the body), and hypertensive heart disease (high blood pressure). <BR/>Record review of Resident # 15's Quarterly MDS, dated [DATE], Section K reflected Resident # 15 did not have a significant weight loss or gain of 5% in the last 30 days, or a 10% weight loss of gain within the last 180 days. Section O reflected the resident did not receive hemodialysis or peritoneal dialysis.<BR/>Record review reflected on 2/2/24, the resident weighed 179.8 lbs. On 3/5/24, the resident weighed 163.8 pounds which is a -8.90 % Loss. <BR/>Record review of Resident #15's physician orders, dated 4/1/24, reflected: dialysis 3 times a week (3/5/24) and check shunt to left arm for signs and symptoms of infection, bleeding, bruising pulsation, or aneurysm (start date 3/1/24), weekly weight for weight loss (start date 2/29/24).<BR/>Record review of Resident #15's care plan reflected the following: hemodialysis. Problem initiated 6/27/23. Intervention encourage resident to go for scheduled dialysis treatments.<BR/>In an interview on 05/17/24 at 03:51 PM, MDS Coordinator B stated I cannot capture dialysis on the MDS without proof from dialysis center, and they will not provide documentation. She stated, We send a binder but 9 times out of 10 there is nothing there. She stated a Significant Change MDS was completed on 3/12/24 for Resident #15 for weight loss, but she should have caught the weight loss on 3/6/24.<BR/>3. Record review of Resident #50's admission profile, dated 5/17/24, reflected a [AGE] year-old female who's most recent admission date was 06/16/21. Resident # 5 had diagnoses which included: hypertension (high blood pressure), Protein calorie malnutrition and liver transplant. <BR/>Record review of Resident #50's Quarterly MDS, dated [DATE], Section K reflected Resident #50 did not have a significant weight loss or gain of 5% in the last 30 days or a 10% weight loss of gain within the last 180 days.<BR/>Record review of Resident #50's weights reflected: On 11/01/2023, the resident weighed 127.8 lbs. On 05/01/2024, the resident weighed 113.6 pounds which is a -11.11 % loss.<BR/>Record review of Resident 50's physician orders, dated 5/17/24, reflected an order for Med Pass 2.0 (dietary caloric supplement) 60 cc three times a day. Order 12/29/23. Regular pureed diet pudding consistency 3 times a day. <BR/>Record review of Resident #50's care plan reflected the following: potential nutritional problem related to dysphagia( difficulty swallowing) initiated 3/18/24. Problem initiated 6/27/23. Intervention monitor resident for signs and symptoms malnutrition, report weight loss or gain of more than 5 percent in one month, 7.5 percent in 3 months, and 10 percent in 6 months (initiated 3/18/24 . Last revised 3/18/24).<BR/>In an interview on 5/16/24 at 1:00 PM Resident #50's family member stated she had trouble swallowing and was going to see the physician this week to see about getting a peg tube for nutrition. He stated she lost a lot of weight.<BR/>Record review of the facility's, undated, policy titled MDS Data Accuracy Policy, reflected the following [in part]:<BR/>The MDS coordinator will receive training to ensure competence in completing the assessment. Federal law requires the assessment accurately reflects the resident's status. Each individual responsible for a portion of the MDS must sign and certify their section of the assessment is accurate and complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices.<BR/>CNA C and CNA D failed to perform hand hygiene and change their gloves at the appropriate times while providing incontinence care for Resident #1.<BR/>These failures placed residents at risk for the spread of infection. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 01/30/24, revealed the resident was a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infections, constipation, and benign prostatic hyperplasia (enlarged prostate).<BR/>Review of Resident #1's MDS assessment, dated 01/17/24, revealed Resident #1 required extensive assistance with most ADLs and one person assist. Resident #1 was always incontinent of bowel and bladder.<BR/>Review of Resident #1's care plan, dated 12/27/23, revealed the resident was care planned for bowel but not bladder incontinence.<BR/>Observation of incontinence care for Resident #1 on 01/29/24 at 2:38 p.m. revealed CNA C and CNA D did not wash their hands or perform hand hygiene before the start of care. Both CNAs donned gloves. CNA C wiped Resident #1 from front to back making 5 strokes of clean with same soiled wipe. Resident #1's brief was soiled with urine and fecal matter. CNA C picked up the clean brief and placed it on the trash bag where the dirty wipes were kept. Her gloves were visibly soiled but she continued to clean the resident with it. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves while repositioning and putting back the resident clean sheets and pillows. She also walked out of the room without washing hands and returned without performing hand hygiene and assisted in putting Resident #1 clothes on. CNA C and CNA D doffed their gloves, picked up the trash and left the room without washing their hands or performing hand hygiene. <BR/>In an interview on 01/29/24 at 2:54p.m. with CNA C she stated she had been employed at the facility for about 1 month. She worked for the facility previously for 7 months. CNA C said she did not receive infection control training during her orientation. She stated cross contamination meant mixing clean with dirty. CNA C noted she should have washed hands and changed gloves at the appropriate times while providing care. She stated Resident #1 could get an infection for not using good infection control practice. <BR/>Interview with CNA D on 01/30/24 at 1:42 p.m. revealed she had been employed at the facility for about 7 months. She stated she received infection control training from the facility 2 months ago. She stated cross contamination was transferring germs from one place to another. CNA D noted she should have changed her gloves and washed her hands after repositioning resident and changing her clean sheets.<BR/>During an interview with the DON on 01/30/24 at 4:17 p.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the aides were expected to follow standard precautions to include appropriate hand washing and hand hygiene when providing incontinent care. <BR/>The facility's infection control policy manual 2019 revealed, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.<BR/>1) <BR/>Hand Hygiene:<BR/>Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.:<BR/>a) <BR/>When coming on duty:<BR/>b) <BR/>When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .<BR/>c) <BR/>Before and after assisting a resident with personal care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices.<BR/>CNA C and CNA D failed to perform hand hygiene and change their gloves at the appropriate times while providing incontinence care for Resident #1.<BR/>These failures placed residents at risk for the spread of infection. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 01/30/24, revealed the resident was a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infections, constipation, and benign prostatic hyperplasia (enlarged prostate).<BR/>Review of Resident #1's MDS assessment, dated 01/17/24, revealed Resident #1 required extensive assistance with most ADLs and one person assist. Resident #1 was always incontinent of bowel and bladder.