**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to follow its policy and procedure for activities of daily living (ADL) to provide care and services for residents who are unable to carry out ADLs independently for one of four sampled residents. This failure has the potential to put clinically compromised resident (Resident 1) health and safety at risk when Resident 1 ' s request for a diaper change was approximately delayed for 3 hours. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that hemiplegia ( is a condition that causes paralysis or weakness on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated February 5, 2025, indicated, Resident 1 ' s score was a 11, which indicated Resident 1 had moderate cognitive (ability to think, learn, remember and make decisions) impairment. During a review of the Minimum Data Set (MDS) section GG-Functional Abilities (focuses on a resident ' s functional abilities and goals, specifically assessing self-care and mobility performance to capture the level of assistance needed), dated February 5, 2025, indicates Resident 1 scored a 1 in toileting hygiene, reflecting complete dependence and inability to maintain personal hygiene independently. During an interview with Resident 1 on March 18, 2025, at 9:35 AM, Resident 1 stated on one occasion, she had requested a diaper change with her assigned certified nursing assistant (CNA 1), to which CNA 1 responded that she only perform diaper changes once per shift. During a telephone interview with CNA 1 on March 18, 2025, at 11:16 AM, CNA 1 stated she changed Resident ' s 1 diaper around 5:00 PM and again at around 10 PM during her shift, when Resident 1 asked for another diaper change, CNA 1 stated she did not fulfill Resident 1 ' s request because it was already 11:00 PM and her shift had ended. During a telephone interview on March 18, 2025, at 12:09 PM, with the certified nursing assistant (CNA 2) assigned to Resident 1 following CNA 1 ' s shift. CNA 2 stated she did not see who the outgoing CNA (CNA 1) was, who worked the 3:00 PM to 11:00 PM shift. CNA 2 stated she remembers changing Resident 1 ' s diaper twice during her shift, once at around 2:00 AM and again at around 5:00 AM. During a review of Resident 1 ' s care plan, initiated on June 4, 2024, it was noted that Resident 1 has a care plan addressing bowel incontinence related to immobility, as well as a separate care plan for bladder incontinence also related to impaired mobility. Both care plans include interventions to provide peri-care (refers to cleaning and maintenance of the genital and anal areas) following episodes of incontinence. During a concurrent interview and record review on March 18, 2025, at 12:16 PM, with the Director of Nursing (DON), the DON was informed about CNA 1 not changing the diaper of Resident 1 and failing to communicate this to CNA 2, as a result, Resident 1 ' s request for diaper change was delayed for approximately three hours. The DON stated it should have been communicated properly and that she would investigate the matter. During a review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated April 2018, the P&P indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, . The DON acknowledged that this policy was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to ensure that a Minimum Data Set (MDS- a computerized assessment instrument) Discharge Assessment was completed and transmitted in accordance with federal guidelines for one of three residents (Resident 53) reviewed for residents assessment. This failure resulted in Resident 53's assessment not completed upon discharge on [DATE]. Findings: During a review of Resident 53's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 53 was admitted to the facility on [DATE], with diagnoses which included hyperlipidemia (an abnormally high concentration of fats or lipids in the blood) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent interview and record review, on August 9, 2024, at 9:15 AM, with the License Vocational Nurse/Minimum Data Set Nurse (LVN/MDS Nurse), the LVN/MDS Nurse reviewed Resident 53's clinical record dated March 28, 2024, indicated Resident was discharged home with home health services . Further review of Resident 53's MDS assessment, indicated last assessment was MDS admission Assessment completed on February 15, 2024. The LVN/MDS nurse, confirmed no other MDS assessments had been completed since February 15, 2024. The LVN/MDS nurse stated he missed completing the discharged assessment for Resident 53 and it should have been completed on March 28, 2024. During an interview on August 9, 2024, at 9:25 AM with the Director of Nurses (DON), the DON stated the discharge assessment should have been completed on March 28, 2024. (The assessment was neither completed nor transmitted, and 133 days had passed since Resident 53's discharge date ). During a concurrent interview and record review on August 9, 2024, at 9:40 AM with DON, The DON reviewed the facility Policy and Procedure titled Resident Assessment, revised March 2022, which indicated, . A comprehensive assessment of every, resident's needs is made at intervals designated by OBRA[Omnibus Budget Reconciliation Act] and PPS [Prospective Payment System] requirements. Policy Interpretation and Implementation. Definitions OBRA-Required Assessments - are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes . 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. required assessments - conducted for all residents in the facility: . (7) Discharge Assessment (return anticipated and return not anticipated) . The DON stated that the facility did not follow the policy. During a review of CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) revised October 2023, it indicated, . OBRA -Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. These assessments are coded on the MDS 3.0 in items A0310A (Federal OBRA Reason for Assessment) and A0310F (Entry/discharge reporting). They include: Tracking records o Entry o Death in facility Assessments o admission (comprehensive) o Quarterly o Annual (comprehensive) o SCSA (comprehensive) o SCPA (comprehensive) o SCQA o Discharge (return not anticipated or return anticipated) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of 55 sampled residents (Resident 58) when tube feeding (process where food is delivered into the stomach by a machine) was not administered based on physician order. This failure had the potential to result in decline in function and unplanned weight change to Resident 58. Findings: A review of Resident 58's admission Record, (contains demographic and medical information), indicated Resident 58 was initially admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disruption of blood supply to the brain), aphasia (difficulty in talking), dysphagia (difficulty in swallowing), and debility (physical weakness). During an observation on August 6, 2024, at 9:45 AM, Resident 58 was laying in his bed. He was not able to answer questions and he appeared frail. His tube feeding was not connected and the machine was off. There was no tube feeding bag hanging next to the machine. During a concurrent interview and record review on August 6, 2024, at 10:00AM with Licensed Vocational Nurse/Minimum Data Set (LVN/MDS), LVN/MDS stated that the tube feeding was stopped at 9:40AM. During a review of Resident 58's physician orders, dated August 2, 2024, Physician order indicated, Osmolite 1.5 (therapeutic nutrition that provides complete, balanced nutrition for tube feeding for patients) at 60ml (milliliters - unit of measure) / hr (hour) x (times) 20 hours via enteral pump (a machine that delivers food to the stomach) .Turn on @ [at] 2:00PM, turn off @10:00 AM or until dose is consumed . During a concurrent observation and interview on August 6, 2024, at 10:30AM in Resident 58's room, LVN/MDS stated he discarded the tube feeding bottle in the trash can. The tube feeding bottle was labeled with Resident 58's name, room number, August 5, 2024 (date the formula bottle had been hung) and time 0900 [9:00AM] (date and time the feeding was started) and the rate of the administration which was 60 mls an hour (60 ml/hr - rate of nutrition administration via enteral pump). LVN/MDS stated that he was not able to calculate how much in total the resident received during his last feeding. During an interview on August 6, 2024, at 11:45AM with the Director of Nurses (DON), DON stated that the resident's tube feeding should be on for 20 hours from 2:00PM through 10:00AM at a rate of 60ml/hr. She stated that the tube feeding bottle was last hung on August 5, 2024 at 9:00AM and resident received 60ml from 9am to 10am. DON further stated that the enteral bottle would have 940 ml left when the feeding was scheduled to be turned on at 2:00PM. DON stated that a new bag should have been hung on August 6, 2024, at 6:00AM until 10:00am so that the resident could get the total 1200ml that is ordered by the physician. She stated that the resident did not get the required dose as ordered by the physician. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), RD stated if the tube feeding is not running, they are not getting their nutrition and residents on tube feeding are more prone to losing weight. During a review of Resident 58's Nutrition Assessment, dated August 6, 2024, the nutrition summary indicated that the resident has malnutrition r/t (related to) dysphagia secondary to dementia (decreased ability to think), severe muscle wasting, severe fat loss, BMI 19, and G-tube dependent. During a review of Resident 58's Care Plan (a plan that provide directions on thre type of care an individual needs), dated August 6, 2024, the care plan indicated, Resident 58 has the potential for nutritional problem r/t (related to) tube feeding, dysphagia, unspecified protein-calorie malnutrition. During a review of Resident 58's Nutrition Assessment, dated August 6, 2024, the nutrition assessment indicated Resident 58 had a recent weight of 131 pounds and a current BMI (body mass index - weight and height measurement) of 19.3. Resident 58's goal weight range is 160-170 pounds. During a review of Resident 58's Speech Therapy Evaluation and Plan of Treatment, dated August 1, 2024 through August 28, 2024, the Speech Therapy Evaluation and Plan of Treatment indicated, Resident 58's risk factor . without skilled therapeutic intervention, the patient is at risk for weight loss and malnutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have nursing staff with appropriate competencies and skills set to provide nursing services to Resident 58 when he only received 940 ml (milliliters - unit of measure) of tube feeding (supply of food delivered via tube to the stomach) but should have received 1200 ml (millimeters) of medically prescribed enteral tube feeding formula as ordered by his physician on August 6, 2024. This failure had the potential to result in altered nutrition status for one of 55 medically compromised residents. Findings: A review of Resident 58's admission Record, (contains demographic and medical information), indicated Resident 58 was initially admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disruption of blood supply to the brain), aphasia (difficulty in talking), and dysphagia (difficulty in swallowing). During a concurrent interview and record review on August 6, 2024, at 10:00AM with Licensed Vocational Nurse/Minimum Data Set (LVN/MDS), LVN/MDS reviewed the electronic medical record and verified that the tube feeding order as Osmolite 1.5 (therapeutic nutrition that provides complete, balanced nutrition tube-feeding for patients) @ 60 ml / hr (hour) x (times) 20 hours via enteral pump (infusion pump used for continuous tube feedings). Turn on @2:00PM, turn off at 10:00AM or until dose is consumed. May hold feedings during ADL care, showers, and transfers. LVN/MDS stated that the tube feeding was stopped at 9:40AM. During a concurrent observation and interview on August 6, 2024, at 10:30AM in Resident 58's room, with LVN/MDS stated he discarded the tube feeding bottle in the trash can. The 1000 ml tube feeding bottle was labeled with the resident's name, room number, August 5, 2024 (date the formula bottle had been hung) and time 0900 [9:00AM] (date and time the feeding was started) and the rate of the administration which was 60 mls an hour (60 ml/hr - rate of nutrition administration via enteral pump). During an interview on August 6, 2024, at 10:35AM with LVN/MDS, LVN/MDS stated that he determined the feeding was complete when he had heard the enteral pump alarm go off. LVN/MDS further stated that he was not able to calculate how much in total the resident received, because he did know how much was infused during the prior shift. During an interview on August 6, 2024, at 11:45AM with the Director of Nurses (DON), the DON stated that the tube feeding bottle was last hung on August 5, 2024 at 9:00AM and resident received 60ml and it was turned off at 10:00AM. The DON further stated that the enteral bottle would have 940 ml left when the feeding was scheduled to be turned back on at 2:00PM. The DON stated that a new bag should have been hung on August 6, 2024, at 6:00AM and that the resident did not get the required dose as ordered by the physician. She [ DON] stated she would have to conduct an investigation to determine why the tube feeding was stopped overnight and why a new bag was not hung at 6:00 AM. The DON stated the LVN/MDS should be able to calculate how much feeding was provided on the shift prior. During a concurrent interview and record review on August 7, 2024 at 12:00PM with the DON, the Licensed Vocational Nurses Competency Evaluation and Performance Satisfactory Completion, Gastric Tube Medication Administration competency was reviewed. The DON stated there is no competency for licensed nursing staff on how to determine how much feeding was administered on the shift prior based on physician orders. During an interview on August 8, 2024 at 2:15PM with the Registered Dietitian (RD), the RD stated the licensed nurses should always give the full dose of the tube feeding. The RD further stated the licensed nurses are responsible for knowing when to change the bottle and how to calculate how much was given per shift. During a review of Resident 58's physician's orders, dated August 2, 2024, the physician's order indicated, Osmolite 1.5 @ [at] 60ml / hr x 20 hours via enteral pump (a machine that delivers food to the stomach) .Turn on @2:00PM, turn off @10:00A or until dose is consumed . During a review of the facility's policy and procedure titled, Alliance Pharmacy Pharmaceutical Services Policy and Procedure Manual, titled Enteral Tube Medication Administration dated November 2020, the P&P indicated, c. Inservice training on .monitoring of enteral solutions and medications via the enteral tube shall be provided by the facility to nursing personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure medication for one of seven sampled residents (Resident 42) observed for medication administration, was administered according to the physician's orders, when Resident 42 received Omeprazole [medication prescribe to minimize the acid reflex] after breakfast, on August 7, 2024. This failure has the potential to cause less effective management of Resident 42's condition, as the medication may not work as intended when taken after meal. Findings: During a record Review of Resident 42's admission Record (contains demographic and medical information) the admission record indicated, Resident 42 was admitted to the facility on [DATE], with the diagnosis which included hepatic encephalopathy (a condition that affects the brain and occurs when the liver isn't working properly), morbid (severe) obesity due to excess calories (the person has an extremely high amount of bodyfat), and phantom limb syndrome with pain (a condition where a person who has had a limb amputated still feels sensation in the missing limb). A medication administration observation for Resident 42 by a License Vocational Nurse 2 (LVN 2) was conducted on August 7, 2024, at 8:20 AM, in Resident 42's room, LVN 2 administered Omeprazole DR [Delayed release, is designed to release medication slowly overtime, used to control acid reflex] 20 mg (mg - milligrams unit of measurement). Resident 42 stated, she already had her breakfast. During a review of Resident 42's physician's orders, dated June 3, 2024, at 2:12 PM the physician's orders indicated, Omeprazole Cap [capsule] Delayed Release 20 mg. Give 1 capsule by mouth in the morning for Gastroesophageal Reflux Disease (GERD - When the stomach acid irritates the food pipe lining). During a follow up interview on August 7, 2024, at 8:42 AM with LVN 2, LVN 2 stated Resident 42 received Omeprazole after breakfast, despite the physician's order to administer it before breakfast. During a concurrent interview and record review on August 8, 2024, at 9:57 AM, with the Director of Nurses (DON), the DON reviewed Resident 42's physician's orders, dated June 3, 2024, and indicated Omeprazole Cap Delayed Release 20 mg cap, to administer 1 cap by mouth in the morning for GERD give before breakfast. The DON stated, Omeprazole should have been given before breakfast. The DON further stated that it would not have the same effect if given after breakfast. During a concurrent interview and record review on August 8, 2024, at 9:59 AM, with the DON, the facility's policy and procedure titled, Pharmaceutical Services Policy and Procedure Manual indicated, Administration .J. Medications shall be administered in accordance with written orders of the attending physician. The DON stated, the nurse should have followed the policy, but she did not.

