DESOTO NURSING & REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident has the right to privacy for 1 of 4 residents (Resident #1) reviewed for privacy and confidentiality: The facility failed to ensure CNA A provided privacy when providing Resident #1 with incontinent care. The door was left open to the hallway, and the privacy curtains were not closed properly. as CNA A began to uncover Resident #1, exposing his body to the open hallway. This failure could place residents at risk for a loss of privacy, emotional distress, and low self-esteem.Findings included: Record review of Resident #1's quarterly MDS dated [DATE] revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. Diagnoses included: Post traumatic stress disorder (mood disorder), hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), and renal insufficiency (kidneys are slow to work). Resident #1 was alert and oriented and able to make decisions. Record review of Resident #1's care plan dated 09/03/2025 reflected the resident had incontinence of bowel and bladder. Required the assistance of one staff for incontinence and two staff for transfer using a mechanical lift. An observation on 10/07/2025 at 9:15 a.m., CNA A entered Resident #1's room and without closing the door removed the covers from the resident exposing his body to the hallway. CNA A preceded to talk to the resident, informing him she was going to perform incontinent care for a bowel movement he had and then get him up and take him to the shower. An observation on 10/07/2025 at 9:20 a.m. revealed CNA A was assisting to take the gown off Resident #1, exposing his entire body to the hallway, at which time the CNA looked up and saw the surveyor partially closed the door to the hallway. The surveyor knocked on the partially closed door and entered the room, at which time the CNA informed the surveyor she was performing patient care and completely shut the door. During an interview on 10/07/2025 at 9:35 a.m., Resident #1 stated he did not notice if the door and privacy curtain were not closed properly. He said he would be visible to others if the door and the curtain were not closed properly. Resident #1 did comment when asked about the open door when CNA A removed his gown, he stated he did not want others to see this old broken-down body. During an interview on 10/07/2025 at 11:35 a.m. with CNA A stated, by not closing the door and the curtain, the privacy and dignity of Resident #1 was compromised as anyone passed by the room could see the care provided. When asked about the training she received on resident's rights, CNA A stated she was fully aware of resident's right to have privacy, dignity, and respect and received in-service on resident's rights at least once a year. During an interview 10/07/2025 at 1:00 p.m., the DON stated privacy and dignity must be provided during nursing care and the door and privacy curtain to Resident #1 and room should have been closed completely by CNA A. The DON stated the training was an ongoing process and resident rights was one of the in-services given annually. During an interview on 04/17/24 at 4:30 p.m., the Administrator stated the residents' rights at the facility should be maintained during nursing care. She said staff was expected to respect privacy and dignity by making sure doors to rooms were closed, privacy curtains fully drawn, and the window blinds were shut properly. Review of the facility's policy Resident Rights undated, reflected: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside our facility, including those specified in the policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of lord.We protect and promote the following rights of each resident. Privacy and Confidentiality-The resident has a right to personal privacy and confidentiality. 1. Privacy includes accommodations, medical treatment, personal care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences of two (Residents #13 and #35) of 8 residents reviewed for accommodation of needs and preferences. <BR/>The facility failed to ensure Resident #13 and #35 personal hair care needs were addressed.<BR/>These failures could cause residents to be at risk of having a loss of dignity and self-worth which could cause a decline in their psycho-social and physical well-being. <BR/>Findings included:<BR/>Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old female who admitted on [DATE] and current BIMS score of 13 (no cognitive impairment), ADL: personal hygiene was extensive 2 person assistance with diagnoses of hypertension, neurogenic bladder, CVA (Stroke), hemiplegia, multiple sclerosis. <BR/>Record review of Resident #13's Care Plans Target date: 12/20/23 ADL Self-care performance deficit related to visually impaired, functionally decline for bathing/showering, dressing. <BR/>Interview and observation on 10/03/23 at 10:40 am, Resident #13 was sitting in wheelchair and her hair was approximately 4 inches long and combed straight back. She stated they did not have a beautician to do their hair and it had been two or three months since her hair had been done by a beautician. She stated she did not know if they were looking into getting another beautician but really would like to get her hair styled and permed because it was hard to manage her hair into a style currently. She stated she asked Housekeeper I to braid her hair and was waiting on if she could do it. She stated the facility needed to get a beautician to come in once a month or every 2 weeks to keep her hair looking nice. She stated she had spoken to the nursing staff about wanting the beautician to come out to do her hair and so far no beautician had come out yet. She stated it was not a good feeling to have her hair not groomed and the CNA's tried to comb it but there were not able to style it in any kind of way. She stated the AD braided it one time 3 weeks ago and her hair had since been taken a loose about a week ago and now her hair was just sitting on the top of her head. She stated she wanted a perm and freeze wave hairstyle. <BR/>Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old female who admitted to this facility 11/03/14 and current BIMS Score 1 (severe cognitive deficit), ADL: Personal Hygiene was extensive one person assistance with diagnoses anemia, aphasia, CVA (Stroke), Non-Alzheimer's dementia, hemiplegia, depression and asthma. <BR/>Record review of Resident #35's Care Plans Target date: 11/05/23 ADL Self Care performance deficit related to dementia. <BR/>Interview and observation on 10/05/23 at 11:30 am, Resident #35's hair was in two ponytails and twisted to the ends and she stated she would like to get her hair done. <BR/>Interview 10/04/23 at 4:40 pm, CNA B stated she never saw a beautician doing the resident's hair since she worked here nine months ago. <BR/>Interview 10/04/23 4:51 pm, CNA C stated the last time she saw a beautician here was 5 months ago. She stated if the residents hair was not combed the other residents could possibly laugh at them and they could feel embarrassed. <BR/>Interview on 10/04/23 at 5:09 pm, SW D stated the facility did not have a beautician and had not seen a beautician come in to do the resident's hair since she started working here 3 months ago. She stated she spoke to the Administrator about getting the resident's hair done by a beautician and the Administrator told her the family members did the resident's hair in the beauty shop room. She stated the CNA's, and the Nurses were responsible for ensuring the residents hair was done and if a resident requested to get a perm or other service, she would ask their Responsible party if it was okay and then talk to the BOM to see what funding they had. She stated she spoke to Resident #13 today about getting a perm and