<BR/>Review of Resident #1's care plan, dated 12/27/23, revealed the resident was care planned for bowel but not bladder incontinence.<BR/>Observation of incontinence care for Resident #1 on 01/29/24 at 2:38 p.m. revealed CNA C and CNA D did not wash their hands or perform hand hygiene before the start of care. Both CNAs donned gloves. CNA C wiped Resident #1 from front to back making 5 strokes of clean with same soiled wipe. Resident #1's brief was soiled with urine and fecal matter. CNA C picked up the clean brief and placed it on the trash bag where the dirty wipes were kept. Her gloves were visibly soiled but she continued to clean the resident with it. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves while repositioning and putting back the resident clean sheets and pillows. She also walked out of the room without washing hands and returned without performing hand hygiene and assisted in putting Resident #1 clothes on. CNA C and CNA D doffed their gloves, picked up the trash and left the room without washing their hands or performing hand hygiene. <BR/>In an interview on 01/29/24 at 2:54p.m. with CNA C she stated she had been employed at the facility for about 1 month. She worked for the facility previously for 7 months. CNA C said she did not receive infection control training during her orientation. She stated cross contamination meant mixing clean with dirty. CNA C noted she should have washed hands and changed gloves at the appropriate times while providing care. She stated Resident #1 could get an infection for not using good infection control practice. <BR/>Interview with CNA D on 01/30/24 at 1:42 p.m. revealed she had been employed at the facility for about 7 months. She stated she received infection control training from the facility 2 months ago. She stated cross contamination was transferring germs from one place to another. CNA D noted she should have changed her gloves and washed her hands after repositioning resident and changing her clean sheets.<BR/>During an interview with the DON on 01/30/24 at 4:17 p.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the aides were expected to follow standard precautions to include appropriate hand washing and hand hygiene when providing incontinent care. <BR/>The facility's infection control policy manual 2019 revealed, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.<BR/>1) <BR/>Hand Hygiene:<BR/>Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.:<BR/>a) <BR/>When coming on duty:<BR/>b) <BR/>When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .<BR/>c) <BR/>Before and after assisting a resident with personal care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment, and include to the extent practicable, the participation of the resident and the resident's representative(s) for 1 of 3 residents (Resident #1) whose records were reviewed for assessments and care plans.<BR/>The facility failed to ensure or provide a current comprehensive care plan. Resident #1 did not have a comprehensive care plan meeting or an updated care plan. <BR/>This failure placed the residents at risk for not having individual needs identified and care and services provided to meet their needs and promote quality of care, feelings of well-being and quality of life.<BR/>The findings included:<BR/>Review of Resident #1's face sheet, dated 01/26/23, revealed a [AGE] year-old male, with a current admission date of 03/03/21. Diagnosis included: heart disease (disease of the heart ), Post Traumatic Stress Disorder (mental health disorder that is triggered by terrifying or stressful events), Alzheimer's Disease, Hypertension (high blood pressure), and Major Depressive Disorder (psychiatric mood disorder). <BR/>Review Resident #1's MDS assessment history revealed an annual assessment dated [DATE].<BR/>Review of Resident #25's comprehensive care plan revealed it was last Reviewed/Revised on 04/23/21. There was no documented evidence that a care plan meeting was conducted for this care plan . <BR/>Interview with the RN MDS Coordinator on 01/26/23 at 1:20 PM revealed the following: She stated that she should have updated the care plan after the annual assessment. She said that she did not because there was Covid in the building and they were short staffed. She said that she was helping in other areas and was not able to complete care plans and the care plan meetings. She said that she was going to correct the issue and update his care plan . She stated that for the month of December they had gotten behind on all care plans and care plan meetings due to having a Covid outbreak. <BR/>Interview with the DON on 01/26/23 at 1:40 revealed that she did not do the care plans or schedule the care plan meetings. She said that the RN MDS coordinator was responsible for that. <BR/>Review of the facility's policy and procedure for Care Plans - Comprehensive, (not dated), revealed the following [in part]:<BR/>Comprehensive Care Plans will be- <BR/>Developed within 7 days after completion of the comprehensive assessment.<BR/>Prepared and/or contributed to by an intradisciplinary team.<BR/>The resident's care plan will be reviewed after each Admission, Quarterly, Annual, and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. <BR/>Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. <BR/>The facility will provide the resident and the resident's representative, if applicable with advance noticed of care planning conferences to enable the resident/resident's representative participation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain personal hygiene to 1 of 2 residents (Resident #2) reviewed for activities of daily living, by failing to ensure:<BR/>Resident #2 received nail care as needed. <BR/>The facility's failure could affect residents who required assistance with activities of daily living, placing them at risk for infection, and a decline in health.<BR/>The findings included:<BR/>Review of Resident #2's Face Sheet, not dated, revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included Cerebral Palsy (movement disorders), Schizoaffective Disorder(mental disorder characterized by abnormal thought processes) and Epilepsy (neurological disorder characterized by recurrent seizures). <BR/>Review of Resident #2's annual MDS assessment, dated 01/12/2023, revealed a BIMS (Brief Interview for Mental Status) score of 10 (moderately impaired). The assessment documented she required total dependence, with 2 people physically assisting, with personal hygiene tasks. <BR/>Review of Resident # 2's care plan initiated on 10/18/2021, revealed that the resident has an ADL self-care performance deficit and requires x1 staff participation with personal hygiene and oral care.