Based on observation, interview and record review, the facility failed to store medications under proper temperature control, as specified by the manufacturer when two vaccine solutions were found inside the medication cart (used to transport medication between patients' rooms), instead of the refrigerator. This failure had the potential to increase the risk of residents receiving vaccine medications with decreased efficacy. Findings: During a concurrent observation and interview on August 6, 2024, at 12:10 PM, while inspecting the 30's hall medication cart with Licensed Vocational Nurse 1 (LVN 1) 1 unopened vial of Covid Spikevax 23-24 (an updated COVID-19 vaccine for the 2023-2024 year), was stored inside the medication cart, the vial was labeled Do not freeze. Keep Medicine in Refrigerator. In addition, 1 unopened syringe of medication Afluria Quad 2023-2024 (a flu vaccine for the 2023-2024 flu season), labeled Refrigerator, was stored inside the medication cart. LVN 1 stated the vaccines had been in the medication cart since the start of his shift at 7:00 AM. Furthermore, LVN 1 stated that both vaccines should not have been in the medication cart and should had been stored in the refrigerator. During an interview on August 6, 2024, at 1:10 PM, with the Director of Nurses (DON), the DON acknowledge the two vaccines were inside the medication cart. The DON further stated the two vaccines should had been stored in the refrigerator. During an interview and concurrent record review with the DON, on August 9, 2024, at 10:11 AM, the DON reviewed the facility's policy and procedure titled, Storage of Medication, effective date November 2020, which indicated, Policy Statement. Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . K. Medications requiring refrigeration or temperatures between 2°C (36°F) and 8°C (46°F) shall be kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place shall be refrigerated unless otherwise directed on the label . The DON stated, the facility did not follow the policy. Manufacture product information quick guide for Spikevax (COVID-19 Vaccine, mRNA) by Moderna 2023-2024 Formula, dated September 2023, indicated, . Store Refrigerated (up to 30 days, until expiration date) 36°F to 46°F (2°C to 8°C) Thawed vials and syringes can be handled in room light conditions . CDC Dosage, Administration, and Storage of Influenza Vaccines, indicated, Storage of Influenza Vaccines In all instances, approved manufacturer packaging information should be consulted for authoritative guidance concerning storage of all influenza vaccines. Vaccines should be protected from light and stored at recommended temperatures. In general, influenza vaccines should be refrigerated between 2° to 8° C (36° to 46° F) and should not be frozen; vaccine that has frozen should be discarded .

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs when the regular diet (no modifications) meatloaf was not served to 26 residents who are on a medically prescribed mechanical soft diet (designed for people who have trouble chewing and swallowing) instead of meatloaf that is mashable and topped with gravy. This failure had the result to increase the risks of choking and aspiration (process when swallowing food enters the lungs) for 26 out of 52 highly vulnerable residents. Findings: During an observation in the kitchen on August 5, 2024, at 11:46 AM, the [NAME] (Cook) prepared a plate for a resident on a mechanical soft diet. She served the resident the regular diet meatloaf. During a review of the facility document titled, Cooks Spreadsheet - Summer Menus, [undated], indicated that mechanical soft diet meatloaf should be served mashable & moist with gravy. During an interview on August 5, 2024, at 3:37 PM with the Dietetic Services Supervisor (DSS), DSS stated the cook should follow the menu. During an interview on August 8, 2024, at with the Registered Dietitian (RD), the RD stated that the cook should serve the meatloaf with gravy to prevent aspiration and should follow the menu. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2000, the P&P indicated: #4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician Orders, to the extent medically possible.

Based on observation, interview and record review, the facility failed to follow the menu on Monday August 5, 2024, for lunch for 45 residents when: 1. The cook served 1/2 cup of mashed potatoes instead of 1/3 cup as indicated on the menu for the CCHO (carbohydrate controlled- diet involves eating the same number of carbohydrates every day, and the purpose is to help people manage their blood sugar levels) diets. 2. Facility did not have a way to ensure 4 oz (ounce - unit of measure) of meat was served for residents on the CCHO and regular diets, for lunch on August 5, 2024, as indicated on the menu. These failures have the potential for 45 of 52 highly vulnerable residents to have altered nutrition intake and weight loss. Findings: 1. During an observation of the kitchen's meal preparation and tray line (process where the cook serves food on plates for each resident) for lunch on August 5, 2024, at 11:45 AM with the Dietetic Services Supervisor (DSS) and [NAME] (Cook), [NAME] served residents on a CCHO diet, mashed potatoes using a #8 scoop (4 oz). During a review of the Cooks Spreadsheet, [undated], the lunch menu indicated the following serving sizes, Herb Mashed Potatoes for the CCHO diet, #12 scoop (3.25 oz). During an interview on August 5, 2024, at 3:37 PM with the Dietetic Services Supervisor (DSS), DSS stated the cook should follow the menu. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated that the staff should always follow the menu. 2. During an observation of the kitchen's meal preparation and tray line for lunch on August 5, 2024, at 11:45 AM, with the DSS and Cook, after the cook plated a meal for a resident on a regular diet, the surveyor asked to validate the weight of the portion of meatloaf. DSS stated he could not verify the weight of the meatloaf served because they did not have an ounce scale. During an interview on August 5, 2024, at 3:37 PM with the Dietetic Services Supervisor (DSS), DSS stated the cook should follow the menu. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated that the staff should always follow the menu. RD further stated that the expectation is that the menu is followed to ensure that the portion size is correct and a scale is needed to ensure portion size is correct. During a record review of the facility document titled, Cooks Spreadsheet the lunch menu indicated the meatloaf portion size for the regular diet as 4 oz. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2000, the P&P indicated: #4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician Orders, to the extent medically possible.