she said she wanted one. She stated she was not sure what could happen to a resident if their hair was not done honestly .it could look like they were not being taken care of. She stated she was not sure but thought she would be responsible for arranging the resident's beautician appointments. <BR/>Interview on 10/05/23 at 9:22 am, Transporter/Barber stated she was a licensed barber and at times she cut the residents hair while they currently looked for another beautician because the last one had not been here in a while. She stated she could not remember the last time she saw a beautician at this facility, since working here a year. She stated she did not do perms or curl the resident's hair but cut the male residents hair at times if the request was known. <BR/>Interview on 10/05/23 at 9:46 am, the BOM stated the current Beautician used to come out monthly and the last time she did the resident's hair was around Memorial Day (May 2023). She stated the female residents did not always get their hair done because it was their choice to get their hair done or not. She stated the last time Resident #13 saw the beautician was May 2023 when she got her hair braided. She stated at times she noticed the resident's hair messed up and notified the nurses. She stated Resident #13 and #35 had their hair done by the beautician in the past and also saw them out in activities with their hair not done. She stated Resident #13's family member did her hair but did not come out to do it all the time. She stated was not sure who was responsible for ensuring the beautician was scheduled but she made sure the residents had the money in their accounts to get their hair done or asked their family's to pay. <BR/>Interview o 10/05/23 at 10:35 am, SW D stated she was responsible for getting the beauty shop list created and beautician scheduled. She stated since working here for the past 3 months she had not contacted the beautician because no one ask to get their hair done . She stated she did not have the beautician's contact information to schedule the resident's hair appointment but would get it from the Administrator. <BR/>Interview on 10/05/23 at 10:35 am, the Administrator stated she noticed Resident #13 wore her hair combed straight back and had not thought to get the beautician because the resident or family did not make a request to get her hair done . She stated the facility had a contracted cosmetologist/barber, but she was not sure when the beautician was last out to do the resident's hair. She stated if the resident's ADL care was not done timely it could make them feel bad or unkept and ungroomed. <BR/>Interview on 10/05/23 at 11:00 am, the BOM said SW D was responsible for getting the resident seen by the beautician. <BR/>Interview on 10/05/23 at 11:48 am, the Administrator stated SW D would be responsible for arranging the beauty shop appointments and getting a list of residents to get their hair done. <BR/>Interview on 10/05/23 at 3:23 pm, the Activity Director stated Resident #13's family member did her hair at times. She stated she braided Resident #13's hair about 3 weeks ago and the beautician braided it was either June 2023 or July 2023. <BR/>Record review of the facility's Social Service dated 2002 and revised October 2010 revealed, Policy Statement: Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practical physical, mental, or psychological well-being .Policy interpretation and implementation: .f. assistance in meeting the social and emotional needs of residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three ( #2, #16, #71) of 8 residents reviewed for ADL care. <BR/>The facility failed to ensure Residents' (#2, #16, #71) hair was cut and combed, faces shaved, and fingernails clipped. <BR/>These failures could place residents at risk of infections and skin tears resulting in pain, discomfort and decrease their dignity which could lead to a decreased psycho-social well-being and feeling of self worth. <BR/>Findings included: <BR/>A)Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed a [AGE] year old male who admitted [DATE] and had a BIMS Score of 03 (Severe Cognitive deficit) .with diagnosis of hypertension, Gastroesophageal Reflux (Stomach acid) , Renal insufficiency (kidney failure), arthritis (joint inflammation), aphasia (language deficit), cerebrovascular accident (stroke), hemiplegia (one side paralysis), seizure disorder (electricity burst in brain), malnutrition (nutrient deficit), depression (mood disorder), vascular dementia (memory loss). And total dependence one person assist for personal hygiene by CNA. <BR/>Record review of Resident #2's Care Plan revealed communication problem related to expressive aphasia (anticipate and meet needs), cognitive function and impaired thought processes related to CVA, terminal prognosis hospice (Adjust provision of ADL's to compensate for resident's changing abilities and ADL Self-care performance deficit related to hemiplegia, stroke: Personal hygiene/oral care: the resident requires (x1) staff participation with personal hygiene and oral care by CNA) <BR/>Observation and interview on 10/03/23 at 10:38 am, Resident #2 was lying in bed and his hair was 2 inches long the edges were different lengths, his nails were &frac14; inch long from the nail bed and he gestured nodding his head yes, he would like to get his nails cut. <BR/>Observation and interview on 10/04/23 at 9:02 am of Resident #2 revealed his nails were &frac14; inch long from the nail bed on both hands. He gestured by nodding his head yes , he would like to get his nails clipped and was not sure when they were last clipped. <BR/>Record review of Resident #2's Shower Sheets were requested from ADON on 10/04/23 at 9:43 am and was not provided. <BR/>B) Record review of Resident #16's admission MDS assessment dated [DATE] revealed a [AGE] year old male who admitted on [DATE] with a BIMS score of 07 (Severe cognitive deficit) .with diagnoses of Anemia, Atrial Fibrillation (irregular heart beat), Hypertension (high blood pressure), Peripheral Vascular Disease (circulatory disorder), Renal insufficiency (kidney failure), Pneumonia (lung infection), diabetes mellitus (high blood sugar), hyperlipidemia (high cholesterol) and non-Alzheimer's Dementia (memory impairment) and required extensive one person assist for personal hygiene by CNA. <BR/>Record review of Resident #16's Care plan revealed he required pain management (chronic) pain related to diabetic neuropathy (diabetic nerve damage) and PVD .ADL Self-care performance deficit related to Dementia, impaired balance, ADL self-care performance deficit (Personal hygiene/oral care: the resident requires extensive (x1) staff participation by CNA. <BR/>Observation and interview of Resident #16 on 10/03/23 /23 at 11:17 am, Resident #16's hair was 2 inches long and fingernails were &frac12; inch long from the nail bed and had a &frac14; inch beard and long uneven mustache. He stated he was last shaved last week and needed to be shaved again and needed his fingernails clipped. He stated CNA C was supposed to shave his face as soon as she got some free time. He stated getting bed baths as he preferred three times weekly but did not get shaved on a regular basis. He stated he had some hair clippers in the closet and said if he could get someone here to cut his hair would be nice, maybe CNA C could do it. He stated he felt better after being shaved, haircut and nails clipped. He stated the staff told him they would groom him when they could get to him and said he felt they always put him off. He stated he spoke to the SW about needing to be groomed and she said okay she would see about it and added his family member cut his hair about three weeks ago.