<BR/>Observation and interview on 01/26/2023 at 1:50 PM revealed Resident #2 was seated in a wheelchair in the hallway by the front door of the facility. The resident was able to answer questions appropriately. A staff member wheeled her to the room to talk in privacy. The resident was wearing eyeglasses and had long uneven fingernails, chipped nail polish and a dark brown substance underneath the nails. Resident stated that she had been requesting that her nails be cut and to be cleaned better. She stated that when she asks, staff tells her that they are shorthanded. She was unsure which staff member she had asked for assistance. <BR/>In an interview on 01/26/2023 at 2:00 PM, the resident's family member stated that she asked the DON to keep the resident bathed and clean numerous times. She was told that they were working on it and the issue would be corrected. <BR/>In an interview on 01/26/2023 at 2:15 PM, the DON stated it was the aide's responsibility to see that the residents received the proper nail care and that their nails were kept clean each time they assisted them to bathe. She stated the activity director painted their nails if they wish to participate in that activity during the week. She stated that the resident did not ever refuse nail care. She looked at the Resident #2's nails and agreed they needed to be cleaned and cut. She stated she did not notice the residents' s dirty fingernails until the surveyor brought it to her attention but agreed that they needed to be clipped and that she would do it that day. She stated that she was also doing an in-service training for staff to correct the issue. <BR/>Review of the facility's policy and procedures for Quality if Life or Activities of Daily Living was requested to the DON but was not available at the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 4 residents (Residents #39) whose records were reviewed for assessments.<BR/>1) The facility failed to recognize and assess Resident #39's weight loss, IV medications while in the facility, decline in ADL's and a decline in Bowel and Bladder function. <BR/>This failure placed residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments.<BR/>The findings included:<BR/>Review of Resident #39's Face Sheet, dated 04/04/2023, reflected Resident #39 was a [AGE] year-old female re-admitted to the facility on [DATE]. The resident had Acute Respiratory Failure with Hypoxia (impaired gas exchange between the lungs and blood), Bacterial Infection (infection by microorganisms that invade the tissue), and malnutrition (lack of proper nutrition). <BR/>Review of Resident #39's MDS assessments showed significant changes from her Quarterly MDS Assessment 10/09/2022 to her Quarterly MDS Assessment 11/29/2022 as follow:<BR/>1) The Quarterly MDS dated [DATE] section G revealed the resident had extensive assistance in dressing and was not steady but able to stabilize with staff assistance while moving from seated to standing position, was not steady but able to stabilize with staff assistance in walking, was not steady but able to stabilize with staff assistance in turning around, was not steady but able to stabilize with staff assistance in moving on and off toilet and was not steady but able to stabilize with staff assistance in surface to surface transfers. A wheelchair was used for mobility devices. <BR/>The Quarterly MDS dated [DATE] section G revealed the resident had total dependance in dressing, activity did not occur in transfers, activity did not occur while moving from seated to standing position, activity did not occur in walking, activity did not occur in turning around, activity did not occur in moving on and off toilet and activity did not occur in surface-to-surface transfers. None of the above was used for mobility devices. <BR/>2) Resident had a significant weight loss from 10/09/2022 to 11/29/2022. The Quarterly MDS dated [DATE] section K revealed the resident weighed 195 with no significant weight loss or weigh gain coded. The Quarterly MDS dated [DATE] section K revealed the resident weighed 171 with no significant weight loss or weight gain coded. <BR/>3) Review of the MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident was not receiving IV Medications while in the facility and was receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 0 days of Antibiotics, 7 days of Antidepressants and 7 days of Antianxiety. <BR/>The MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident received IV Medications while in the facility and was not receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 7 days of Antibiotics, 0 days of Antidepressants and 0 days of Antianxiety. <BR/>Observation and interview on 04/02/2023 at 10:30 AM revealed Resident #39 was alone in her room lying in her bed. She stated that she had been doing much better after her recent hospitalization. <BR/>In an interview on 04/02/2023 at 3:15 PM, the MDS Coordinator said that Resident #39 had a significant change and that a significant change assessment should have been completed within 14 days after the change. She said failure to do a significant change assessment could result in inadequate care areas and an appropriate care plan not being established. She said she did not know that she needed to complete a Significant Change Assessment with some of these areas and she had not realized she had more than one care area where the resident declined. She stated she knew the resident had a weight loss and she forgot to code it. She said that she was the one responsible for completing and the assessment and ensuring it was done accurately. <BR/>Review of the facility's policy and procedure for Resident Assessment, dated 2003, revealed the following [in part]:<BR/>A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument in (RAI). <BR/>The assessment will include at least the following:<BR/>Medically defined conditions and prior medical history<BR/>Medical status measurement<BR/>Physical and mental functional status <BR/>Nutritional status and requirements<BR/>Special treatments or procedures<BR/>Drug therapy<BR/>RAI assessments must be conducted within 14 days after the date of admission, probably after a significant change in the residence physical or mental condition as soon as the resident stabilizes at a new functional are cognitive level or within two weeks, whichever is earlier<BR/>The results of the assessment are used to develop, review, and revise the residence comprehensive plan of care.<BR/>Any individual who willing play knowingly certifies or causes another individual to certify immaterial and false statement in a resident assessment will be terminated in a septic to civil many penalties.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that:<BR/>1. The dietary staff did not operate the low temperature dish machine and check the chlorine sanitizer content to ensure it was operating correctly to clean and sanitize the dishes consistently each meal.<BR/>2. Dietary Aide C did not use disposable gloves while handling soiled dishes and did not wash or sanitize his hands before handling the clean dishes.<BR/>3. Food items in the non-perishable food storage areas were not stored in sealed containers or resealable storage bags after the manufacturer's package seal was opened.<BR/>4. Floors were soiled throughout the kitchen food preparation area.<BR/>5. The deep fryer unit was soiled with dried fried food crumbs and contained dark colored cooking oil.<BR/>6. The reach-in freezer unit #2 interior temperature was not maintained at zero degrees F or lower and foods stored in the unit were not frozen solid.<BR/>The facility's failure placed residents at risk for foodborne illness and a decline in health status.<BR/>The findings included:<BR/>Observation on 4/02/23 at 9:25 AM, during the initial tour of the facility kitchen revealed the hand washing sink was located by the door to the short hallway that led to the nurses' station. There was not another hand washing sink in the kitchen or dish washing room.<BR/>Interview and observation on 4/02/23 at 9:30 AM revealed Dietary Aide C was washing dishes in the low temperature dish machine. He was not wearing gloves when handling the soiled dishes. He stated he had worked in facility for about 1 month.