Based on observation, interview and record review, the facility failed to ensure food was stored/prepared under sanitary conditions when: 1. Shelf under coffee maker had crumbs and dust and this had the potential to attract pests and for microorganism (bacteria) growth. 2. Floor under shelves in the dry storage had a build-up of food crumbs, white crumbs under one shelf and a liquid spill which can attract pests and cause microorganism growth. 3. Old food and dust under the fridges stored in the staff lounge and this had the potential to attract pests and microorganism growth. 4. Ice machine had some black and yellow discoloration in the area where ice is formed which can potentially contaminate the ice. These failures had the potential to contaminate resident's food and cause food illness to 52 out of 52 vulnerable residents who receive food from the kitchen. Findings: 1. During an observation on August 5, 2024, at 9:40 AM in the kitchen, there was crumbs and dust in the bottom shelf where the coffee maker is stored. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated the expectation is for everything to be tidy and there should be no crumbs or dust. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 2. During an observation on August 5, 2024, at 9:50 AM in the dry storage room, there was a build-up of food crumbs on the floor around the wheels of the metal shelves. There were white crumbs under one side of the shelves on the floor and a liquid spill present. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated the floors should be kept clean. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 3. During a concurrent observation and interview on August 5, 2024, at 3:31 PM with Dietetic Services Supervisor (DSS) in the break room, there was dust and old food underneath the refrigerator and freezer. The DSS acknowledged the presence of dust and old food underneath the refrigerator and freezer. DSS stated that housekeeping is responsible for cleaning around the refrigerator and freezer in the breakroom. During an interview on August 8, 2024, at 2:15PM with the RD, the RD stated the area underneath the refrigerator and freezer should be kept clean, up to the same standards that they have in the main kitchen. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 4. During a concurrent observation and interview on August 5, 2024, at 3:42 PM with Maintenance (MTN), in the presence of DSS, the area of the ice machine where the ice is formed was noted to have some black and yellow buildup. MTN acknowledges that there is black and yellow buildup in the ice machine. During an interview on August 8, 2024, at 2:15P with the RD, the RD stated that the ice machine is expected to be clean and free of any discoloration. During a review of Blueair Installation and User's Manual, dated 2022, indicated Depending on the installation condition, the machine may need more frequent cleaning and sanitizing. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, the P&P indicated, The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacture recommendations . During a review of the FDA Federal Food Code, dated 2022, 4-602.11 indicated, (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. In addition, ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a representative (ensures residents wishes are respected) was in place for two of three sampled residents (Resident 1 and Resident 2). Resident 1 and Resident 2 had impaired decision making abilities and did not have a representative in place to give consent for medical decisions. This failure resulted in two clinically compromised residents making medical decisions in which resident 1 and resident 2 were unable to understand or comprehend based on their History and Physical. Findings: An abbreviated survey was conducted on October 23, 2023, at 3:55 PM, to investigate a complaint related to Resident Rights. 1.A review of Resident 1's, face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included: schizoaffective disorder (affects your thoughts, mood, and behavior), bipolar disorder (feelings of extreme happiness and sadness), psychosis (not in touch with reality), depression, and anxiety, A review of Resident 1's, History and Physical (physicians' exam) dated August 26, 2023, indicated Resident 1 cannot make medical decisions. A review of Resident 1's, Informed Consent for Medical Treatment (permission granted in the knowledge of the possible consequences) dated August 25, 2023, indicated a representative for Resident 1 had not given consent for medical treatment. A further review of the Informed Consent indicated The resident and responsible party hereby consent to the facility providing such routine nursing care as may be directed by said attending physician. Resident 1's Informed Consent for medical treatment was not signed by Resident 1's representative, a facility representative or the attending Physician. A review of the Resident 1's record titled Physicians Orders for Life Sustaining Treatment (POLST- presents a person's wishes for care in the event of incapacity or inability to communicate), dated August 28, 2023, indicated Resident 1 declined to complete the POLST. The POLST was not signed by a representative of Resident 1. 2.A review of Resident 2's face sheet (contains demographic information) indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included: Depression, and Anxiety. A review of Resident 2's History and Physical dated August 3, 2023, indicated Resident 2 cannot make medical decisions. A review of Resident 2's record titled Physician Orders for Life-Sustaining Treatment (POLST), dated August 2, 2023, indicated Resident 2 signed this medical document as a legally recognized decision maker. A responsible party for Resident 2 did not sign this document. A review of Resident 2's Informed Consent to (give a) Psychotropic Drug undated, indicated I have obtained informed consent from the resident and/or responsible party for the use of Olanzapine (medication used to treat schizophrenia). I have obtained informed consent from Resident 2. This document was signed by a staff member. This form did not indicate Resident 2's representative gave consent for this medication. During an observation and concurrent interview of Resident 2 on October 23, 2023, at 4:08 PM, Resident 2 stated, I am supposed to be leaving in November. They (facility staff) are supposed to find me a place. I make all the decisions here. If I can't make my decisions, then I don't know who will make my decisions. During an interview and concurrent record review with the Director of Nursing (DON), on October 23, 2023, at 4:58 PM, DON stated, Resident 1 and Resident 2 do not have a responsible person. I didn't find any notes from the Social Services Director or Interdisciplinary Team about finding a responsible person or informing the ombudsman about Resident 1 and Resident 2 receiving representation. DON stated further, the documentation does not state that the SSD tried to contact anyone regarding a responsible person for Resident 1 and Resident 2. After the DON reviewed resident 1's consents, in which resident 1 either refused to sign or there were no signatures, the DON stated for the ' Consent for Medical Treatment' which was unsigned, the doctor should have signed it and the Ombudsman should have been contacted at the start of Resident 1's stay for representation. The DON then reviewed the H&P for resident 2 and stated, Resident 2, is not supposed to sign or give consent. It is a medical decision. During an interview and concurrent record review on October 23, 2023, at 5:44 PM, the Administrator, stated, To find out if the resident can make decisions we go by the H&P. After reviewing Resident 1 and Resident 2's H&P, the Administrator stated, There should be documentation to indicate we notified the ombudsman and attempted to find representation. They should have had representation. The facility could not provide documentation that indicated they informed the ombudsman or attempted to locate a responsible party or a family member for medical consents for Resident 1 and Resident 2. During a review of the facility's Policy and Procedure titled Informed Consent undated indicated To facilitate the Attending physician informed consent procedure and to meet the requirements of section 772528(a)(b) of Title 22 of the California Code of Regulations, California Health, and Safety Code Section 1418.8 and the State Operations Manual. It is the policy of this Facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic days, physical restraints and medical devices which may lead to the inability to regain use of a body function and prolonged use. Procedure A. The facility informs Attending Physicians of the informed consent process and their responsibilities according to the regulations. B. The Attending Physician determines the capacity of the resident to make decisions and give informed consent on his/her History and Physical. If the resident is determined to not have the capacity to make informed decisions, a surrogate decision maker is identified G. If the resident is not capable of making decisions and there is no surrogate, the Interdisciplinary Team may give consent on behalf of the resident.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a repeated resident to resident altercation, for one of three sampled residents (Resident 2) when Resident 2 had been placed on 1:1 (one-to-one) monitoring (one-to-one monitoring uses continuous staff observation to safeguard patients judged likely to harm themselves or others) and the monitor stepped away from Resident 2 leaving him unattended. This failure had the potential to cause Resident 2 to begin an altercation with another resident. Findings: An unannounced visit was made to the facility on September 19, 2023, at 10:28 AM, to investigate a facility reported incident regarding a resident-to-resident altercation. A review of Resident 2's face sheet (a document that gives a summary of resident information), undated, indicated an admission date of August 25, 2023, with diagnoses that included: psychosis (a mental disorder characterized by a disconnection from reality), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (a mental illness that affects thoughts, mood and behavior), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During an interview with the Administrator (Admin) on September 19, 2023, at 11:03 AM, the Admin stated the incident happened when both Resident 1 and Resident 2 were waiting to go out to the smoking patio. The Admin stated Resident 2 had been speaking in a very loud voice and Resident 1 asked him to be quiet which triggered Resident 2 to assault Resident 1. Staff intervened quickly and neither resident sustained injury. The Admin stated the facility was working on placement in another facility for Resident 2 as his unpredictable and aggressive behavior was escalating towards other residents and staff. The Admin stated Resident 2 had received a psychiatric evaluation and the physician had changed some of Resident 2's medications. The Admin stated Resident 2 would stay on 1:1 monitoring until appropriate placement had been secured. During an observation and interview with a Minimum Data Set Coordinator (MDS Coord) and Resident 2 on September 19, 2023, at 11:58 AM, The MDS Coord walked down the hallway towards the nursing station. The MDS Coord. pointed to Resident 2 and stated, That is [name of Resident 2] walking toward us. Resident 2 was independently and rapidly walking down the hallway. There was no 1:1 monitor following Resident 2. The MDS Coord. stated he did not know where the 1:1 monitor was. Resident 2 stopped walking and came very close and stated very loudly, What questions?! What questions?! My psychiatrist told me I don't have to answer any questions! Resident 2 was asked if he was doing OK. Resident 2 turned away and continued walking down the hallway and shouted, No! No! No! Resident 2 was followed, and Resident 2 ended up at the front office and spoke briefly with an Activities Director (AD) and then turned and walked back down the hallway unmonitored. During an interview with the Activities Director (AD) and MDS Coord on September 19, 2023, at 12:06 PM, The AD stated she had been assigned the 1:1 monitoring duty for Resident 2. The AD stated she understood she needed to always maintain a line of sight on Resident 2. The AD stated she had passed off the duty to a Director of Staff Development (DSD) so she could come to the front office and make popcorn. The MDS Coord stated neither the AD nor DSD had been with Resident 2 when Resident 2 was observed walking down the hallway. During an interview with the DSD on September 19, 2023, at 12:16 PM, The DSD stated the AD had not passed off the 1:1 monitoring duty for Resident 2 until she had been questioned about it. The DSD stated he understood that during a 1:1 monitoring one must always remain within a line of sight of the resident. During an interview with the Admin and Director of Nursing (DON) on September 19, 2023, at 12:21 PM, The Admin and DON stated during a 1:1 monitoring of a resident a line of sight must be always maintained. The Admin and DON stated the AD had not maintained the line of sight for Resident 2's monitoring. A review of the facility's policy and procedure titled, 1:1 SUPERVISION/ SITTERS, undated, indicated, PURPOSE: 1. To assist residents who need additional supervision . POLICY: . Sitters must agree to comply with the facility sitter 1:1 supervision policy approved by the facility. 2. Sitters Responsibilities: . 4. Accompanying the resident to the bathroom if the resident is able to ambulate independently. 5. Notifying facility's staff of any resident's needs. D. The sitter will notify the facility staff when taking a break or when the sitter will be away from the resident during his/ her work shift. G. Sitter(s) must report to nurse supervisor/ charge nurse when coming on and going off duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2's care being prolonged and put them at risk for physical and psychosocial harm. Findings: 1.During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: joint replacement surgery, left artificial hip, left artificial knee and morbid obesity. During a review of the clinical record for Resident 1, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated July 3, 2023, indicated, Resident 1's score was a 15, which indicated that there was no mental impairment. In an interview with Resident 1, on August 24, 2023, at 3:41 PM, Resident 1 stated, Call lights. It takes 45 minutes to answer the call lights. I am calling them for basic stuff, like drink refills, urinals, or a message out to the front desk (nurses' station) because they're not answering the call lights. I ' ll call the front desk (nurses' station) because they are not answering the call lights. 2.During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 3 was admitted on [DATE], with diagnoses which includes: rheumatoid arthritis (painful swelling of the joints) and abnormalities of gait. During a review of the clinical record for Resident 2, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated June 29, 2023, indicated, Resident 2's score was a 15, which indicated there was no mental impairment. In an interview with Resident 2 on August 24, 2023, at 4:09 PM, Resident 2 stated, I turn on my call light and it may take a while for them to come in. What they do is when they come into my room they say, I am going to tell the person that is listed as my certified nursing assistant. They then turn off the call light and the cna that is assigned to provide care doesn't come into my room. So, what I do is call again and then by the third call for help. I'm frustrated. I'm calling because I need to be changed or I'm ready for my patient care, fresh water. I try not to call. I call for my medications. From beginning to end, it takes maybe a half an hour. During a record review of the Resident Council Meeting Minutes, dated June 27, 2023, and July 27, the Resident Council Minutes indicated the Residents complained of staff not answering the call lights in a timely manner. The Resident Council Minutes did not indicate the call light complaints were resolved or addressed. During a concurrent interview and record review of the resident council meeting minutes with the Director of Staff Development (DSD) on August 24. 2023, at 4:26 PM, DSD stated, I deal only with the resident council minutes if there are problems with the call lights or resident care. After the DSD reviewed the resident council minutes and searched for in-services related to call lights the DSD stated, There are no in-services for July or June for the call lights. DSD stated further, Call lights should be answered in 5 minutes. Why? To make sure the residents are not in immediate danger, an emergency, or not able to breathe. The facility was unable to provide documentation that stated the resident councils' concerns were addressed. During an interview with the Director of Nursing (DON) on August 24, 2023, at 4:42 PM, DON stated, Call lights. Everyone is to answer the call lights. It should be within 5 minutes. We answer the call lights to prevent falls, prevent any unusual occurrence and to answer their needs. DON was informed of the time residents stated that it takes staff to answer the call lights, 30 to 45 minutes. The DON stated further, That should not be happening because it is our duty to take care of the resident's needs. The facility policy and procedure titled, Answering the Call Light dated October 2010, indicated The purpose of this procedure is to respond to the resident's request and needs. General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .8. Answer the resident's call as soon as possible .