<BR/>Observation and interview of Resident #16 on 10/05/23 at 9:15 am, Resident #16's hair was 2 inches long and his nails were &frac12; long from his nail bed and four of the nails were broken, he stated he was not sure when his fingernails had last been clipped. <BR/>Record review of Resident #16's Shower Sheets revealed he was showered on 09/20/23, 09/22/23 and bed bath on 09/25/23, 09/27/23, 09/29/23, 10/02/23 and 10/04/23. <BR/>C) Record review of Resident #71's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old male who admitted [DATE] with a BIMS score of 07 (severe cognitive deficit), did not resist care, with diagnoses hypertension, Alzheimer's Disease (cognitive impairment), Cerebrovascular Accident (stroke), muscle wasting, muscle weakness, lack of coordination .Personal hygiene/oral care: the resident requires extensive (x1) staff participation by CNA. <BR/>Record review of Resident #71's Care Plan on 10/05/23 revealed terminal prognosis (work cooperatively with the hospice team to ensure the resident's .physical needs are met by LVN .ADL self-care performance deficit related to Alzheimer's). Personal/oral care: the resident requires extensive (x1) person staff participation by CNA. <BR/>Observation and interview on 10/03/23 at 11:50 am, Resident #71 hair was 2 inches long and uneven and his nails were &frac12; inch long from the nail bed and he said he would like to get them clipped. <BR/>Observation and interview on 10/04/23 at 9:20 am, Resident #71 hair was not combed and appeared uneven, and his nails were approximately &frac12; inch long from the nail bed. He stated he needed his nails clipped and if someone would give him some nail clippers he would clip them himself. He stated his family member cut his hair and was not sure when it was last cut. <BR/>Record review of Resident #71's Shower Sheet revealed he was showered by his hospice aide on 09/22/23, 09/25/23, 09/27/23, 09/29/23, 10/02/23 and 10/04/23. <BR/>Interview on 10/04/23 at 9:25 am, LVN A stated after the residents showered their nails were cleaned and clipped if needed and said the nurses and CNA's were responsible for the resident's ADL Care. She stated Resident #71's nails did appear to be long. She stated the residents' hair should be washed every shower and said she told the CNA's to please remember to shave and wash their hair and clip their nails. She stated they used shower sheets to reflect what care was provided to the residents. She stated if a resident's nails were not clipped on a regular basis the resident could be a danger to themselves by tearing off and scratching their skin or by having physical contact with another resident. She stated unclipped nails was a source for germs to accumulate, increasing infection. She explained to Resident #71 that he would not be able to clip his own nails and told him she would get his CNA to clip them. <BR/>Interview 10/04/23 at 4:40 pm, CNA B stated Resident #71 was showered on a regular basis and assigned to care for him recently and said she sometimes noticed he was not shaved, and his nails were long. She stated a week ago she noticed his nails were long and she reported it to his hospice nurse and thought they had been clipped but was not for sure if that had been done. She stated she never saw a beautician doing the resident's hair since she worked here nine months ago. She stated every time a resident showered there were supposed to get shaved, and if they noticed the resident's nails were long she clipped them unless the resident was a diabetic then the nurse would clip them. She stated if the resident's nails were not done they could get an infection under their nails from food and nasty stuff under their nails. She stated they could scratch skin and get an infection. She stated if residents were not shaved regularly, they could get an infection on their face. <BR/>Interview 10/04/23 4:51 pm, CNA C stated the last time she saw a beautician here was 5 months ago. She stated on the Resident's shower days their hair was washed, bed linen changed, teeth brushed, and nails were done as needed. She stated she noticed Resident #2's nails were long for a couple of weeks and had not cut his nails because he leaned and was unsteady and had not spoken to anyone about assisting her because she got busy and forgot. She stated residents with long nails could scratch themselves or someone else and dirt could get off in their nails. She stated she provided care to Resident #71 in the past and had not noticed his nails or hair needed to be cut. She stated if they residents hair was not combed the other residents could possibly laugh at them and they could feel embarrassed. She stated she never combed his hair but a month ago she clipped his nails, because he asked her to clip them. She stated the nurses were responsible for ensuring the CNA's did ADL care appropriately. <BR/>Interview on 10/04/23 at 5:09 pm, SW D stated the facility did not have a beautician and had not seen a beautician come in to do the resident's hair since she started working here 3 months ago. She stated she spoke to the Administrator about getting the resident's hair done by a beautician and the Administrator told her the family members did the resident's hair in the beauty shop room. She stated the CNA's, and the Nurses were responsible for ensuring the residents hair was done and if a resident requested to get a perm or other service, she would ask their Responsible party if it was okay and then talk to the BOM to see what funding they had. She stated she was not sure what could happen to a resident if their hair was not done honestly .it could look like they were not being taken care of. She stated she was not sure but thought she would be responsible for arranging the resident's beautician appointments. <BR/>Interview on 10/05/23 at 9:22 am, Transporter/Barber stated she was a licensed barber and at times she cut the residents hair while they currently looked for another beautician because the last one had not been here in a while. She stated she could not remember the last time she saw a beautician at this facility, since working here a year. She stated she did not do perms or curl the resident's hair but cut the male residents hair at times if the request was known. She stated the nursing staff used shower sheets to document the resident's ADL services such shaving, podiatry, skin and nail care. She stated if the resident's ADL's were not done it could affect their self-esteem by lowering it. <BR/>Interview on 10/05/23 at 9:46 am, the BOM stated the current Beautician used to come out monthly and the last time she did the resident's hair was around Memorial Day (May 2023). She stated the female residents did not always get their hair done because it was their choice to get their hair done or not. She stated was not sure who was responsible for ensuring the beautician was scheduled but she made sure the residents had the money in their accounts to get their hair done or asked their family's to pay. She stated basic ADL care should also be done and had spoken to the DON and Administrator about the residents hair not being done and they would say okay they would look into it. <BR/>Interview on 10/05/23 at 10:35 am, SW D stated she noticed yesterday Resident #71's hair looked a little fluffy, it was 2 inches all around his head and scruffy around his face. She stated Resident #71 said he wanted to get his hair cut and it was done this morning. She stated she was responsible for getting the beauty shop list created and beautician scheduled. She stated since working here for the past 3 months she had not contacted the beautician because no one asked to get their hair done. She stated she did not have the beautician's contact information to schedule the resident's hair