<BR/>Review of the dish machine temperature log form, dated April 2023, revealed columns to document wash and rinse water temperatures and sanitizer levels 3 times daily. No entries were documented on the form for 4/01/23 or breakfast 4/02/23. <BR/>Observation on 4/02/23 at 9:35 AM revealed Dietary Aide C operated the dish machine. He started to record temperatures for breakfast on 4/01/23, then scratched them out when reminded today was 4/02/23. When Dietary Aide C checked the chlorine sanitizer content, the test strip did not react when dipped in the dish machine water. He primed the sanitizer and ran the dish machine again. No sanitizer was observed in the tube that emptied into the dish machine. Dietary Aide C checked the one-gallon sanitizer bottle, which was almost full. He removed the bottle cap which was connected to tubing and observed the siphon device was stuck down in the neck of the bottle and did not reach the cap. He stated he would go to the storage room and get another bottle of sanitizer. <BR/>In an interview and observation on 4/02/23 at 9:40 AM, after returning to the kitchen, Dietary Aide C stated he could not find another bottle of sanitizer. He stated he was not going to wash dishes by hand and stated he might as well go home. He removed the cap to the sanitizer bottle and was able to pry the siphon device to the top of the bottle neck with a knife. He replaced the bottle cap with the tubing, primed the dish machine again and ran the machine. Chlorine sanitizer was observed flowing through the tubing and emptying into the dish machine. He tested the sanitizer and measured a level of 200 ppm. Observation of the low temperature dish machine manufacturer's recommendations revealed wash and rinse water temperatures at a minimum of 120 degrees F and a sanitizer level minimum of 50 ppm. When asked about the procedure for handling soiled and clean dishes, Dietary Aide C stated he put the dirty dishes in the racks, ran them through the dish machine, and then stacked the clean dishes. Inquired if he washed or sanitized his hands between touching the soiled and clean dishes, as he was not using disposable gloves, and he stated no. A two-compartment sink for rinsing dishes was in the dish room, but there was no hand soap, paper towel dispenser, or hand sanitizer in the room. Dietary Aide C stated he would start using gloves when handling dirty dishes. He got gloves from a box in the kitchen and put them on his hands.<BR/>Observation and interview on 4/02/23 at 10:00 AM, during the initial tour of the facility kitchen revealed the following: <BR/>- The reach-in refrigerator unit contained a rectangular pan covered with foil which was not labeled or dated. [NAME] D removed the pan from refrigerator and placed the pan on the stove top. She lifted the foil and stated it looked like a roast. The piece of meat had been cooked as a whole piece of meat (not sliced) and was surrounded by white colored cold grease/fat. [NAME] D stated she did not know when it had been cooked.<BR/>- The reach-in freezer unit #2 had an interior thermometer with a temperature of 25 degrees F. The freezer was filled with unevenly stacked cardboard boxes, dated 3/29/23, which contained sweet dough and beef steak fritters (meat patties) which were not frozen solid.<BR/>- The exterior surfaces of the stainless steel reach-in refrigerator and freezer units were soiled with dried food splatters.<BR/>- The storage room for storing bread items on shelf rack had an open bag with potato chips rolled closed and dated 3/28/23. The potato chips were not in a sealed container or resealable bag.<BR/>- The non-perishable food storage room had wire rack shelf units for storing dry food items. A large plastic bag containing flake coconut, dated 3/23/22, was rolled closed and had a trombone paper clip; a 5-pound bag with pecan pieces, dated 3/08/23, was rolled closed and had a trombone paper clip. The coconut and pecans were not in sealed containers or resealable bags.<BR/>- The deep fryer unit top surface was covered with a large rectangular baking sheet and was not in use. The pan was moved to the side and dark colored cooking oil and fried food crumbs on the interior surface were observed.<BR/>- The floor was soiled with food throughout the kitchen. <BR/>In an interview on 4/02/23 at 10:10 AM, [NAME] D stated the food on the floor was from breakfast that morning and she had not yet swept the floor. She stated she sweeps the floor two times during her shift.<BR/>In an observation and interview on 4/02/23 at 3:04 PM, a chest freezer was located in a storage room located in the short hallway outside the kitchen. A thermometer was not observed inside the freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. The DSM stated the roast in the reach-in refrigerator this morning was from last Wednesday, 3/29/23. She stated it should have been labeled and dated. When asked about the supply of chlorine sanitizer for the low temperature dish machine, she stated she had more in storage. She stated the new bottle of sanitizer must have been defective. <BR/>In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake.<BR/>In an interview on 4/04/23 at 11:35 AM, the DSM stated she had worked as a dietary aide and dishwasher for the morning shift on Saturday, 4/01/23. When asked if she had changed the bottle of chlorine sanitizer for the dish machine that day, she stated no and she did not recall doing it. The DSM stated the evening shift dietary aide would have switched the sanitizer bottle with a new one. She did not recall checking the wash and rinse water temperatures and chlorine sanitizer for the Saturday 4/01/23 breakfast and lunch meals. When asked about the April 2023 dish machine temperature and sanitizer log not having any documented entries for 4/01/23, she stated she had not checked them.<BR/>Review of the facility's policy and procedure for Dishwashing Preparation and Dishwashing, included in the Dietary Services Policy and Procedure Manual 2012 , revealed the following [in part]:<BR/>The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils.<BR/>Procedure:<BR/>2. Automatic dishwasher: Low temperature machine .<BR/>d. Prior to washing the soiled dishes after a meal, the dish machine should be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be run empty for a few cycles to ensure the proper temperature is attained, and no dishes will be washed prior to achieving this standard.<BR/>e. Hands should be sanitized before touching clean items and use care in removing utensils from conveyors in order not to contaminate clean items .<BR/>Review of the facility's policy and procedure for Food Storage and Supplies, included in Dietary Services Policy and Procedure Manual 2012, revealed the following [in part]:<BR/>All facility storage areas will be maintained in and orderly manner that preserves the condition of food and supplies. Will ensure storage areas are clean, organized, dry and protected from vermin and insects.<BR/>Procedure:<BR/>4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened.<BR/>5. Storeroom floors should be swept and mopped to be maintained in a sanitary manner to prevent vermin or pest infestation .<BR/>Review of the U.S. Food and Drug Administration, 2017 Food Code, specified [in part]:<BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days.<BR/>6-501.12 Cleaning, Frequency and Restrictions. <BR/>Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared.