Based on observation, interview, and record review, the facility failed to protect the privacy of personal information for five of five sampled residents (Resident's 40, 6, 42, 10, and 19) when Licensed Vocational Nurse 1 (LVN 1) left the electronic health record (EHR) exposed to public view during medication administration. This failure had the potential to violate Resident 40, 6, 42, 10, and 19's right to privacy and confidentiality of medical information. Findings: During a medication administration observation on June 28, 2023, at 1:18 PM, the computer screen displayed the EHR for Resident 40. LVN 1 walked away from the medication cart, leaving the EHR exposed to public view. During an interview with LVN 1, on June 28, 2023, at 1:25 PM, LVN 1 stated, it's ok to leave the computer screen exposed with the resident's health information as long as it's facing the door to the resident's room. During a second observation on June 28, 2023, at 1:30 PM, LVN 1 walked away from the medication cart and walked into Resident 6's room leaving the EHR exposed to public view. During a third observation on June 28, 2023, at 1:45 PM, LVN 1 walked away from the medication cart leaving the EHR exposed to public view and walked inside Resident 42's room. During a fourth observation on June 28, 2023, at 1:50 PM, LVN 1 walked away from the medication cart and into Resident 10's room leaving the EHR exposed to public view. A resident walked inside the room, moved the medication cart with the EHR exposed. During a fifth observation on June 28, 2023, at 2:05 PM, LVN 1 walked inside Resident 19's room to give his medication, left the EHR unlocked and exposed to public view. During an interview with Director of Staff Development (DSD), on June 29, 2023, at 8:30 AM, DSD stated the computer screen containing the EHR should be locked before walking away, to protect privacy of each resident. During an observation and interview with Licensed Vocational Nurse 2 (LVN 2), on June 28, 2023, at 6:04 PM, LVN 2 stated the medication cart and the computer screen with the resident's health information should be both locked before walking away. During a concurrent interview and record review with the Director of Nursing (DON) on June 29, 2023, at 2:24 PM. The DON reviewed the Medication Pass Guidelines dated March 8, 2023 which indicated .3. Medication Administration .b. Confidentiality of MAR (Medication Administration Record) is protected (e.g., resident names covered, book closed when unattended). DON stated that the laptop screen should be locked before walking away from it. During a record review of the facility policy and procedure titled, Confidentiality of Information and Personal Privacy revised October 2017, indicated, Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy .Policy Interpretation and Implementation: 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessments were completed accurately to reflect the residents' current health status, care, and services for one of eight residents' (Resident 4) reviewed for antibiotic therapy. Findings: A review of Resident 4's face sheet (a document containing resident's basic information and diagnoses) indicated Resident 4 was admitted on [DATE], with diagnoses that included Type 2 diabetes mellitus, (a chronic condition that affects the way the body processes blood sugar), and benign prostatic hyperplasia with lower urinary tract symptoms. (age-associated prostate gland enlargement that can cause urination difficulty with any combination of urinary symptoms). During a review of Resident 4's Minimum Data Set, (MDS), dated [DATE], the MDS indicated Resident 4 was receiving antibiotic therapy for five (5) days. A review of Resident 4's physician's order and interview with Registered Nurse 1 (RN 1) on June 29, 2023, at 3:30 PM was conducted. Resident 4's physician's order, from May 24, 2023, to June 29, 2023, indicated Resident 4 had no order for antibiotic therapy on admission and after MDS assessment. RN 1 verified Resident 4 did not receive any antibiotics since May 24, 2023, admission to the facility. During a concurrent interview and record review of physician's order and MDS assessment, with the Director of Nursing (DON) and Registered Nurse 1 (RN 1), on June 29, 2023, at 3:32 PM, the DON, stated the assessment for Resident 4's MDS was done and signed by the facility's MDS coordinator on May 30, 2023. The RN 1 verified that the MDS assessment under Section N (Medications) indicated Resident 4 was receiving antibiotic therapy for five days was miscoded. RN 1 stated the accuracy of MDS assessment is important to ensure Resident 4 receives the appropriate care and services related to antibiotic use. During an interview and record review with the Director of Nursing (DON), on June 29, 2023, at 3:32 PM, the policy and procedure, titled, Residents Assessments, revised on November 2019, indicated, 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriately resident assessments and reviews 11. All persons who have completed any portion of the MDS Residents Assessment Form must sign the document attesting to the accuracy of such information. The DON stated the MDS section for medications for Resident 4 did not accurately reflect Resident 4's actual medications. The DON stated the facility did not follow their policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- a screening done upon admission into a facility to determine if a resident with serious mental illness and/or intellectual/development disability require nursing facility services and/or specialized services) was completed accurately for one resident reviewed for PASSR (Resident 12). This failure had the potential to delay identification and treatment of Resident 12's mental disorder. Findings: During a concurrent observation and interview with Resident 12, on June 26, 2023, at 8:19 AM, in Resident 12's room, Resident 12 was sitting on the edge of her bed eating breakfast. Resident 12 stated she was a survivor of satanic cult. During a review of Resident 12's Face sheet (contains demographic and medical information), it indicated Resident 12 was admitted to the facility on [DATE], with the diagnoses of schizophrenia (mental disorder in which a person interpret reality abnormally), hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure, and bipolar disorder (mental illness that causes unusual shifts in mood). During a review of Resident 12's, (Hospital Name) Take Home Medication List, dated April 7, 2022, it indicated Resident 12 had an order to receive Caplyta (bipolar I and bipolar II depression medication) oral capsule and Seroquel (antipsychotic medication) tablet upon admission to the facility. During a review of Resident 12's PASRR Level I Screening, dated April 11, 2022, it indicated Resident 12 does not have any mental disorder diagnosis. During a concurrent interview and record review with the Administrator, on June 29, 2023, at 11:25 AM, the Administrator reviewed Resident 12's (Hospital Name) Take Home Medication List, dated April 7, 2022, and PASRR Level I Screening, dated April 11, 2022, and acknowledged the PASRR was not accurately completed. The Administrator stated, the admitting staff who completed the PASRR, did not have clinical knowledge. During an interview and record review, on June 29, 2023, at 11:27 AM, with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Resident Pre-admission Screening (PASRR), undated, was reviewed. The P&P indicated, . 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process .b. if the level I screen indicates that the individual may meet criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The Admin stated the P&P was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when: 1. The central supply medication storage cabinet was found open and unattended on June 26, 2023, at 9:55 AM. 2. The medication storage room was found open and unattended on June 26, 2023, at 10:01 AM and June 27, 2023, at 12:42 PM. 3. The treatment cart #3 was left unlocked and unattended on June 26, 2023, at 11:30 AM. These failures had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 56 residents. Findings: 1. During a concurrent observation and interview, on June 26, 2023, at 9:55 AM, in the Central Supply Room, with the Central Supply Supervisor (CSS), the central supply medication storage cabinet was found open and unattended. The CSS verified the finding and stated it should be not be unlocked and unattended. The CSS further stated she would put a lock on it right away. 2. During a concurrent observation and interview, on June 26, 2023, at 10:01 AM, in front of the Medication Storage Room, with the Infection Preventionist Nurse (IPN), the medication storage room was found open and unattended. The IPN verified the finding and stated the room should be always locked. During a follow-up observation and interview on June 27, 2023, at 12:42 PM, in front of the medication storage room, with the Case Manager (CM), the medication storage room remained open and unattended. The CM verified the findings and stated the room should be locked. 3. During an observation on June 26, 2023, at 11:28 AM, the treatment cart #3 was parked in front of room [ROOM NUMBER]. It was left unlocked and unattended. During an interview on June 26, 2023, at 11:30 AM, with the Treatment Nurse (TN 1), the TN 1 verified she left the treatment cart #3 unlocked and unattended. The TN 1 stated she forgot to lock it. During a concurrent interview and record review, on June 29, 2023, at 9:09 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2007, was reviewed. The P&P indicated, .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals (diverse group of medicines that includes vaccines) shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The DON stated the P&P was not followed. The DON further stated the expectation was for all rooms, cabinets, and carts to be locked.

Based on interview and record review the facility failed to designate a qualified Director of Food Services to provide oversight of the dietary department which includes, implementing menus, purchasing food, training of staff, and ensuring compliance with all state and federal regulations. This failure had the potential to result in a lack of effective oversight in the operations of the dietary department and supervision which could lead to poor quality of services in the dietary department. Findings: During an interview on June 28,2023, at 1:38 PM, the Dietary Services Supervisor (DSS) stated, she is waiting to take her exam to become a Certified Dietary Manager. During a review of facility's document titled FNS (Food and Nutrition Services) JOB DESCRIPTION dated, 2018, indicated, .for QUALIFICATIONS .3. Must meet the qualifications of FNS Director as stated under State & Federal Regulations. During an interview with the Administrator (Admin) on June 29, 2023, at 2:18 PM, the Admin acknowledged that the DSS did not meet one of the state qualifications for a dietary supervisor, she stated she thought that she was qualified because she worked at other health care facilities as a dietary supervisor.

Based on observation, interview, and record review, the facility failed to store and serve food that conserved flavor and appearance when: 1. Five packages of flour tortillas were found dry and had expired 10 days ago. This failure had the potential to cause food-borne illness (stomach issues from expired and contaminated food) and less palatable. Findings: 1.During an observation on June 26, 2023, at 8:35 AM with the Dietary Services Supervisor (DSS) in the dry storage room area on the top shelf five packages of flour tortillas were found dry and had expired 10 days ago. During an interview with the DSS on June 26, 2023, at 8:35 AM, the DSS acknowledged that the flour tortillas were found expired and dry, and they should not be used. During a record review of facility's policy and procedure titled DRY GOODS STORAGE GUIDELINES dated, 2018, indicated Do check expiration dates on boxes of foods to be sure the length of time is correct.

Based on interview, and record review, the facility failed to ensure the antibiotic stewardship program (a program to measure and improve how antibiotics are prescribed by clinicians and used by patients) was implemented in accordance with facility policy when the monitoring of antibiotic usage and resistance data (monitoring the effectiveness of the antibiotics) were not documented for two consecutive months (May and June 2023). This failure had the potential to inaccurately monitor the use of antibiotics for 56 residents. Findings: During a review of the Antibiotic Stewardship binder, undated, was conducted on June 28, 2023, at 3:50 PM, the binder forms Nursing Center Infection Control Summary Report (a monthly report of the infections and the facility's plan to address) and Infection Prevention and Control Surveillance Log (log of infections, the signs/symptoms, organism on culture, treatment and comments) were not filled out for the months of May and June 2023. During a concurrent interview and record review with the Infection Prevention Nurse (IPN) and the Consultant Infection Preventionist (CIP), on June 28, 2023, at 11:30 AM, the IPN reviewed the Antibiotic Stewardship binder and acknowledged the binder was not completed for the months of May and June 2023. The IPN stated she started to fill out the binder but was not sure how to fill out the binder. The CIP stated the facility has an antibiotic stewardship program; however, it has not been implemented recently due to turnover in the IPN position. During further interview and record review with the IPN and the Administrator (Admin), on June 29, 2023, at 8:44 AM, the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated revised December 2016, was reviewed. The P&P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The Admin stated the P&P was not followed.