appointment but would get it from the Administrator. <BR/>Interview on 10/05/23 at 10:35 am, the Administrator stated the residents were showered 3 times weekly and the nursing staff were responsible to ensure their hair was washed, nails checked and shaved. She stated when the resident were showered the CNA's were to provide ADL Care. She stated if a resident was getting hospice services, the caregiver took care of all the resident's ADL care and if they did not, her staff was responsible for cutting the resident's nails and shaving them. She stated she was not sure when the beautician was last out to do the resident's hair, She stated Resident #16 had stubble on his face and she went to the nurse or CNA to address. She stated if the resident's ADL care was not done timely it could make them feel bad or unkept and ungroomed and their nails could get dirty if too long. She stated her expectation for ADL care was for everyone to be well groomed and for ADL care to be ever Q shift and as often as necessary. She stated she saw Resident #71's nails needed to be clipped and stated she would start looking at the residents nails when she made her rounds. <BR/>Interview on 10/05/23 at 11:00 am, the BOM said SW D was responsible for getting the resident seen by beautician. <BR/>Interview on 10/05/23 at 11:48 am, the Administrator stated SW D would be responsible for arranging the beauty shop appointments and getting a list of residents to get their hair done. She stated ADL care fell under nursing services and the DON and ADON was responsible for ensuring the residents ADL care was done. <BR/>Interview on 10/05/23 at 3:04 pm, the ADON stated the charge nurse and herself followed up with the residents and if they were hospice patient's, the nurse or herself contacted hospice if they noticed their ADLs were not being done. She stated they stepped in also to provide their hospice resident's ADL care also. She stated she had not noticed any of the resident's had long nails, facial hair and hair undone and the felt the nursing staff did a good job with the residents ADL care. She stated they had enough staff to care for the resident, but had they not had any request to get her hair done by. She stated Resident #16 had not requested to get ADL care and Resident #2 never requested he needed his nails clipped and Resident #71 they offered to clip his nails and he said no. She stated they had enough staff to care for the residents, but the residents had not requested to get their hair done by the beautician. She stated when the residents were showered or bathed their hair was washed, nails cleaned and clipped, and they were shaved and skin moisturized. She stated if ADL care was not done she was not sure how it could affect the residents then said it could make them feel unkept and not clean.<BR/>Interview on 10/05/23 at 3:23 pm, the Activity Director stated Resident #16 had long nails, but he said he did not want his nails clipped. She stated she noticed Resident #71's fingernails long one day ago (Wednesday 10/04/23). She stated she notice Resident #71's fingernails were long about 2 weeks ago, and he said no to getting them clipped. She stated 2 weeks ago she trimmed Resident #2's fingers nails and was not sure if they were long or not. She stated if the resident's fingernails were long they should be getting their nails and hair done by the CNA's when they get showered and was not sure why the CNA's were not doing the ADL care right. She stated she had not asked nursing why and would try to clip their nails. <BR/>Interview on 10/05/23 at 4:23 pm, the DON stated she was responsible for insuring the residents received adequate ADL Care. She stated ADL Care started with the CNA's and for hospice residents her nursing staff was supposed to notify the hospice provider if ADL care was lacking. She stated the department heads visited the resident's daily to ensure there ADL Care needs were met they. She stated all of the residents were getting appropriate ADL care including Residents #2, #16, #71. <BR/>Record review of the facility's ADL Care undated revealed, Policy Statement: Residents will provide with care, treatment and services as appropriate to maintain and improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

Based on observation, interview and record review the facility failed to store foods in accordance with the professional standards for food service safety in the facility's only kitchen. <BR/>The facility failed to discard items stored in the refrigerator or freezer that were not properly sealed/secured, damaged or past the best use by, consume by or expiration dates.<BR/>The facility failed to discard items stored in the dry storage area that are past the best by, consume by or expiration date.<BR/>The facility failed to label and date stored items in the refrigerator, freezer, or dry storage area<BR/>These failures could place residents at risk for food-borne illness and cross contamination. <BR/>Findings included:<BR/>Observation of walk -In refrigerator on 08/09/22 at 9:47 a.m. revealed the following:<BR/>-Open pack of lunch meat, repackaged in a plastic sandwich bag that was exposed to air. The lunch meat was dated 08/07/22, there was no use by date indicated and the item was placed back in the original box with other packets of lunch meat.<BR/>-Corn repackaged in a medium plastic container with a lid, had a label applied by dietary staff. Date opened reflected 08/02/22, section on label for use by: 3 days was filled in<BR/>-On the 2nd shelf from the door, on the left side, a medium container of pureed food, no label of the item name/description, dated 8/2/22, no use by date listed.<BR/>-Pre-made cheddar ham omelets, opened, in its original box dated 08/02/22. The box reflected to Keep Frozen and there was no use by date listed. The date on the box was unclear if it was the received by or opened date.<BR/>- On the right side of the refrigerator, there was tartar sauce in a plastic container with an open date of 06/24/22 but a use by date was not indicated.<BR/>- Immediately on the left side, on the 2nd shelf, from the top, there were 3 trays with small foam bowls with lids, stacked one on the other. There were adhesive labels on the top tray that reflected 8/9 (today's date) but the label did not identify the item (fruit cocktail or peaches removed from its original container) or a use by date.<BR/>- On the 3rd shelf on the left side, there were 3 metal containers covered with aluminum foil. The 1st medium sized metal container covered in foil reflected the label was dated 08/08/22. The label had been written on the foil in black marker, but it was unclear what it said as well as no use by date written on the covering.<BR/>- The middle container was dated 8/8 in black marker on top of the foil, and the seal was broken. The foil had some tears/holes in it. There was no label of what the food item was and no use by date.<BR/>- Next to that was a medium metal container covered in foil that had brown gravy, dated 08/05/22, and there was no use by date.<BR/>- Chopped Bell Peppers were repackaged in a shallow pan, placed in a large zip top bag. The package reflected a date of 07/26/22 but no use by date was indicated. <BR/>- 1 large metal container of frozen mixed vegetables, covered with foil, dated 08/08/12 no pulled from freezer date or use by date. <BR/>-Ketchup repackaged in a large clear container with no label of the item or dates.<BR/>- Yellow cheese slices repackaged in a large zip top bag with a date of 07/31/22 but no use by date listed<BR/>- Mozzarella cheese slices repackaged in large zip top bag with a date written of 08/04/22 but there was no use by date listed.<BR/>- 5 bread rolls in a bag sealed but no use by date listed or item description.