Based on observation, interview, and record review, the facility failed to ensure the maintenance of mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that:<BR/>One of two reach-in freezers was not maintained at an interior temperature of zero degrees or below and food stored in the freezer was not frozen solid.<BR/>This failure placed the residents at risk for foodborne illness from being served food that had not been stored at the proper temperature.<BR/>The findings included:<BR/>Observation on 4/02/23 at 10:00 AM revealed a row with one reach-in refrigerator unit and two reach-in freezer units. Observation of reach-in freezer unit #1 revealed an interior thermometer with a temperature of -4 degrees F. Freezer unit #1 contained vegetables in clear plastic bags and the vegetables were frozen solid. Observation of reach-in freezer unit #2 revealed an interior thermometer with a temperature of +25 degrees F. Freezer unit #2 contained cardboard boxes dated 3/29/23. The boxes were unevenly stacked to the ceiling of the freezer. A box contained sweet dough, which was thawed and soft, and a box contained beef steak fritters (meat patties) which were not frozen solid.<BR/>In an interview on 4/02/23 at 10:02 AM, [NAME] D stated grocery delivery was received one time weekly on Wednesdays. She stated the grocery boxes dated 3/29/23 were from the delivery last week. The [NAME] left the kitchen through the door to the short hallway that led to the nurses' station.<BR/>In an interview on 4/02/23 at 10:05 AM, [NAME] D stated she had called the DSM and she had not answered. She stated the DSM was good about calling back. [NAME] stated D stated she had talked with the nurses about the reach-in freezer unit, and they would try to reach the maintenance man.<BR/>In an interview on 4/02/23 at 2:43 PM, the Administrator stated the Maintenance Director was trying to repair the reach-in freezer.<BR/>In an interview on 4/02/23 at 2:48 PM, the DSM stated there had not been a problem with the end reach-in freezer unit #2 and it must have started during the past few days. She stated she would take all the food from the end freezer unit #2 and place it in the middle freezer unit #1 and in the chest freezer in the hallway storage room. The DSM stated she would defrost freezer unit #2. She stated if the freezer unit did not work after that it would need to be serviced. She stated the freezer was not older than 2 years. <BR/>In an interview on 4/02/23 at 2:52 PM, the Maintenance Director stated the boxes of food in the reach-in freezer #2 were stacked too close together and too high and were blocking the fan. He stated the food needed to be removed and the freezer needed to be defrosted and then it should work ok. <BR/>Observation and interview on 4/02/23 at 3:04 PM revealed a chest freezer was in the storage room located in the short hallway leading from the kitchen. The chest freezer had space for additional food from freezer unit #2 in the kitchen. A thermometer was not found inside freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. <BR/>Observation on 4/03/23 at 9:43 AM revealed all food items had been removed from the reach-in freezer unit #2 and the unit had been defrosted. The fan blades in the interior ceiling had not yet been covered. Observation on 04/03/2023 at 9:43 AM of the reach-in freezer unit #1 revealed it contained food items, including the beef steak fritters, that had been removed from freezer unit #2. <BR/>Observation and interview on 4/04/23 at 8:35 AM revealed reach-in freezer unit #2 was running and the interior thermometer temperature was 12 degrees F. The freezer remained empty at that time. The Maintenance Director stated he needed to replace the cover for the fan in the ceiling of the unit. <BR/>In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake.<BR/>In an interview on 4/04/23 at 1:55 PM, the DSM stated she had 3 freezers, the 2 reach-in freezers in the kitchen and the chest freezer in the supply room. She stated freezer unit #2 was only about 2 years old. She stated she never had problems with reach-in freezer #1, and it was the oldest unit. She stated daily freezer temperatures were documented on the temperature log form. She stated she would look for a policy and procedure for maintenance of equipment and temperatures.<BR/>Review of the daily freezer temperature log forms revealed columns for documenting temperatures 2 times daily, in the morning and in the evening. <BR/>Review of the March 2023 daily temperature log for Freezer #1 revealed a temperature of -10 degrees F was consistently documented daily in the morning and the evening.<BR/>Review of the March 2023 daily temperature log for freezer unit #2 revealed the documented morning and evening temperatures were above zero and ranged from 6 degrees F to 24 degrees F, except on 3/28/23 which documented -10 degrees F for both the morning and evening (possibly a documentation error). The documented morning temperature on 3/29/23 was 10 degrees, on 3/30/23 was 8 degrees, and on 3/31/23 was 11 degrees. No temperatures were documented for the evening on 3/29/23, 3/30/23, and 3/31/23.<BR/>A policy and procedure for maintaining essential kitchen equipment, including checking and documenting refrigerator and freezer temperatures, was not provided as requested prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain PASARR level 1 prior to admission for 1 of 2 residents reviewed for PASARR (Resident #3).<BR/>The facility failed to obtain PASARR screening prior to admission for Resident #3.<BR/>This failure could place residents at risk for inappropriate placement in the nursing facility for long term care and at risk of not receiving appropriate care and services from the local authority.<BR/>Findings included:<BR/>Record Review of physician orders, dated 01/26/23, indicated Resident #3, admitted [DATE], was a [AGE] year-old female with diagnoses of bipolar disorder (mental disorder with periods of intense mood wings), post-traumatic stress disorder (mental health condition that is triggered by a terrifying event), and schizoaffective disorder (severe mood disorder).<BR/>Record review revealed that Resident #3 did not have a PASARR screening (PL1) performed prior to admission. <BR/>During an interview on 01/26/23 at 11:30 a.m., LVN MDS Coordinator acknowledged the PASARR screening for Resident #3 had not been obtained prior to admission. She stated that she had forgotten to do it and that she would be completing it that day. She said that she was the only one that was responsible for completing the PL1 prior to the resident entering the facility. She said that the resident would qualify for services, but that she had not alerted the local authorities that the resident had entered the building by completing the PL1. She said this failure could put the resident at risk for not receiving the services she is entitled to for her mental illness. <BR/>Interview with Resident #3 on 01/26/23 at 11:45 a.m., revealed that she was not pleased with the facility. She said that she had a history of mental illness and she felt that they were not addressing her mental illness needs. <BR/>On 01/26/23 A copy of the facilities policy and procedures dated 03/06/19a was provided over PASRR Level 1 Screen- It revealed the following: <BR/> Policy: It is the policy of [company name] facilities to obtain a PL1 screening form from the referring entity prior to admission to the nursing facility. The PL1 will be submitted via Simple timely per PASRR regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR program is important because it provides options for individuals to choose where they live, who they live with and the therapy they need to live independently as possible.<BR/>6. A new PL1 is required for the following reasons:<BR/>For every respite stay<BR/>For someone returning from a medical acute care hospital stay of 30 days or more <BR/>For someone returning from a Psychiatric Behavioral hospital stay.<BR/>For every new admission to the same or another nursing facility.