Based on observation, interview and record review, the facility failed to ensure equipment was maintained in safe operating condition when: One of three refrigerators observed, had condensation (water) dripping from the top of the refrigerator to the bottom area. This failure had the potential for the refrigerator to not function properly to cool the food and/or contamination of the food stored inside the refrigerator which could cause foodborne illnesses to a population of 56 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on June 26, 2023, at 9:05 AM, one of the three refrigerators located inside of the Central Supply room area, had condensation dripping from the top of the refrigerator area to the bottom. The refrigerator was storing boxes of vegetables. An open box of yellow squash under the refrigerator was wet from the dripping water. DSS stated that the refrigerator should be fixed and remove the contaminated vegetables. During an interview on June 29, 2023, at 11:55 AM, with Maintenance Supervisor (MS), acknowledged the dripping water and stated his expectations is to get it fixed. During a review of the FDA Federal Code, dated 2022, 4-501.11 indicated Proper maintenance of equipment to manufacturer specifications helps ensure that will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three (Residents 10, 54, and 64) of five sampled residents received care in accordance with the facility's policy and procedure. 1. For Resident 10 and 64, the facility failed to ensure their blood sugar levels were monitored and documented prior to administering insulin (medication used to lower blood sugar) according to physician's order. 2. For Resident 54, the facility failed to ensure weekly weights monitoring were carried out per physician's order. These failures had the potential to result in harm or death of the resident from medical complications caused by elevated or decreased blood sugar levels and resident harm from complications of nutritional deficiencies. Findings: 1. During a review of Resident 10's Face Sheet (a summary of medical and demographic data) dated June 27, 2023, the Face Sheet indicated, Resident 10's admitting diagnosis on April 17, 2023 included; Type 2 diabetes mellitus with diabetic neuropathy (insulin-dependent diabetes resulting in nerve pain), unspecified protein-calorie malnutrition (chronic lack of protein and calories), muscle wasting and atrophy (weakened and shrinking muscles), hypertensive heart disease (heart disease caused by high blood pressure) with heart failure , morbid (severe) obesity, and chronic kidney disease. During a review of Resident 10's Physician Orders dated April 17, 2023, indicated, 1. Diet order; regular diet, mechanical soft small portions. 2. humulin R (regular, short acting insulin [used to regulate blood sugar level] )100 U/ml (unit per milliliter) - inject QAC (before meals) and QHS (at bedtime) R/T DM (related to diabetes mellitus), per sliding scale: (a variable amount of insulin based on blood sugar levels) 0-150= 0 Units, give orange juice, 151-200=2 Units, 201-250=4 Units, 251-300=6 Units, 301-350=8 Units, 351-400=10 Units, 401-999=12 Units, Notify MD. During a review of Resident 10's Nursing Orders dated April 17, 2023, indicated May have finger stick blood sugar checks prior to insulin administration. During a review of Resident 10's Patient Care Plan: Diabetes Mellitus dated April 18, 2023, the care plan indicated, Goal is to maintain blood sugar <200 mg/dl (milligrams per deciliter) x 90 days. Monitor BS (blood sugar) per Physician's order and Medication/Insulin as ordered. During a review of Resident 10's Medication Administration Record (MAR), dated from April 18, 2023, through June 27, 2023, the MAR indicated, documentation of blood sugar checks and insulin administration were missing for 23 scheduled instances on 20 days as follows: April 18, 2023 at 11:30 AM April 25, 2023 at 11:30 AM May 06, 2023 at 11:30 AM May 12, 2023 at 06:30 AM May 16, 2023 at 06:30 AM May 17, 2023 at 06:30 AM May 18, 2023 at 06:30 AM May 24, 2023 at 11:30 AM May 29, 2023 at 11:30 AM May 30, 2023 at 11:30 AM May 30, 2023 at 09:00 PM June 04, 2023 at 11:30 AM June 06, 2023 at 11:30 AM June 10, 2023 at 11:30 AM June 11, 2023 at 11:30 AM June 11, 2023 at 04:30 PM June 11, 2023 at 09:00 AM June 17, 2023 at 11:30 AM June 18, 2023 at 11:30 AM June 22, 2023 at 06:30 AM June 22, 2023 at 11:30 AM June 24, 2023 at 11:30 AM June 27, 2023 at 11:30 AM During a review of Resident 10's Nursing Notes dated April 18, 2023, through June 27, 2023, indicated, no documentation was found regarding missed blood sugar checks or insulin administration. During a concurrent interview and record review on June 29, 2023, at 10:26 AM, with the Director of Medical Records, (MRD), the MRD reviewed Resident 10's MAR notes from April 18, 2023, through June 27, 2023, and verified that she could find no supporting documentation regarding rationale for the 20 days of missed blood sugars and insulin dose in the chart. During an interview on June 29, 2023, at 11:01 AM, with the Director of Nursing (DON), the DON stated, When this was brought to my attention today, I looked for documentation regarding these missed doses and could not find anything. The DON stated, the expectation is that it's supposed to be done, supposed to be documented. The DON further stated, their policy for sliding scale insulin orders, the blood glucose should be documented, and the dose of insulin should be given as per doctor's orders. The DON stated, that is the standard nursing practice and there is really no excuse, so they will take this as an opportunity to improve. During an interview on June 29, 2023, at 11:03 AM, with Registered Nurse 1 (RN 1), RN 1 reviewed the MAR with missing documentation of blood glucose and insulin and agreed this would be interpreted as not done; it would be an error. She further stated, she could not find any nursing notes, MAR notes, or any other documentation on the rationale for the missing blood sugars. RN 1 further stated, the expectation is that it should be done, and should be on the MAR. RN 1 further clarified, when you prepare to give insulin, it will prompt you for the blood sugar level and it has to be entered on the e-MAR for you to give the insulin. It is possible that maybe it was below 150 and did not require insulin but there is no way to know because it was not charted. RN 1 stated, this is not according to proper procedure, it should be measured and charted every time it is ordered. When asked if the sliding scale is considered an order to do a blood sugar check, RN 1 stated, Yes, the order for insulin includes checking the blood sugar, you cannot give insulin without it. During a review of the facility's policy and procedure (P&P) titled Insulin Administration dated September 2014, the P&P stated: Documentation 1. The residents blood glucose result, as ordered; 2. The dose and concentration of the insulin injection . 2. During an observation on June 26, 2023, at 10:00 AM, in Resident 54's room, Resident 54 was on her back on an air mattress, her eyes were closed. She was on oxygen via nasal canula (a device used to deliver supplemental oxygen). During an interview on June 26, 2023, at 12:13 PM, with the Restorative Nurse Assistant 1 (RNA 1), RNA 1 stated, she checks the weight of the resident according to the dietician's verbal instruction. RNA 1 stated she never document the weight in the electronic record. RNA 1 stated, she documents the weight on a paper, then attach it to the resident's hard chart. During an interview on June 26, 2023, at 12:30 PM, with the Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated, if there is an order for a weekly weight, the RNA will be notified by the dietician and the order will be carried out. LVN 1 further stated she was not aware about the standing order for weekly weight check and the reason why the order was not carried out. A review of Resident 54's face sheet (patient demographics) indicated that Resident 54 was admitted on [DATE], with the diagnoses that included heart disease (a condition affecting the normal functioning of the heart), muscle wasting (weakening and loss of muscle) and atrophy (a condition in thinning of the muscle). During a review of Resident 54's physician's order, dated April 21, 2023, indicated Weight weekly and notify RD. During a review of Resident 54's clinical record, weight was not done and not documented for the following dates: 1. Week of May 8,2023 2. Week of May 15,2023 3. Week of May 22,2023 4. Week of June 5,2023 5. Week of June 12,2023 6. Week of June 19,2023 During a concurrent interview and record review on June 29, 2023, at 10:30 AM, with the Director of Nursing (DON), the physicians order dated April 21, 2023, was reviewed. The DON stated, if the doctor's order was to check weight weekly it should be carried out as ordered. The DON further stated, and she was not aware about the weekly weight order not being followed. During a review of Resident 54's care plan dated April 20,2023, the care plan indicated weigh weekly x 4 weeks and notify RD. During a review of Resident 64's Face Sheet (a summary of medical and demographic data) dated June 27, 2023, the Face Sheet indicated, the Resident 64's admitting diagnoses on May 4, 2023 included; Type 2 diabetes mellitus with ketoacidosis without coma (is when the blood sugar is too high for too long), Type 2 diabetes with diabetic neuropathy (nerve damage cause by poor blood sugar control), pressure ulcer of sacral region, stage 4 (sacral is located in the lower back near the pelvis, stage 4 is a full thickness tissue loss with exposed bone, tendon or muscle). During a review of Resident 64's Physician Orders, dated May 5, 2023, indicated, 1. Diet Order : CCHO, REG [control carbohydrate diet], [REGULAR] thin liquids, May 4, 2023, indicated 2. Insulin Lispro (rapid acting insulin) [used to regulate blood sugar level] (U-100) 100 unit/ ml (unit per milliliter) - inject AC (before meals) and HS (at bedtime) per sliding scale: (a variable amount of insulin based on blood sugar levels) 0-69=0 units, Notify MD, give orange juice, 70-150= 0 units, 151-200=2 units, 201-250 = 4 units, 251-300 = 6 units, 301-300=8 units, 351-400 = 10 units, 401-999 = 12 units, notify MD. 3. Lantu 100 unit/ml (long-acting insulin) [use to regulate blood sugar level] inject 20 units [unit of measure] subcutaneous [under the skin] q HS, [Every night at bedtime] R/T [related to] DM [Diabetes Mellitus] *HOLD IF BS [blood sugar] <70 [less than 70]. During a review of Resident 64's Patient Care Plan: Diabetes Mellitus dated, May 4, 2023, the care plan indicated Problem/Needs At risk for hyperglycemia or hypoglycemia r/t [related to] Diabetes Mellitus Goals: Free from s/s [signs and symptoms] of hypoglycemia or hyperglycemia daily x 90 days. Approaches/Plan Medication/insulin as ordered, Monitor BS [blood sugar] per MD [Medical Doctor] order. During a review of Resident 64's Medication Administration Record, (MAR), dated June 2023, MAR indicated, documentation of blood sugar checks and insulin administration were missing for 11 schedule instances on 10 days as follows: June 4, 2023, at 11:30 AM June 8, 2023, at 9:00 PM June 10, 2023, at 11:30 AM June 11, 2023, at 4:30 PM June 11, 2023, at 9:00 PM June 16, 2023, at 11:30 AM June 17, 2023, at 11:30 AM June 18, 2023, at 4:30 PM June 21, 2023, at 4:30 PM June 24, 2023, at 11:30 AM June 26, 2023, at 11:30 AM During an interview with Registered Nurse (RN 1) on June 28, 2023, at 6:44 PM, RN 1 reviewed the MAR with missing documentation of blood glucose, and stated there was no documentation found in their system. During an interview on June 29, 2023, at 11:03 AM, with Director of Nursing (DON), DON stated that when this was brought to her attention, she looked for the documentation regarding these missed doses and could not find any nurses notes in the records. Her expectation is that it's supposed to be done and documented. The DON further stated, The facility's policy is that for sliding scale insulin orders, the blood glucose should be documented, and the insulin orders should be given per doctor's order. DON stated that she was going to create a QAPI (Quality Assessment Performance Improvement- a plan to correct any possible negative outcomes related to resident's care) to in-service the nurses. During a review of the facility's policy and procedure titled Insulin Administration dated September 2014, the policy and procedure indicated Preparation 4. The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies before given the insulin .Documentation 1. The resident's blood glucose result, as ordered .2. The dose and concentration of the insulin injection. DON acknowledged that their nurses failed to follow the insulin administration policy.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Three oranges and seven onions with mold were found in the kitchen inside of a plastic box. 2. A box of 14 yellow squash was wet and leaking inside of the refrigerator, that was stored in the central supply room. 3. Thirty two ounces (unit of weight) of plain yogurt container found inside the refrigerator expired. 4. The ice machine was found dusty outside and inside with dark black stain seen on both sides of the ice maker tray. 5.A shelf storing clean water pitchers were stored in the Central Supply room, near the laundry room. These failures had the potential to contaminate resident's food and cause food -borne illness to a population 56 medically compromised residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview on June 26, 2023, in the kitchen at 8:06 AM, there were three oranges with mold inside a plastic box inside at the bottom of a stainless steel shelf. Dietary Staff Aid 2 (DA 2) stated the oranges should be thrown away because they have mold. During a concurrent observation and interview on June 26, 2023, at 8:11AM, in the kitchen, there were seven onions with mold found inside a plastic box on the bottom of a stainless shelf. DA 1 stated the onions should be thrown away because they have mold. During an interview on June 27, 2023, at 8:20 AM, Dietary Services Supervisor (DSS), acknowledged the mold and stated, they should be thrown away. During a record of the facility's policy and procedure titled PRODUCE STORAGE GUIDELINES, dated 2018, indicated, May use longer if no signs of spoilage are visible. 