<BR/>-3 heads of cabbage repackaged in a box were wilted and had damaged leaves, no clear use by date written on box but dates listed were 07/05/22 and 7/26/22<BR/>-6 foam cups with lids, on a tray, and the label did not reflect the item name or use by date<BR/>Observation of the dry storage room on 08/09/22 at 10:15 a.m. revealed the following: <BR/>-1 large bag of dry base muffin mix dated 05/20/21 across the front and at the top of the bag was a date of 09/04/19. The white bag was soaked where the oil in the mix has seeped into the bag, there were two small holes in the bag, and the expiration date was 07/10/2020.<BR/>- 1 large bag of basic muffin mix with an oil-soaked bag dated 05/02/22 across the front and 08/09/21 at the top of the bag and an expiration date of 06/10/22<BR/>-1 large bag of basic muffin mix with an oil-soaked bag dated 09/19/21 and an expiration date of 06/10/22<BR/>-1 large bag of basic muffin mix with an oil-soaked bag dated 03/11/21 and an expiration date of 11/03/21<BR/>-1 large bag of chocolate frosting mix dated 10/25/21 with an expiration date of 08/12/22<BR/>-1 opened bag of plain potato chips, folded over. The bag was not closed securely, and no dates were listed.<BR/>-1 large dented can of carrots. <BR/>On 08/09/22 at 10:52 a.m., Interview with [NAME] A, he stated an opened item was supposed to be discarded no more than 3 days later. [NAME] A stated when a food item was placed in a reusable container a label with item description, open date and use by date was placed on the container. He said, To calibrate a thermometer put in ice bath, should read 0 degrees Fahrenheit or stick in boiling water and should read 220 degrees Fahrenheit.<BR/>On 08/09/22 at 10:55 a.m. Interview with the Dietary Manager, she said, Yes, 3 days for holding items in the fridge (then discard).<BR/>The Dietary Manger stated she expected staff to put the full date on the packages when receiving and opening. She said, That is what I do. I put the full date. She stated there should be two dates on packages, packets and repackaged items; when it was received and when opened. She stated she goes by the expiration date or best buy date on the container/package to know when to discard the item.<BR/>Observation of the kitchen on 08/09/22 9:47 a.m. revealed the following: <BR/>-Cook A showed the surveyor where the handwashing sink was located. The sink was currently being blocked by 2 bakers racks. [NAME] A moved the racks. <BR/>-The Surveyor turned on the hot side of the faucet to wash hands and then dried her hands The hot water did not get hot. The water had been turned on before the Surveyor placed soap into her hands, then the water ran a little after drying her hands and still was not hot or warm. <BR/>-The foot pedal on the garbage can was inoperable and the lid had to be lifted manually. There was a medium sized blue material cloth-like object in the trash other than paper towels. <BR/>- Daily job assignment expectations were posted on the wall across from the walk-in fridge but all the spaces from previous dates and not all areas had not been initialed. <BR/>-The Floor in the dishwashing room was dirty. <BR/>-Racks where pans were hanging from were dirty with dust and chipping paint. <BR/>-There was a metal shelf in front of the Dietary Manager's office that had 4 clear plastic bins. 3 bins had lids that had cooking utensils such cooking spoons, spatulas, and whisks. There was one bin without a lid. <BR/>On 08/11/22 at 11:45 a.m., Interview with the Dietary Manger She stated if staff were to touch their clothes or hair, during meal service or prep, they must immediately wash their hands as well as when they return to kitchen. During service this occurred- Dietary Aide B touched his clothes and Dietary Manger asked Dietary Aide B to wash his hands, then told both aides to stand with their hands clasped together in front of them to avoid touching unclean surfaces/items/areas until they need to take carts to the hallways. The Dietary Manger stated all the kitchen staff are direct hires for the facility. The Dietary Manager stated snacks are available all day and at set times of day. The Dietary Manger stated everyone was responsible for labeling.<BR/>On 08/11/22 at 11:57 a. m, Interview with Dietary Aide A said, that we wash our hands to keep down germs, pathogens because those pathogens can spread to the residents. For us younger people, a small cold is nothing but for our population here, it could be really severe.<BR/>On 8/11/22 at 12:45 p.m. Interview with [NAME] A, he stated he steps in when the Dietary Manager is not in. [NAME] A states that the sanitizing solution and towels are changed out every 2 hours. He stated they have a separate area for the dented cans, right outside the dry storage room door. he said, we send the cans back to the distributor.<BR/>Review of the Facility's Nutrition Services Food Receiving and Storage Policy and Procedure, Version 1.3 (H5MAPL0335), effective October 2017, it reflected that Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. The policy reflected that Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. Dry Storage: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in-first out system. Refrigerator/Freezer: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 11.Wrappers of frozen foods must stay intact until thawing. 14. D. Beverages must be dated when opened and discarder after twenty-four (24) hours. E. Other opened containers must be dated and sealed or covered during storage. References: OBRA Regulatory References Numbers: 483.60(i) Food safety requirements. Survey Tag Numbers: F812. Other References U.S. Food and Drug Administration Food Code http://www.fda.gov/Food?GuideanceRegulations/RetailFoodProtection/FoodCode/.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, on each resident that are- complete; accurately documented; readily accessible; and, systematically organized for 1 of 3 residents (Resident #1).<BR/>The facility failed to maintain medical records for Resident #1's progress notes from his mental health visit on 8/18/23 that were complete and accurate until 10/05/23. <BR/>This failure could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a residents' stay. <BR/>Findings included:<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (kidney failure), schizophrenia (psychological disorder), post-traumatic stress disorder, and Hypertension (high blood pressure). He had a BIMS of 08 (mild cognitive impairment). Resident #1 required limited to extensive assistance with ADLs. <BR/>Record review of Resident #1's Physician Order dated 05/26/23. It read psych services to evaluate and treat PRN (as needed) an order for Aripiprazole 5mg 1 tablet by mouth at bedtime related to schizoaffective disorder, and Amitriptyline HCl 25mg 1 tablet at bedtime related to post-traumatic-stress disorder. <BR/>Record review of Resident #1's MAR dated 10/01/23 revealed she received psychotropic medications on 5 out of 5 days reviewed. <BR/>Record review of Resident #1's MAR dated 09/01/23 revealed she received psychotropic medications on 28 out of 30 days reviewed. <BR/>Record review of Resident #1's MAR dated 08/01/23 revealed she received psychotropic medications on 30 out of 30 days reviewed. <BR/>Record review of Resident #1's care plans dated 06/13/23 revealed a psychotropic medication (aripiprazole) care plan with an intervention of consult with pharmacy, MD to consider dosage reduction when clinically appropriate; monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications. <BR/>Record review of Resident #1's care plan dated 6/13/23 revealed a psychotropic medication (amitriptyline) care plan with an intervention of monitor/document/report to MD prn ongoing s/sx (signs and symptoms) of depression.