Based on observation and interview, the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift in a place readily accessible to residents and visitors, in that:<BR/>1. The facility failed to update and post the daily nurse staffing information on 4/02/23.<BR/>2. The nursing staff on duty on 4/02/2023 did not know the current resident census.<BR/>This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.<BR/>The findings included:<BR/>Observation on 04/02/2023 at 09:05 AM revealed the daily nurse staffing pattern was not posted on the wall in the location designated for it. <BR/>In an interview on 04/02/2023 at 9:15 AM, RN A could not explain why the daily nurse staffing information was not posted where it could be seen but RN A did show where it was located in a three-ring binder at the nurses' station. The facility had a standardized form for documenting the date, resident census, and nurse staffing hours for each shift.<BR/>In an interview on 04/02/2023 at 9:20 AM, RN A stated she worked weekends, double shifts, from 6:00 AM to 10:00 PM. She stated she did not know the current resident census.<BR/>In an interview on 04/04/2023 at 02:00 PM, the DON said she did not understand why the daily nurse staffing information was not put out. The DON said that she placed the daily nurse staffing form for Friday, Saturday, and Sunday in the binder before she leaves the facility for the staff to put out (post).

Based on observation, interview, and record reviews , the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one meal reviewed for palatable meals and preferred temperatures.<BR/>The facility failed to ensure that the food was appetizing temperature, flavor, and texture.<BR/>The deficient practice could affect the residents who received their meals from the kitchen by contributing to poor intake of nutrition, weight loss, and illness.<BR/>This finding include:<BR/>In an observation on 5/16/24 at 11:50 AM the holding food temperatures were as follows:<BR/>Chicken corn casserole -154 F.<BR/>Rice -158 F.<BR/>Beans -148 F.<BR/>Kool-aide with melted ice, a temperature was not obtained.<BR/>In an observation on 05/16/24 at 01:27 PM of a sample test tray with [NAME] E present, revealed the following: <BR/>Chicken corn casserole was at 110 degrees F, The warmth of the casserole was room temperature and not appetizing. <BR/>The rice was gummy and not flavorful . The rice was difficult to swallow due to the texture.<BR/>Kool-aide was room temperature and with melted ice.<BR/>In an interview on 5/16/24 at 1:30 PM, [NAME] E said she had trouble with residents not liking the Kool-aide if the ice had melted and the drinks were watered down.<BR/>In an interview on 05/14/24 at 10:04 AM, MDS Nurse B stated she had been working at the facility for 19 years. She said the food was consistently cold that was served down the halls. She said it had been an ongoing problem. <BR/>In an interview on 05/17/24 at 11:15 AM with the DON she said the cold food and kitchen issues had been an ongoing issue and they were implementing things to improve cold food.<BR/>In an interview on 5/17/24 at 11:30 AM, the Regional Compliance Nurse said they have known about the problems with the food. She said this was addressed in the Resident Council and with other residents on the halls. She said they completed a training about using plate warmers and she said they needed to be more efficient during mealtimes. <BR/>In an interview on 05/17/24 at 03:45 PM with the Administrator, she revealed the cold food was an ongoing issue. She stated she tried changing the order the hall meal tray carts were being sent from the kitchen so the Hall 400 residents would not feel they always came last. The Administrator mentioned in the Resident Council meetings the food was frequently a concern.<BR/>In a record review of the facility's Dietary Services & Policy & Procedure Manual 2012: FP 00-10.0 reflected the following [in part]:<BR/>Under section 4. Every attempt will be made to honor resident food preferences .<BR/>Under section 8. The menu will reflect the needs of the resident population as well as input from residents and resident groups.