2. During an observation on June 26, 2023, at 9:09 AM, in the Central Supply Room Area, there was a box of 14 yellow squash that was wet and leaking inside of the refrigerator. During an interview with the DSS on June 26, 2023, at 9:10 AM, DSS acknowledged the wet yellow squash, and stated the refrigerator should be fixed. During a review of the FDA Federal Food Code 2022, 3-305.11 indicated, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) in clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; Pathogens can contaminate and/ or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. 3. During a concurrent observation and interview on June 26, 2023, at 9:12 AM, with the DSS in the Central Supply Room Area, there was a 32 ounces (2 pounds) plain yogurt container that was expired in Refrigerator 3. The DSS acknowledged that the yogurt was expired and should not be used. During a review of the facility's policy and procedure titled REFRIGERATED STORAGE GUIDE, dated 2019, indicated, .Yogurt .follow expiration date or 7 days after opening, whichever comes first. 4. During an observation on June 26, 2023, at 9:31 AM, the ice machine was found with dry, chalky dust like particles outside and inside with dark black stains seen on both sides of the ice maker tray. During an interview with the Maintenance Supervisor (MS) on June 26, 2023, at 9:42 AM, in the Central Supply room, he acknowledged that the ice machine was found dusty. During a record review of facility document titled Ice Machine Cleaning Log, indicated Frequency of Cleaning: Monthly .PROCEDURE FOR CLEANING STORAGE COMPARTMENT OF ICE MACHINE .1. The ice machine storage compartment will be cleaned monthly .7. The outside of the machine is cleaned weekly or wiped down as need with clean cloth and approved cleaning agent. During a record review of facility document titled, Invoice from [Company Name] dated, September 30, 2022, indicated Last ice Machine Maintenance was performed on September 30, 2022 nine months ago. During a review of the FDA Federal Code, dated 2022, 4-602.11 indicated Ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 5. During an observation on June 26, 2023, at 10:43 AM, a shelf, storing clean water pitchers was stored in the Central Supply Room. During an interview on June 26, 2023, at 10:45AM, with the Housekeeper Supervisor (HKS) stated the pitchers should not be there. During a review of the FDA Federal Food Code 2022, 4-903.11 indicated, (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination;. In addition, Clean equipment and multiuse utensils which have been cleaned and sanitized, laundered linens, and single-service and single-use articles can become contaminated before their intended use in a variety of ways such as through water leakage, pest infestation, or other unsanitary condition. The improper storage of clean and sanitized equipment, utensils, laundered linens, and single-service and single-use articles may allow contamination before their intended use. Contamination can be caused by moisture from absorption, flooding, drippage, or splash. It can also be caused by food debris, toxic materials, litter, dust, and other materials. The contamination is often related to unhygienic employee practices, unacceptable high-risk storage locations, or improper construction of storage facilities

Based on observation, interview, and record review, the facility failed to ensure their infection control practices were implemented in accordance with their policy and procedure when: 1. One of the kitchen sink air gaps (a form of backflow prevention device) had black, brown grime. 2. Two bar guns (a device used to serve types of carbonated drinks and non-cabonated drinks) were found to contain red residual fluid and were not clear. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to 56 medically compromised residents and staff in the facility. Findings: 1. During a concurrent observation and interview on June 27, 2023, at 12:55 PM, with the Dietary Aide (DA 3), the kitchen sink air gap had black, brown grime. The DA 3 verified the air gap and stated it was the Maintenance Supervisor responsibility to clean the air gap. During an interview with the Maintenance Supervisor (MS), on June 29, 2023, at 9:02 AM, the MS acknowledged the air gap and stated it is the responsibility of the kitchen staff to clean the kitchen sink's air gap. During an interview with the Dietary Services Supervisor (DSS) on June 29, 2023, at 10:01 AM, the DSS acknowledged the air gap and stated it is the responsibility of the Maintenance Supervisor to clean the kitchen sink's air gap. During a review of document titled, Weekly Cleaning Schedule, dated May 28, 2023, through June 4, 2023, the weekly cleaning schedule did not indicate the air gap was part of the cleaning schedule. During a concurrent interview and record review with the Administrator (Admin), on June 29, 2023, at 1:45PM, the Admin reviewed the Cal Code Official Inspection Report invoice dated January 11, 2022 and acknowledged the report which indicated, All plumbing and plumbing fixtures shall be installed in compliance with local plumbing ordinances, shall be maintained so as to prevent any contamination, and shall be kept clean, fully operative, and in good repair. The Admin acknowledged the air gap was not clean. 2. During an observation of the kitchen, on June 27, 2023, at 12:55 PM, two bar guns were observed to contain a red residual liquid inside. During a concurrent observation and interview on June 27, 2023, at 12:59 PM, with the DA 3, the bar guns were run with drinkable water and emptied into a basin. The drinkable water appeared pink in color. The DA 3 stated the bar guns are cleaned every night and last maintenance was done about two months ago. The DA 3 further stated he would not drink the water if served to him. During a review of invoice titled, [Company Name], dated December 3, 2022, the invoice indicated, Changed water filter, water is crystal clear, bar guns needs new O rings. During a concurrent interview and record review with the DSs, on June 29, 2023, at 10:15 AM, the DSS reviewed the [Company Name] invoice dated December 3, 2022, and acknowledged the invoice was the most recent. The DSS stated she placed an emergency service request to the company to repair the juice guns. The DSS further acknowledged the juice guns were not running clear in between juice dispensing. During an interview with the DSS, on June 29, 2023, at 10:20 AM, the DSS stated that the company had canceled her emergency service request. The DSS stated she would provide documentation. The documentation requested was not provided by the DSS. During a review of facility's policy and procedure (P&P) titled, Infection Prevention and Control in LTC, undated, the P&P indicated, .Proper environmental service management is essential to resident quality of life and for infection prevention and control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the correct completion of initial PASARR (Preadmission Screening and Resident Review - intended to ensure residents in a nursing home are screened for mental disorders (MD) or intellectual disabilities (ID), and the individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs) evaluations for two of 13 sampled residents (Residents 14 & 2) when: 1) Resident 14's mental illnesses were not included on the resident's initial PASARR evaluation; 2) Resident 2's neurocognitive disorder was not included on the resident's initial PASARR evaluation; This failure had the potential to result in resident harm, as not completing the initial PASARR evaluations correctly risked improper care and/or services being provided for the residents to meet their individual care needs. Findings: 1) During a review of the Face Sheet (contains demographic and medical information) clinical record for Resident 14, dated May 4, 2021, the document indicated Resident 14 was admitted to the facility on [DATE], and had medical diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia (Respiratory Disorder), Bipolar Disorder (Mental Disorder), and Major Depressive Disorder (Mental Disorder). During a concurrent interview and record review on May 4, 2021, at 11:07 AM, with the Director of Nursing (DON), the Preadmission Screening and Resident Review (PASRR) Level I Screening Document for Resident 14, dated July 31, 2020, was reviewed. The document indicated that Resident 14 did not .have a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder (Mental Disorder), Psychotic/Psychosis (Mental Disorder) . Depression (Mental Disorder), Mood Disorder (Mental Disorder), Bipolar (Mental Disorder) . Per review of Resident 14's clinical record, current as of May 4, 2021, the clinical record indicated that Resident 14 was diagnosed with Bipolar Disorder, unspecified as of July 31, 2020, and Major Depressive Disorder, Single Episode, unspecified as of July 31, 2020. The DON reviewed the documentation for Resident 14 and stated the PASARR Level I evaluation was not completed correctly for Resident 14. During a concurrent interview and record review on May 4, 2021, at 11:13 AM, with the DON and Medical Records (MR), they both reviewed Resident 14's clinical record and were unable to locate an updated initial PASSAR Level I evaluation, and stated no other PASSAR evaluations were available for the resident. During an interview on May 4, 2021, at 11:15 AM, with the DON, the DON stated Resident 14 was last admitted to the facility on [DATE]. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, revised March 2019, the P&P indicated, . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD . 2) During a review of the Face Sheet (contains demographic and medical information) clinical record for Resident 2, dated May 4, 2021, the document indicated Resident 2 was admitted to the facility on [DATE], and had medical diagnoses that included, Acute Respiratory Failure with Hypoxia (Respiratory Disorder) and Unspecified Dementia with behavioral disturbance (Brain Disorder). During an interview on May 4, 2021, at 4:12 PM, with the DON, the DON stated Resident 2 was never re-admitted , and his admission date to the facility was October 5, 2020. The DON further stated Resident 2's diagnosis for Unspecified Dementia was included in his clinical record upon his admission to the facility on October 5, 2020. During a concurrent interview and record review on May 4, 2021, at 4:17 PM, with the DON, the Preadmission Screening and Resident Review (PASRR) Level I Screening Document for Resident 2, dated October 5, 2020, was reviewed. The document indicated that Resident 2 did not have . a diagnosis or other evidence of a neurocognitive disorder, e.g., Alzheimer's Disease (Brain Disorder) . other dementias (Brain Disorder) . Per review of Resident 2's clinical record, current as of May 4, 2021, the clinical record indicated that Resident 2 was diagnosed with Unspecified dementia without behavioral disturbance. The DON reviewed the documentation for Resident 2 and stated the initial PASSAR evaluation for Resident 2 should have included his diagnosis for Unspecified Dementia, as the resident had this diagnosis upon his original admission date on October 5, 2020. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, revised March 2019, the P&P indicated, . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two medications for one Resident (Resident 15) had the correct labeling to indicate the route to be given as ordered.This failure had the potential for Resident 15 to receive the wrong route for medication administration, as a result of inaccurate labeling. Findings: During review on Resident 15's clinical record, the face sheet (contains demographic and medical information), indicated Resident 15 was admitted to the facility on [DATE] , with diagnosis that included Chronic Kidney Disease Stage 1 ( Longstanding disease of kidneys leading to renal failure) and Urinary Tract Infection (Infection of the urinary system). During an observation on May 5, 2021, at 8:32 AM, with Licensed Vocational Nurse 1 (LVN 1) while passing medication to Resident 15, two medications indicated: -Gabapentin (Medication for peripheral neuropathy, a disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness) 300 mg (milligrams, a unit of measure) 1 capsule via G-tube (Gastrostomy tube that is inserted into the abdomen and is used to deliver nutrition and/or medication directly to the stomach) twice daily. -Baclofen (Medication for muscle spasm) 20 mg, take 10 mg via G-tube three times daily, are labeled on the bubble pack and in the MAR (Medication Administration Record) to be given via G-tube instead of via per mouth. Per observation, all other medications for the Resident 15 are labeled to be given by mouth. During a concurrent observation and interview on May 5, 2021, at 8:40 AM with LVN 1, LVN 1 stated, Resident's G-tube was removed since last year of 2020 and I will update this medication order in the MAR and in the bubble pack. Per observation, Resident 15 was taking all her medications by mouth being crushed and taken with apple sauce or yogurt. During a concurrent observation and interview on May 5, 2021, at 11:45 AM, with the Director of Nursing (DON), the DON stated that bubble pack of medications should have a new sticker attached and updated with label that says, Directions changed, refer to chart. The DON further stated that the MAR should also be updated with the new medication order. During an interview on May 6, 2021, at 8:26 AM with LVN 2 regarding the process of reconciliation of new or changes in medication, as per MD (Medical Doctor) order. LVN 2 stated, Discontinue the order, write the new MD order in the MAR, print it, and fax it to the pharmacy. LVN 2 further stated that the bubble pack should have a sticker/label indicating, Directions changed, refer to chart. During