<BR/>Record review of Resident #1's progress notes from 05/26/23 to 10/05/23 revealed there was no MD or psych services provided to Resident to include medication and or behavioral management review was provided. <BR/>Interview on 10/05/23 at 12:16pm with LVN E revealed that Resident #1's psychotropic medications are evaluated by the psych doctor, but she was unsure if the Resident was seen in the facility or outpatient. She stated if he went outpatient then the after-visit notes should be uploaded to the EMR under the miscellaneous section and there should be a progress note from the date the resident left and returned to the facility. Residents return from appointments with an after-visit summary and if was not brought back with the residents than the facility could miss new orders or future appointment that were scheduled. She stated the DON and Medical Records are the ones who are responsible to make sure the notes are in the chart. <BR/>Interview on 10/05/23 at 2:01pm with Medical Records revealed there should be an after-visit summary uploaded to the EMR after the residents return from outpatient appointments. He stated there was no pending documents needing uploading for Resident #1 and he requested last after visit summary from outpatient facility to be faxed on 10/05/23. <BR/>Interview on 10/05/23 at 2:33pm with the ADON revealed that Resident #1 received psych services and medication management outside of facility. She stated that the notes for this visit should be under the miscellaneous tab on the EMR. She stated if the residents came back from appointments without the after visit summary, then the facility would reach out to the outpatient clinic to request the information. The person who would do this would be DON, ADON or Medical Records. She stated if this was not done than it meant there must be no changes to their medications or treatment plan . <BR/> Interview on 10/05/23 at 3:13pm with Medical Records revealed he received the outpatient after visit summary via fax dated 8/18/23 and stated it was not in the EMR. This could cause the residents to miss getting the proper care due to missing information or follow up. He also stated that it should be in the EMR under the miscellaneous tab. He stated he is responsible to upload the documents and the DON or ADON is responsible to make sure the after-visit summary is reviewed for changes to plan of care and to make sure it was not missing. <BR/>Record review of Resident #1's Mental Health Outpatient Note dated 8/18/23 revealed Resident was seen by an outside provider, note revealed Resident #1 as not appropriate to attend future appointments without a caregiver and Facilities management of psychotropic medications was unclear. <BR/>Interview on 10/05/23 at 4:23pm with the DON revealed Resident #1 had been seen by an outpatient psych services provider. She stated they did not have the notes in the EMR because it was difficult to get them from the social workers at the outpatient facility. She stated her expectation is that the Medical Records and nurse managers make sure the notes were received after appointments because it could lead to residents not getting the appropriate care and changes to medications and lead to adverse effects. <BR/>Request for accuracy or medical records policy from Administrator and DON on 10/05/23 at 4:40pm revealed the facility did not have one.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services. <BR/>The facility failed to ensure Medication Cart #1 was locked when unattended.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>In an observation and interview on 05/15/24 at 9:39 AM, Medication Cart #1 was observed unlocked an unattended in an open, unlocked office in the memory care unit. Two residents and housekeeping staff were observed walking near the open office. Charge Nurse A was in the hallway and walked into the office. Charge Nurse A stated she was the one responsible for the unlocked and unattended medication cart. She stated she did not know she left it unlocked, and Charge Nurse A proceeded to lock the medication cart. Charge Nurse A stated the medication cart should have been locked and the risk was a resident could have gotten into the medication on the cart. <BR/>In an interview on 05/16/24 at 2:37 PM, DON B stated all staff were trained on locked medication carts and knew medication carts should not be unlocked when unattended. She stated the risk of the unlocked medication cart was someone taking the medications from the medication cart. <BR/>In an interview on 05/16/24 at 3:16 PM, Administrator C stated the medication cart should not be unlocked and unattended. Administrator C stated the risk of the unlocked medication cart was the memory care residents could wonder to the medication cart and take medication that could be harmful. <BR/>Record review of the facility's policy dated 09/18, titled, Medication Administration General Guidelines, reflected the following:<BR/>Policy<BR/>17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications when unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #15 and #162) of eight residents reviewed for infection control.<BR/>MA B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #15 and #162.<BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Review on 08/10/22 of Resident #15's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including elevated blood pressure, lack of adequate blood supply to brain cells, and constriction of the airway and difficulty in breathing.<BR/>Review of Resident #15's MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate impairment, his functional status indicated he needed setup help only with his ADLs. <BR/>Review of Resident #162's MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction, paralysis of the left side of the body, elevated blood pressure, and overactive bladder. <BR/>Review of Resident #162's care plan, dated 08/09/22, revealed she was care planned for risk for COVID-19 infection related to probable exposure. Resident#162 was not on isolation. <BR/>Observation on 08/10/22 at 8:15 AM revealed MA B performing morning medication pass, during which time she checked the blood pressures on Resident #15. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #15.<BR/>Observation on 08/10/22 at 8:25 AM revealed MA B performing morning medication pass, during which time she checked the blood pressures on Resident #162. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #162.<BR/>Interview on 08/10/22 at 8:30 PM, MA B stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use in order to prevent transmitting an infection from one resident to another. She stated if she forgot to wipe the cuff it was because of the presence of the surveyor made her more nervous.<BR/>Interview on 08/11/22 at 11:43 AM with the ADON she stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another.<BR/>Review of facility's Policies and Practices - Infection Control, revised October 2018, reflected the following: . f. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services. <BR/>The facility failed to ensure Medication Cart #1 was locked when unattended.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>In an observation and interview on 05/15/24 at 9:39 AM, Medication Cart #1 was observed unlocked an unattended in an open, unlocked office in the memory care unit. Two residents and housekeeping staff were observed walking near the open office. Charge Nurse A was in the hallway and walked into the office. Charge Nurse A stated she was the one responsible for the unlocked and unattended medication cart. She stated she did not know she left it unlocked, and Charge Nurse A proceeded to lock the medication cart. Charge Nurse A stated the medication cart should have been locked and the risk was a resident could have gotten into the medication on the cart. <BR/>In an interview on 05/16/24 at 2:37 PM, DON B stated all staff were trained on locked medication carts and knew medication carts should not be unlocked when unattended. She stated the risk of the unlocked medication cart was someone taking the medications from the medication cart. <BR/>In an interview on 05/16/24 at 3:16 PM, Administrator C stated the medication cart should not be unlocked and unattended. Administrator C stated the risk of the unlocked medication cart was the memory care residents could wonder to the medication cart and take medication that could be harmful. <BR/>Record review of the facility's policy dated 09/18, titled, Medication Administration General Guidelines, reflected the following:<BR/>Policy<BR/>17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications when unlocked.