Based on observation, interview, and record reviews , the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one meal reviewed for palatable meals and preferred temperatures.<BR/>The facility failed to ensure that the food was appetizing temperature, flavor, and texture.<BR/>The deficient practice could affect the residents who received their meals from the kitchen by contributing to poor intake of nutrition, weight loss, and illness.<BR/>This finding include:<BR/>In an observation on 5/16/24 at 11:50 AM the holding food temperatures were as follows:<BR/>Chicken corn casserole -154 F.<BR/>Rice -158 F.<BR/>Beans -148 F.<BR/>Kool-aide with melted ice, a temperature was not obtained.<BR/>In an observation on 05/16/24 at 01:27 PM of a sample test tray with [NAME] E present, revealed the following: <BR/>Chicken corn casserole was at 110 degrees F, The warmth of the casserole was room temperature and not appetizing. <BR/>The rice was gummy and not flavorful . The rice was difficult to swallow due to the texture.<BR/>Kool-aide was room temperature and with melted ice.<BR/>In an interview on 5/16/24 at 1:30 PM, [NAME] E said she had trouble with residents not liking the Kool-aide if the ice had melted and the drinks were watered down.<BR/>In an interview on 05/14/24 at 10:04 AM, MDS Nurse B stated she had been working at the facility for 19 years. She said the food was consistently cold that was served down the halls. She said it had been an ongoing problem. <BR/>In an interview on 05/17/24 at 11:15 AM with the DON she said the cold food and kitchen issues had been an ongoing issue and they were implementing things to improve cold food.<BR/>In an interview on 5/17/24 at 11:30 AM, the Regional Compliance Nurse said they have known about the problems with the food. She said this was addressed in the Resident Council and with other residents on the halls. She said they completed a training about using plate warmers and she said they needed to be more efficient during mealtimes. <BR/>In an interview on 05/17/24 at 03:45 PM with the Administrator, she revealed the cold food was an ongoing issue. She stated she tried changing the order the hall meal tray carts were being sent from the kitchen so the Hall 400 residents would not feel they always came last. The Administrator mentioned in the Resident Council meetings the food was frequently a concern.<BR/>In a record review of the facility's Dietary Services & Policy & Procedure Manual 2012: FP 00-10.0 reflected the following [in part]:<BR/>Under section 4. Every attempt will be made to honor resident food preferences .<BR/>Under section 8. The menu will reflect the needs of the resident population as well as input from residents and resident groups.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Residents #219) reviewed for oxygen in that:<BR/>Resident #219 did not have physician's orders for oxygen administration.<BR/>This deficient practice could affect 8 residents who received respiratory treatments and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.<BR/>The findings included:<BR/>Record review of Resident #219's face sheet dated 04/04/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep and characterized by loud snoring and episodes of stop breathing). <BR/>Record review of Resident #219's MDS Assessment for Medicare Part A Stay dated 03/30/2023, revealed a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and sleep apnea. The MDS assessment indicated Resident #219 received oxygen therapy.<BR/>In an observation and interview on 04/02/23 at 9:33 AM, there was an oxygen concentrator in Resident's 219's room. A nasal cannula was connected to the concentrator and was bagged. There was a CPAP machine on her dresser next to her bed. She said that she used oxygen with her CPAP machine at night. She said she had sleep apnea and had been using this since she was admitted to the facility since last week. <BR/>Record review of Resident #219's Physician Order Summary Report, dated 04/04/2023, revealed that there were no orders for oxygen administration. <BR/>Record review of Resident #219's Care Plan revised on 04/03/2023, revealed: Focus - The Resident has COPD; Intervention - Give oxygen therapy as ordered by the physician. <BR/>In an interview on 04/04/23 at 1:56 PM, the DON said Resident #219 should have had an order for oxygen administration with her CPAP machine. She said the admitting nurse should have put in the order. Failure to do so would risk the resident of not getting the oxygen support that was needed. <BR/>Record review of the facility policy for Oxygen Administration, dated as revised February 13, 2007, revealed the following [in part]:<BR/>Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems .<BR/>Goals: 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain PASARR level 1 prior to admission for 1 of 2 residents reviewed for PASARR (Resident #3).<BR/>The facility failed to obtain PASARR screening prior to admission for Resident #3.<BR/>This failure could place residents at risk for inappropriate placement in the nursing facility for long term care and at risk of not receiving appropriate care and services from the local authority.<BR/>Findings included:<BR/>Record Review of physician orders, dated 01/26/23, indicated Resident #3, admitted [DATE], was a [AGE] year-old female with diagnoses of bipolar disorder (mental disorder with periods of intense mood wings), post-traumatic stress disorder (mental health condition that is triggered by a terrifying event), and schizoaffective disorder (severe mood disorder).<BR/>Record review revealed that Resident #3 did not have a PASARR screening (PL1) performed prior to admission. <BR/>During an interview on 01/26/23 at 11:30 a.m., LVN MDS Coordinator acknowledged the PASARR screening for Resident #3 had not been obtained prior to admission. She stated that she had forgotten to do it and that she would be completing it that day. She said that she was the only one that was responsible for completing the PL1 prior to the resident entering the facility. She said that the resident would qualify for services, but that she had not alerted the local authorities that the resident had entered the building by completing the PL1. She said this failure could put the resident at risk for not receiving the services she is entitled to for her mental illness. <BR/>Interview with Resident #3 on 01/26/23 at 11:45 a.m., revealed that she was not pleased with the facility. She said that she had a history of mental illness and she felt that they were not addressing her mental illness needs. <BR/>On 01/26/23 A copy of the facilities policy and procedures dated 03/06/19a was provided over PASRR Level 1 Screen- It revealed the following: <BR/> Policy: It is the policy of [company name] facilities to obtain a PL1 screening form from the referring entity prior to admission to the nursing facility. The PL1 will be submitted via Simple timely per PASRR regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR program is important because it provides options for individuals to choose where they live, who they live with and the therapy they need to live independently as possible.<BR/>6. A new PL1 is required for the following reasons:<BR/>For every respite stay<BR/>For someone returning from a medical acute care hospital stay of 30 days or more <BR/>For someone returning from a Psychiatric Behavioral hospital stay.<BR/>For every new admission to the same or another nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the state mental health authority promptly for resident review after a significant change in mental condition for two residents (Residents #21 and #55) with the PASRR screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations.<BR/>The facility did not update the PASRR Level 1 forms for Resident #21 and Resident #55.<BR/>This failure placed the residents at risk for not being evaluated for psychiatric conditions and not receiving needed PASRR specialized services for which they may be eligible.