an interview on May 6, 2021, at 1:12 PM, with LVN 1, LVN 1 stated that if direction for use was changed as per MD order, the MAR should be updated, and the Pharmacy informed. During a record review on May 6, 2021, at 9:15 AM, of the Department Notes, dated August 1, 2020, at 11:30 PM, the Department Notes indicated, Per hospice, orders to convert all GT medication to PO as GT no longer present on patient. Noted, carried out. During a review of the facility's policy and procedure titled, Medication Labels, effective date: November 2020, the policy indicated, Medication shall be labeled in accordance with the facility requirements and state and federal laws .a nurse may place change of order- check chart label on the container indicating there is a change in directions for use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy and procedure review, the facility failed to ensure the necessary services to maintain good grooming, and personal hygiene for four of 13 sampled residents (Resident 34, Resident 11, Resident 7, and Resident 43) when: 1. Resident 34 received four showers in April 2021, 2. Resident 11 received one shower in April 2021, 3. Resident 7's family indicated Resident 7 was not showered and had greasy hair, 4. Resident 43's Shower Day Skin Integrity, and ADL [activities of daily living] Flow Sheet, indicated Resident 43 had a documented shower/tub bath two times in April 2021. These failures resulted in psychosocial harm for Residents 34, 11, 7 and 43. The lack of these necessary services to provide and maintain grooming and personal hygiene had the potential to affect a reasonable individual's dignity and self-worth. Findings: 1. During a review of Resident 34's clinical record the Face Sheet (contains demographic information) the document indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which included, lack of coordination and depressive episodes. During a review of Resident 34's, MDS [Minimum Data Set a computerized assessment tool] under Section G, Functional Status, dated, March 23, 2021, G0120 had a score of 4, which indicated Resident 34 had total dependence on staff for showering. During a review of Resident 34's, MDS, Section C, Cognitive Patterns, Brief Interview for Mental Status [BIMS], Section C0500, the document indicated a score of 15 (intact cognitive response rated from 13-15). During a review of Resident 34's, Shower Day Skin Inspection, the documents indicated Resident 34 had four showers and/or bed baths for the month of April 2021, rather than the twice per week showering/bed baths Resident 34 should have received per facility bathing schedule as follows: a. April 6, 2021, Resident 34 had a shower, b. April 16, 2021, Resident 34 had a bed-bath c. April 23, 2021, Resident 34 had a shower d. April 30, 2021, Resident 34 had a shower. During a review Resident 34's, ADL [Activities of Daily Living] Flow Sheet, dated, April 2021, the ADL Flow Sheet indicated, Resident 34 received a shower and/or bed bath less than the two times per week, per the facility bathing schedule on the following dates only: a. April 6, 2021 Shower b. April 16, 2021 Bed Bath c. April 23, 2021 Shower d. April 30, 2021 Shower The ADL Flow Sheet document indicated Resident 34 received four showers and/or bed baths for the month of April 2021. There was no documented evidence Resident 34 had refused a bath or shower. During an interview on May 3, 2021, at 8:39 AM, with Resident 34, in Resident 34's room, when asked about showering, Resident 34 stated when she first arrived at the facility, No shower, no shower, no shower, it was a couple of weeks. Resident 34 further stated when she asked about the showers, Resident 34 was told she was never put on the shower schedule. During a follow-up interview on May 6, 2021, at 8:36 AM, with Resident 34, when asked when the lack of showering occurred, Resident 34 stated it was in April 2021. When asked how it made her feel when she was not getting her showers, Resident 34 stated, When I wasn't getting my showers, I felt pissed and I felt forgotten. During a concurrent interview and record review on May 6, 2021, at 11:41 AM, with Licensed Vocational Nurse 3 (LVN 3), Resident 34's Shower Day Skin Inspection sheets for April 2021, and ADL Flow Sheet for April 2021, were reviewed. LVN 3 was asked how often residents were supposed to get a shower, LVN 3 stated, Two times a week. When asked what the documents reflected, LVN 3 stated, according to the documents, Resident 34 received a shower on April 6, 2021, April 16, 2021, April 23, 2021, and April 30, 2021, less than the required twice per week schedule. During a concurrent interview and record review on May 6, 2021, at 2:35 PM, with CNA 1 and CNA 2, Resident 34's Shower Day Skin Inspection sheets and ADL Flow Sheet for April 2021, were reviewed. CNA 1 and CNA 2 acknowledged, according to the documentation, Resident 34 received four showers in April, 2021. During a review of the facility's policy and procedure (P & P) titled, Bath, Shower/Tub, revised February 2018, the P & P indicated, Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath 2. During a review of Resident 11's clinical record the, Face Sheet, the document indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included, type 2 diabetes with diabetic neuropathy (A type of nerve damage that can occur with diabetes. Symptoms include pain and numbness in the legs) and muscle wasting and atrophy (a decrease in muscle mass, often due to extended immobility). During a review of Resident 11's, Minimum Data Set under Section G, Functional Status, dated, February 19, 2021, Section G, G0120, indicated Resident 11 had a score of 4 which indicated Resident 11 had total dependence on staff for showering. During a review of Resident 11's, MDS, Section C, Cognitive Patterns, Brief Interview for Mental Status [BIMS], Section C0500, the document indicated a score of 11 (moderate impairment rated from 8-12). During a review of Resident 11's, Shower Day Skin Inspection, dated, April 24, 2021, the document indicated Resident 11 had one shower for the month of April 2021, less than the required twice per week showering schedule established by the facility. During a review of Resident 11's, ADL Flow Sheet, dated, April 2021, the document indicated Resident 11 received one shower for the month of April 2021 on April 24, 2021. During a review Resident 11's, ADL Flow Sheet Additional Notes, (undated), the document indicated Resident 11 received a shower on April 24, 2021, and there was no documented evidence that Resident 11 had refused showers or baths during April 2021. During an interview on May 3, 2021, at 9:02 AM, with Resident 11, in Resident 11's room, when asked about showering, Resident 11 stated he didn't get a shower for 6 weeks, he further stated they [staff] didn't have time for him. Resident 11 stated when he asked for a shower he was told they have other patients and too much work to do. When asked how the staff treated him, Resident 11 stated, It's like I'm really cutting into their time, I'm imposing on them. One of them came in after a half hour and said, 'I have to go to lunch,' it was a day I was supposed to get a shower, I didn't like get a shower. During a follow-up interview on May 6, 2021, at 10:08 AM, with Resident 11, when asked how not receiving showers made him feel, Resident 11 stated, I felt dirty, they [the nurses] would giggle and congregate, and I wouldn't get a shower. I didn't give it much thought, I felt dirty. During a concurrent interview and record review on May 6, 2021, at 11:41 AM, with Licensed Vocational Nurse 3 (LVN 3), Resident 11's Shower Day Skin Inspection sheets for April 2021, and ADL Flow Sheet for April 2021, were reviewed. LVN 3 was asked how often residents were supposed to get a shower, LVN 3 stated, Two times a week. When asked what the documents reflected, LVN 3 stated, according to the documents, reflected Resident 11 only received one shower in April 2021, on April 24, 2021, less than the required twice per week schedule. During a concurrent interview and record review on May 6, 2021, at 2:35 PM, with CNA 1 and CNA 2, Resident 11's Shower Day Skin Inspection, sheets for April 2021, and ADL Flow Sheet, were reviewed. CNA 1 and CNA 2 acknowledged, according to the documentation, Resident 11 received one shower in April 2021. During a review of the facility's policy and procedure (P & P) titled, Bath, Shower/Tub, revised February 2018, the P & P indicated, Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath 3. During a review of the clinical record for Resident 7 the Face Sheet indicated Resident 7 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and a depressive disorder. During a review of Resident 7's, Minimum Data Set, under Section G, Functional Status, dated, April 16, 2021, Section G, G0120, indicated Resident 7 had a score of 4, which indicated Resident 7 had total dependence on staff for showering. During a review of Resident 7's, MDS, Section C, Cognitive Patterns, Brief Interview for Mental Status [BIMS], Section C0500, the document indicated a score of 00 (severe cognitive impairment rated from 0-7). During a review of Resident 7's, Shower Day Skin Inspection, dated, April 2021, the document indicated: a. April 10, 2021, Resident 7 had a shower and a bed bath, b. April 14, 2021, Resident 7 had a bed-bath, c. April 17, 2021, Resident 7 had a shower, d. April 22, 2021, Resident 7 has a shower. The Shower Day Skin Inspection documents indicated Resident 7 had four showers and/or bed baths for the month of April 2021, rather than the twice per week showering and/or bed baths Resident 7 should have received per facility bathing schedule. During a review Resident 7's ADL Flow Sheet dated, April 2021, the document indicated, Resident 7 received three showers and/or bed baths for the month of April 2021, less than the two times per week, per facility bathing schedule as follows: a. April 10, 2021 Shower b. April 17, 2021 Shower c. April 22, 2021 Shower The ADL Flow Sheet document had no documented evidence Resident 7 had refused showers or baths during April 2021. During a resident representative interview on May 4, 2021, at 5:44 PM, with a Family Representative (FM 1) of Resident 7, the FM 1 stated she had concerns regarding Resident 7 not being bathed often enough in the facility, as prior to COVID-19, she would notice Resident 7's hair to be greasy. During a concurrent interview and record review on May 6, 2021, at 11:41 AM, with Licensed Vocational Nurse 3 (LVN 3), Resident 7's Shower Day Skin Inspection sheets for April 2021, and ADL Flow Sheet for April 2021, were reviewed. LVN 3 was asked how often residents were supposed to get a shower, LVN 3 stated, Two times a week. When asked what the documents reflected, LVN 3 stated, according to the documents, reflected Resident 7 received a shower on April 10, 2021, on April 22, 2021, and on May 1, 2021, less than the required twice per week schedule. During a concurrent interview and record review on May 6, 2021, at 2:35 PM, with CNA 1 and CNA 2, Resident 7's Shower Day Skin Inspection sheets for April 2021, and ADL Flow Sheet were reviewed. CNA 1 and CNA 2 acknowledged, according to the documentation, Resident 7 received three, possibly four, showers in April, 2021. During a review of the facility's policy and procedure (P & P) titled, Bath, Shower/Tub, revised February 2018, the P & P indicated, Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath 4. During a review of Resident 43's clinical record the Face Sheet the document indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart is unable to pump blood efficiently to the body) and end stage renal disease (a medical condition in which the persons kidneys are no longer functioning). During a review of Resident 43's, Minimum Data Set under Section G, Functional Status, dated, April 16, 2021, Section G, G0120 indicated Resident 43 had a score of 3, which indicated Resident 43 required some assistance by staff for showering. During a review of Resident 43's, MDS, Section C, Cognitive Patterns, Brief Interview for Mental Status [BIMS], Section C0500, the document indicated a score of 7 (severe cognitive impairment rated 0-7). During a review of Resident 43's Shower Day Skin Inspection for the following dates indicated: a. April 7, 2021, Resident 43 had a shower, b, April 12, 2021, Resident 43 had a shower, c. April 15, 2021, Resident 43 refused a shower and/or bed bath, d. April 29, 2021, Resident 43 refused a shower and/or bed bath. The Shower Day Skin Inspection documents indicated Resident 43 had two showers and/or bed baths for the month of April 2021, and refused two showers and/or bed baths for the month of April 2021, still receiving and being offered less than the twice per week showering/bed baths Resident 43 should have received, per facility bathing schedule. During a review of Resident 43's ADL Flow Sheet dated, April 2021, the document indicated, Resident 43 received two showers and/or bed baths and refused two showers and/or bed baths for the month of April 2021, as follows: a. April 4, 2021 Refused b. April 7, 2021 Shower c. April 12, 2021 Shower d. April 15, 2021 refused During a concurrent interview and record review on May 6, 2021, at 11:41 AM, with Licensed Vocational Nurse 3 (LVN 3), Resident 43's Shower Day Skin Inspection sheets for April 2021, and ADL Flow Sheet for April 2021, were reviewed. LVN 3 was asked how often residents were supposed to get a shower, LVN 3 stated, Two times a week. When asked what the documents reflected, LVN 3 stated, according to the documents, reflected Resident 43 received a shower on April 7, 2021, and April 12, 2021. Resident 43 is noted to have refused his showers on, April 4, 2021, and April 15, 2021, which still reflects showers offered less than the required twice per week schedule. During a concurrent interview and record review on May 6, 2021, at 2:35 PM, with CNA 1 and CNA 2, Resident 43's Shower Day Skin Inspection sheets for April 2021, and ADL Flow Sheet were reviewed. CNA 1 and CNA 2 acknowledged, according to the documentation, Resident 43 