Based on observation and interview the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Nurse medication cart) of 2 medication carts reviewed for pharmacy services. <BR/>LVN D did not report 1 damaged blister pack of Resident #61's Tramadol 50 mg tablet (controlled medication).<BR/>This failure could place resident at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.<BR/>Findings Included:<BR/>An observation on 08/10/2022 at 12:15 PM of the Nurse Cart Hall 200 revealed the blister pack for Resident #61's Tramadol 50 mg (pain reliver) had 1 blister seal broken and the pill was still inside the broken blister and taped over.<BR/>In an interview on 08/10/22 at 12:20 PM LVN D stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She said the risk of a damaged blister was a potential for drug diversion. She said the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She said the count was done at shift change and the count was correct. She said she did not see the broken blister during the count. At this time the count was compared to the blister pack and the count was correct.<BR/>Interview on 08/11/22 at 11:43 AM with the ADON, she stated if a blister pack medication seal was broken the pill should be discarded. The ADON said it would not be acceptable to keep a pill in a blister pack that was opened. The ADON said the risk would be losing the medication because the seal was broken. She said nurses were responsible for checking the medication blister packs for broken seals.<BR/>Review of facility's Storage of medications, revised November 2020, reflected the following: . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review the facility failed to store foods in accordance with the professional standards for food service safety in the facility's only kitchen. <BR/>The facility failed to discard items stored in the refrigerator or freezer that were not properly sealed/secured, damaged or past the best use by, consume by or expiration dates.<BR/>The facility failed to discard items stored in the dry storage area that are past the best by, consume by or expiration date.<BR/>The facility failed to label and date stored items in the refrigerator, freezer, or dry storage area<BR/>These failures could place residents at risk for food-borne illness and cross contamination. <BR/>Findings included:<BR/>Observation of walk -In refrigerator on 08/09/22 at 9:47 a.m. revealed the following:<BR/>-Open pack of lunch meat, repackaged in a plastic sandwich bag that was exposed to air. The lunch meat was dated 08/07/22, there was no use by date indicated and the item was placed back in the original box with other packets of lunch meat.<BR/>-Corn repackaged in a medium plastic container with a lid, had a label applied by dietary staff. Date opened reflected 08/02/22, section on label for use by: 3 days was filled in<BR/>-On the 2nd shelf from the door, on the left side, a medium container of pureed food, no label of the item name/description, dated 8/2/22, no use by date listed.<BR/>-Pre-made cheddar ham omelets, opened, in its original box dated 08/02/22. The box reflected to Keep Frozen and there was no use by date listed. The date on the box was unclear if it was the received by or opened date.<BR/>- On the right side of the refrigerator, there was tartar sauce in a plastic container with an open date of 06/24/22 but a use by date was not indicated.<BR/>- Immediately on the left side, on the 2nd shelf, from the top, there were 3 trays with small foam bowls with lids, stacked one on the other. There were adhesive labels on the top tray that reflected 8/9 (today's date) but the label did not identify the item (fruit cocktail or peaches removed from its original container) or a use by date.<BR/>- On the 3rd shelf on the left side, there were 3 metal containers covered with aluminum foil. The 1st medium sized metal container covered in foil reflected the label was dated 08/08/22. The label had been written on the foil in black marker, but it was unclear what it said as well as no use by date written on the covering.<BR/>- The middle container was dated 8/8 in black marker on top of the foil, and the seal was broken. The foil had some tears/holes in it. There was no label of what the food item was and no use by date.<BR/>- Next to that was a medium metal container covered in foil that had brown gravy, dated 08/05/22, and there was no use by date.<BR/>- Chopped Bell Peppers were repackaged in a shallow pan, placed in a large zip top bag. The package reflected a date of 07/26/22 but no use by date was indicated. <BR/>- 1 large metal container of frozen mixed vegetables, covered with foil, dated 08/08/12 no pulled from freezer date or use by date. <BR/>-Ketchup repackaged in a large clear container with no label of the item or dates.<BR/>- Yellow cheese slices repackaged in a large zip top bag with a date of 07/31/22 but no use by date listed<BR/>- Mozzarella cheese slices repackaged in large zip top bag with a date written of 08/04/22 but there was no use by date listed.<BR/>- 5 bread rolls in a bag sealed but no use by date listed or item description.<BR/>-3 heads of cabbage repackaged in a box were wilted and had damaged leaves, no clear use by date written on box but dates listed were 07/05/22 and 7/26/22<BR/>-6 foam cups with lids, on a tray, and the label did not reflect the item name or use by date<BR/>Observation of the dry storage room on 08/09/22 at 10:15 a.m. revealed the following: <BR/>-1 large bag of dry base muffin mix dated 05/20/21 across the front and at the top of the bag was a date of 09/04/19. The white bag was soaked where the oil in the mix has seeped into the bag, there were two small holes in the bag, and the expiration date was 07/10/2020.<BR/>- 1 large bag of basic muffin mix with an oil-soaked bag dated 05/02/22 across the front and 08/09/21 at the top of the bag and an expiration date of 06/10/22<BR/>-1 large bag of basic muffin mix with an oil-soaked bag dated 09/19/21 and an expiration date of 06/10/22<BR/>-1 large bag of basic muffin mix with an oil-soaked bag dated 03/11/21 and an expiration date of 11/03/21<BR/>-1 large bag of chocolate frosting mix dated 10/25/21 with an expiration date of 08/12/22<BR/>-1 opened bag of plain potato chips, folded over. The bag was not closed securely, and no dates were listed.<BR/>-1 large dented can of carrots. <BR/>On 08/09/22 at 10:52 a.m., Interview with [NAME] A, he stated an opened item was supposed to be discarded no more than 3 days later. [NAME] A stated when a food item was placed in a reusable container a label with item description, open date and use by date was placed on the container. He said, To calibrate a thermometer put in ice bath, should read 0 degrees Fahrenheit or stick in boiling water and should read 220 degrees Fahrenheit.