<BR/>The findings included:<BR/>Resident #21<BR/>Review of Resident #21's Face Sheet dated 04/02/2023 revealed she was admitted to the facility on [DATE] with Admitting diagnosis of schizoaffective disorder (mental disorder with abnormal thought process) and generalized anxiety disorder (persistent anxiety). Resident #21's additional diagnoses were added on 08/25/2022 and included Post traumatic stress disorder (behavioral disorder that develops after exposure to trauma). <BR/>Review of Resident #21's Physician Orders dated 04/28/2022 revealed orders for Risperdal 0.5mg for bipolar and schizoaffective disorder. <BR/>Review of Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #21 could understand others and was usually understood by others; had a mild cognitive impairment with a BIMS score of 8 out of 15. <BR/>Review of Resident #21's Care Plan dated 03/23/2023 revealed complications associated with psychotropic medications and to monitor for target behaviors. Resident had behavioral problems and mood problems.<BR/>Review of Resident #21's PASRR Level One Screening Forms dated 05/17/2021 revealed Resident #21 had a diagnosis and was positive for mental illness. An updated PL1 was not completed after a diagnosis of post-traumatic stress disorder was added on 08/25/2022. An updated PL1 was completed and resubmitted on 04/02/2023.<BR/>Resident #55<BR/>Review of Resident #55's Face Sheet dated 04/02/2023 revealed she was admitted to the facility on [DATE] with Admitting diagnosis of generalized anxiety disorder (persistent anxiety). Resident #55's additional diagnoses were added on 08/25/2022 included psychotic disorder with delusions (mental disorder with paranoid delusions). <BR/>Review of Resident #55's Physician Orders dated 04/28/2022 revealed orders for Seroquel 25 mg two times a day for psychotic disorder with delusions.<BR/>Review of Annual MDS dated [DATE] revealed Resident #55 could usually understand others and was usually understood by others and had mild cognitive impairment with a BIMS score of 8 out of 15. <BR/>Review of Resident #55's Care Plan dated 02/22/2023 revealed complications associated with psychotropic medications and to monitor for target behaviors. Resident had behavioral problems and mood problems.<BR/>Review of Resident #55's PASRR Level One Screening Forms dated 07/10/2021 revealed Resident #55 had a diagnosis and was positive for mental illness. An updated PL1 was not completed after Seroquel was ordered for psychotic disorder with delusions. An updated PL1 was completed and resubmitted on 04/02/2023.<BR/>In an interview on 04/02/2022 at 10:05 AM, the MDS Coordinator said that she thought she did not have to update a PL1 when the resident's condition changed. She stated she contacted her regional manager, and she informed her that it was to be updated if the resident's condition changed.<BR/>Review of the facility's PASRR Policy and Procedures, dated 10/30/2017, revealed the following [in part]:<BR/>Significant Change in status: If the resident's status has changed significantly enough from the initial reviewed status, they must have a new PASRR Level 1 to determine if they now are eligible for PASRR specialized services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Residents #219) reviewed for oxygen in that:<BR/>Resident #219 did not have physician's orders for oxygen administration.<BR/>This deficient practice could affect 8 residents who received respiratory treatments and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.<BR/>The findings included:<BR/>Record review of Resident #219's face sheet dated 04/04/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep and characterized by loud snoring and episodes of stop breathing). <BR/>Record review of Resident #219's MDS Assessment for Medicare Part A Stay dated 03/30/2023, revealed a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and sleep apnea. The MDS assessment indicated Resident #219 received oxygen therapy.<BR/>In an observation and interview on 04/02/23 at 9:33 AM, there was an oxygen concentrator in Resident's 219's room. A nasal cannula was connected to the concentrator and was bagged. There was a CPAP machine on her dresser next to her bed. She said that she used oxygen with her CPAP machine at night. She said she had sleep apnea and had been using this since she was admitted to the facility since last week. <BR/>Record review of Resident #219's Physician Order Summary Report, dated 04/04/2023, revealed that there were no orders for oxygen administration. <BR/>Record review of Resident #219's Care Plan revised on 04/03/2023, revealed: Focus - The Resident has COPD; Intervention - Give oxygen therapy as ordered by the physician. <BR/>In an interview on 04/04/23 at 1:56 PM, the DON said Resident #219 should have had an order for oxygen administration with her CPAP machine. She said the admitting nurse should have put in the order. Failure to do so would risk the resident of not getting the oxygen support that was needed. <BR/>Record review of the facility policy for Oxygen Administration, dated as revised February 13, 2007, revealed the following [in part]:<BR/>Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems .<BR/>Goals: 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of four residents (Resident #21) reviewed for Comprehensive Care Plans.<BR/>This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care.<BR/>The findings included:<BR/>Record review of Resident #21's face sheet revealed he was an [AGE] year-old female, admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. <BR/>Record review of Resident #21's Annual MDS, dated [DATE], revealed in Section I diagnoses included: Psychotic Disorder and Anxiety Disorder. Section N showed 7 days of antipsychotic medications given. <BR/>Record review of Resident #21's care plan revealed it did not have the antipsychotic medication (Seroquel) addressed in the comprehensive care plan. <BR/>Record review on 04/02/2023 of Resident 21's orders showed an order for a Seroquel 35mg given two times a day for psychotic disorder with delusions. <BR/>In an interview on 4/02/2022 at 10:22 AM, the MDS Coordinator said that she should have care planned the Seroquel after it triggered on the MDS from Section V. She said that she was behind and was having a difficult time making sure all of the stuff was completed. She said that they were implementing a new process that should make sure everything is care planned accurately. She said this failure could place the resident at risk for staff not recognizing adverse medication effects and behaviors. She was going to talk to the DON and make sure it was added.<BR/>In an interview on 04/02/2023 at 1:30 PM, the DON said that it was the responsibility of the MDS Coordinator since an annual assessment was done and should have captured it. She stated that she would add it immediately and would start double checking to make sure there is no other areas missed. She stated that the resident was receiving the medication and they were observing her for adverse reactions or behaviors even though it was not care planned. <BR/>A facility policy and procedure for comprehensive care plans was not received at the time of exit.

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 2 medication carts reviewed for pharmacy services. <BR/>The facility did not ensure medications carts were secured and locked. <BR/>This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. <BR/>Findings included: <BR/>During an observation on 12/06/2023 at 3:30 PM, LVN A left a prescription IV medication of Vancomycin on top of the cart 2, unsecured and out of LVN A's sight, while she was in another resident's room. There was not any other staff in visual sight of the medication, and there was a resident that was within 3 feet of the medication cart. Surveyor was unsure where the nurse went and took the medication to the Administrator's office without LVN A realizing it was gone. <BR/>During an interview on 12/06/2023 at 3:35 PM, LVN A said that she walked away to go into a resident's room to help him. She said that she should have locked the medication up before she left it unattended with residents around it. She said that this could cause a patient to get into it or take the medication. <BR/>During an interview on 11/06/2023 at 12:45 PM, the DON said that her expectations were for medications to be locked up anytime a nurse walks away from it. She said that staff are all trained on medication expectations and know not to leave medications out or unattended. <BR/>A policy and procedure titled Storage of Medication was requested on 12/07/2023 and was not received at the time of exit.