<BR/>On 08/09/22 at 10:55 a.m. Interview with the Dietary Manager, she said, Yes, 3 days for holding items in the fridge (then discard).<BR/>The Dietary Manger stated she expected staff to put the full date on the packages when receiving and opening. She said, That is what I do. I put the full date. She stated there should be two dates on packages, packets and repackaged items; when it was received and when opened. She stated she goes by the expiration date or best buy date on the container/package to know when to discard the item.<BR/>Observation of the kitchen on 08/09/22 9:47 a.m. revealed the following: <BR/>-Cook A showed the surveyor where the handwashing sink was located. The sink was currently being blocked by 2 bakers racks. [NAME] A moved the racks. <BR/>-The Surveyor turned on the hot side of the faucet to wash hands and then dried her hands The hot water did not get hot. The water had been turned on before the Surveyor placed soap into her hands, then the water ran a little after drying her hands and still was not hot or warm. <BR/>-The foot pedal on the garbage can was inoperable and the lid had to be lifted manually. There was a medium sized blue material cloth-like object in the trash other than paper towels. <BR/>- Daily job assignment expectations were posted on the wall across from the walk-in fridge but all the spaces from previous dates and not all areas had not been initialed. <BR/>-The Floor in the dishwashing room was dirty. <BR/>-Racks where pans were hanging from were dirty with dust and chipping paint. <BR/>-There was a metal shelf in front of the Dietary Manager's office that had 4 clear plastic bins. 3 bins had lids that had cooking utensils such cooking spoons, spatulas, and whisks. There was one bin without a lid. <BR/>On 08/11/22 at 11:45 a.m., Interview with the Dietary Manger She stated if staff were to touch their clothes or hair, during meal service or prep, they must immediately wash their hands as well as when they return to kitchen. During service this occurred- Dietary Aide B touched his clothes and Dietary Manger asked Dietary Aide B to wash his hands, then told both aides to stand with their hands clasped together in front of them to avoid touching unclean surfaces/items/areas until they need to take carts to the hallways. The Dietary Manger stated all the kitchen staff are direct hires for the facility. The Dietary Manager stated snacks are available all day and at set times of day. The Dietary Manger stated everyone was responsible for labeling.<BR/>On 08/11/22 at 11:57 a. m, Interview with Dietary Aide A said, that we wash our hands to keep down germs, pathogens because those pathogens can spread to the residents. For us younger people, a small cold is nothing but for our population here, it could be really severe.<BR/>On 8/11/22 at 12:45 p.m. Interview with [NAME] A, he stated he steps in when the Dietary Manager is not in. [NAME] A states that the sanitizing solution and towels are changed out every 2 hours. He stated they have a separate area for the dented cans, right outside the dry storage room door. he said, we send the cans back to the distributor.<BR/>Review of the Facility's Nutrition Services Food Receiving and Storage Policy and Procedure, Version 1.3 (H5MAPL0335), effective October 2017, it reflected that Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. The policy reflected that Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. Dry Storage: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in-first out system. Refrigerator/Freezer: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 11.Wrappers of frozen foods must stay intact until thawing. 14. D. Beverages must be dated when opened and discarder after twenty-four (24) hours. E. Other opened containers must be dated and sealed or covered during storage. References: OBRA Regulatory References Numbers: 483.60(i) Food safety requirements. Survey Tag Numbers: F812. Other References U.S. Food and Drug Administration Food Code http://www.fda.gov/Food?GuideanceRegulations/RetailFoodProtection/FoodCode/.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services. <BR/>The facility failed to ensure Medication Cart #1 was locked when unattended.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>In an observation and interview on 05/15/24 at 9:39 AM, Medication Cart #1 was observed unlocked an unattended in an open, unlocked office in the memory care unit. Two residents and housekeeping staff were observed walking near the open office. Charge Nurse A was in the hallway and walked into the office. Charge Nurse A stated she was the one responsible for the unlocked and unattended medication cart. She stated she did not know she left it unlocked, and Charge Nurse A proceeded to lock the medication cart. Charge Nurse A stated the medication cart should have been locked and the risk was a resident could have gotten into the medication on the cart. <BR/>In an interview on 05/16/24 at 2:37 PM, DON B stated all staff were trained on locked medication carts and knew medication carts should not be unlocked when unattended. She stated the risk of the unlocked medication cart was someone taking the medications from the medication cart. <BR/>In an interview on 05/16/24 at 3:16 PM, Administrator C stated the medication cart should not be unlocked and unattended. Administrator C stated the risk of the unlocked medication cart was the memory care residents could wonder to the medication cart and take medication that could be harmful. <BR/>Record review of the facility's policy dated 09/18, titled, Medication Administration General Guidelines, reflected the following:<BR/>Policy<BR/>17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications when unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #15 and #162) of eight residents reviewed for infection control.<BR/>MA B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #15 and #162.<BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Review on 08/10/22 of Resident #15's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including elevated blood pressure, lack of adequate blood supply to brain cells, and constriction of the airway and difficulty in breathing.<BR/>Review of Resident #15's MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate impairment, his functional status indicated he needed setup help only with his ADLs. <BR/>Review of Resident #162's MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction, paralysis of the left side of the body, elevated blood pressure, and overactive bladder. <BR/>Review of Resident #162's care plan, dated 08/09/22, revealed she was care planned for risk for COVID-19 infection related to probable exposure. Resident#162 was not on isolation. <BR/>Observation on 08/10/22 at 8:15 AM revealed MA B performing morning medication pass, during which time she checked the blood pressures on Resident #15. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #15.<BR/>Observation on 08/10/22 at 8:25 AM revealed MA B performing morning medication pass, during which time she checked the blood pressures on Resident #162. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #162.<BR/>Interview on 08/10/22 at 8:30 PM, MA B stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use in order to prevent transmitting an infection from one resident to another. She stated if she forgot to wipe the cuff it was because of the presence of the surveyor made her more nervous.<BR/>Interview on 08/11/22 at 11:43 AM with the ADON she stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another.<BR/>Review of facility's Policies and Practices - Infection Control, revised October 2018, reflected the following: . f. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.