received one shower in April 2021, and CNA 1 and CNA 2 acknowledged Resident 43 had some showering refusals for April 2021. During an interview on May 4, 2021, at 9:42 AM, with the Director of Staff Development (DSD), when asked about the prior shower sheets for January, February, and March of 2021, the DSD stated he throws them away after a month and he did not think there was a need to keep the shower sheets beyond a month. During an interview on May 5, 2021, at 8:51 AM, with the DSD and the Director of Nursing (DON), when asked how often residents should be getting showers, the DSD stated twice a week, the DON stated, The nurse is documenting in the nurses notes the refusals. When asked how long the showering records should be kept, the DON stated, The shower records should be kept at least three years. When asked why the shower sheets were thrown away after a month, the DSD stated, I saved them for quite a while, then I decided to shred the shower records monthly. During an interview on May 5, 2021, at 3:40 PM, with CNA 3, when asked about giving baths to the residents, she stated she usually gives the showers and bed baths. When asked if she was able to get to the scheduled showers in a week, CNA 3 stated, Sometimes we don't get to the residents two times in a week. During a review of the facility document titled, Shower Schedule, (undated), the Shower Schedule, indicated: MONDAY AND THURSDAY A BEDS: AM [7 AM TO 3 PM Shift] 22A, 23A, 25A, 26A, 28A, 29A, 32A, 33A, 35A, 36A, 38A, 38A, 39A; PM [3 PM to 11 PM shift] 21A, 24A, 27A, 30A, 31A, 34A, 37A, TUESDAY AND FRIDAY B AND D BEDS: AM 21B, 22B, 23B, 24B, 25D, 27B, 29B, 30B, 32B, 33B, 34B, 35D, 38B, 37B; PM 23D, 24D, 25B, 26B, 31B, 35B, 36B, 37D, 39B WEDNESDAY AND SATURDAY C BEDS: AM 23C, 24C, 25C, 26C, 28B, 28C, 29C, 30C, 32C, 34C; PM 27C, 31C, 33C, 35C, 36C, 37C, 39C, 1.) DO A SHOWER SHEET FOR EACH RESIDENT 2.) ONLY LICENSED NURSE MAY DOCUMENT A REFUSAL 3.) ONLY DSD MAY MAKE CHANGES TO SHOWER SCHEDULE. During a review of the facility's policy and procedure (P & P) titled, Bath, Shower/Tub, revised February 2018, the P & P indicated, Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath

Based on observation, interview, and record review, the facility failed to ensure the dietary needs of the residents were met, when the facility did not serve lunch for the residents in a timely manner for one of four onsite survey dates (May 4, 2021). This failure affected at least 7 out of 43 residents (Residents 1, 17, 3, 24, 114, 4 & 2) with active physician diet orders in the facility on May 4, 2021, which could have amounted to resident discomfort and harm, due to delayed nutrition provision. Findings: During an observation on May 4, 2021, at 12:28 PM, in the facility's kitchen, tray line for facility residents' lunch meals commenced, with dietary staff actively preparing resident lunch trays for distribution. During an observation on May 4, 2021, at 1:03 PM, in the facility's kitchen, tray line for the facility residents (Residents 1, 17, 3, 24, 114, 4 & 2) with pureed texture diet orders commenced, with dietary staff actively preparing these residents' lunch trays for distribution. During a concurrent observation and interview on May 4, 2021, at 1:06 PM, with the Regional Registered Dietician Consultant (RRD) and the Dietary Services Supervisor (DSS), in the facility's kitchen, tray line for all ordered facility residents' lunch meals was completed, with all ordered meal trays having left the kitchen and out to the facility hallways for distribution by staff. The last trays observed to leave the kitchen at this time were the meal trays with the pureed texture diet orders. The RRD and the DSS stated lunch time for the residents was scheduled for 12:15 PM, and 12:45 PM was the latest the residents' meal trays should have been out of the kitchen, and in the facility hallway for distribution to the residents. The RDD and DSS further stated and confirmed that lunch for the residents was late, with no root cause provided from the RRD nor DSS. During a review of the facility's policy and procedure (P&P) titled, Section 5 Meal Service, dated 2018, the P&P indicated, . Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures . 1. Meal times: . Lunch at 12:15 . 6. Meals or nutritional supplements are provided to residents within 45 minutes .

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety, when: 1) The Dietary Services Supervisor (DSS) did not secure the hair on her head underneath a hair restraint while in the facility kitchen; 2) A dietary staff member (Dietary 1) was observed to drop a chunk of margarine on the stove top grate, retrieve it from the stove top grate, and place it into a saucepan containing clean margarine for melting, which was intended for residents (Residents 42, 5, 33, 17, 24, 113, 32, 21, 16, 26, 46, 6, & 48) with Fortified Diet orders on May 4, 2021; 3) Food items were found in cold storage without the appropriate labels and dates, per professional standards of practice. These failures could have collectively resulted in 43 out of 43 residents, with active physician diet orders in the facility, being served food that was prepared and distributed under less than sanitary conditions, and against professional standards of practice. Findings: 1) During an observation on May 3, 2021, at 7:45 AM, within the facility's kitchen during the initial tour, the Dietary Services Supervisor (DSS) was observed with her hair falling out of her head cap, along her hairline and the edges of the head cap. During a concurrent observation and interview on May 3, 2021, at 3:50 PM, with the DSS, the DSS was observed to continue going in and out of the facility kitchen, with her hair continuing to fall out of her head cap and hairnet. The DSS stated she had been trying to keep her hair tucked under her hat, but she would do what she needed to do to correct her hair from falling out of her hat and hairnet from then onward. The DSS further stated the expectation was that her hair be kept securely underneath a hairnet when working in the kitchen. During a review of the facility's policy and procedure (P&P) titled, Food Handling, dated 2018, the P&P indicated, . Food will be prepared and served in a sanitary manner . During a review of the Food Code, U.S Public Health Service, U.S Food & Drug Administration (FDA), 2017, dated 2017, the guidance indicated, Hair Restraints: 2-402.11 Effectiveness. (A) . Food Employees shall wear hair restraints such as hats, hair coverings or nets . that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles . 2) During an observation on May 4, 2021, at 11:42 AM, near the stove within the facility kitchen, a dietary staff member (Dietary 1) prepared a saucepan for melting margarine. As Dietary 1 was observed placing un-melted clean margarine into the saucepan, Dietary 1 dropped a chunk of un-melted clean margarine on the stove top grate, adjacent to the saucepan. Dietary 1 was then observed to retrieve the chunk of un-melted margarine and place it into the saucepan, along with the clean un-melted margarine he was originally preparing for melting. During an interview on May 4, 2021, at 11:43 AM, with Dietary 1, the observation of the dropped margarine was discussed. Dietary 1 stated he thought he put the dropped margarine in the trash, and that he should not have placed the dropped margarine in the saucepan with the clean margarine. Dietary 1 further stated it was not sanitary to place the contaminated margarine in the saucepan with the clean margarine being prepared for melting. During a concurrent observation and interview on May 4, 2021, at 11:48 AM, with the DSS, in the facility kitchen, the observation of Dietary 1 dropping the margarine was discussed. The DSS stated what Dietary 1 did was not the expectation, and Dietary 1 should have discarded the dropped margarine in the trash, and not placed it in the clean saucepan with the clean margarine. The contaminated margarine was discarded and replaced. During an observation on May 4, 2021, at 12:28 PM, in the facility's kitchen, tray line for facility residents' lunch meals commenced, with dietary staff actively preparing resident lunch trays for distribution. Portions of melted margarine, prepared by the dietary staff, was observed to be poured over the vegetable side dish on the residents' meal trays, specifically for residents with Fortified diet orders. During a review of Physician Orders List, dated May 5, 2021, the document included the diet orders for the residents receiving meals from the facility's kitchen. The Physician Orders List indicated the following Residents were on Fortified diets, which would have indicated the use of melted margarine to be applied to their vegetable side dish: - Resident 42, Fortified diet dated April 30, 2021; - Resident 5, Fortified diet dated January 29, 2021; - Resident 33, Fortified diet dated December 9, 2020; - Resident 17, Fortified diet dated March 8, 2021; - Resident 24, Fortified diet dated February 3, 2021; - Resident 113, Fortified diet dated April 30, 2021; - Resident 32, Fortified diet dated May 2, 2021; - Resident 21, Fortified diet dated April 16, 2021; - Resident 16, Fortified diet dated November 6, 2020; - Resident 26, Fortified diet dated March 24, 2021; - Resident 46, Fortified diet dated March 25, 2021; - Resident 6, Fortified diet dated June 5, 2020; - Resident 48, Fortified diet dated April 16, 2021; During a review of the facility's P&P titled, Food Handling, dated 2018, the P&P indicated, . Food will be prepared and served in a sanitary manner . During a review of the facility's P&P titled, Fortified Diet, dated 2020, the P&P indicated, . The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status . Examples of adding calories may include - Extra margarine or butter to food items such as vegetables, potatoes . 3) During a concurrent observation and interview on May 5, 2021, at 6:06 AM, with the DSS, within the facility kitchen at Refrigerator #2, an unlabeled and undated cup of fresh fruit was observed on the shelf, inside the refrigerator. The DSS observed the cup of fresh fruit and stated it should not have been in the refrigerator because it was not labeled and dated. During a concurrent observation and interview on May 5, 2021, at 6:15 AM, with the DSS, within the facility kitchen at Refrigerator #2, the following was found inside the refrigerator: - Chocolate pudding with a labeled preparation date of May 1, 2021, and a use-by date of May 4, 2021; - Tomato soup with a labeled preparation date of May 1, 2021, and a use-by date of May 4, 2021; - Sliced turkey with a labeled preparation date of May 3, 2021, and a use-by date that indicated, use today; The DSS observed and reviewed the food items found, and stated the following: - The chocolate pudding was labeled correctly, and was expired, beyond the use-by date, as it is only good in cold storage for three days; - Per facility policy, the tomato soup was labeled incorrectly, as the tomato soup was good for five days in cold storage, when the soup is from a canned source; - The sliced turkey was still good to use, as thawed meat is good for 3 days in cold storage, so the actual use-by date would have been May 5, 2021; The DSS stated the expectation is that the refrigerator is cleaned-out of expired and beyond-use items first thing in the morning, and it was not done. During an interview on May 5, 2021, at 8:29 AM, with the Regional Registered Dietician Consultant (RRD), the RRD stated the professional standard for labeling use-by dates is to label using calendar dates, as opposed to labeling with terms such as, use today. The RRD further stated the expectation is that foods are labeled and dated, according to when the foods are prepared and when they are to be used by. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2020, the P&P indicated, Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . All prepared foods need to be covered, labeled and dated . Leftovers will be covered, labeled and dated . During a review of the facility's P&P titled, Refrigerated Storage Guide, dated 2019, the P&P indicated the following: - Desserts, prepared, including puddings & cream pies . (Maximum Refrigeration Time): 3 days .

Based on observation, interview, and record review, the facility failed to ensure all kitchen equipment was maintained in safe operating conditions, when an active water leak was observed under the facility kitchen's dishwashing station, and a cloth towel was wrapped around a leaking hose. This failure had the potential for resident harm for 42 out of 42 residents in the facility with active diet orders and receiving food from the facility's kitchen. The active water leak and the cloth towel wrapped around the leaking hose could have promoted microbial growth, potentially exposing the kitchen area to microbial growth contaminants. Findings: During a concurrent observation and interview on May 5, 2021, at 7:40 AM, with the Dietary Services Supervisor (DSS), within the facility kitchen, a water leak was observed coming from underneath the dishwashing station, adjacent to the water lines, drain pipes and in-floor drain. A white cloth towel was also observed to be wrapped around a leaking water hose. The DSS observed the water leak and cloth towel and stated she will contact Maintenance. During a concurrent observation and interview on May 5, 2021, at 7:44 AM, with the Maintenance Director (Maintenance), within the facility kitchen at the dishwashing station, the Maintenance observed the water leak underneath the dishwashing station. The Maintenance stated the leak was coming from one of the connection threads on the water hoses for the sink. The Maintenance removed the towel that was wrapped around the leaking water hose, and stated the towel should not have been there, as it risked the development of mold from the moisture. The Maintenance further stated the hose should not have been leaking and was unsure how long the observed leak had been active. During an interview on May 5, 2021, at 8:00 AM, with the DSS, the DSS stated the Maintenance is responsible for checking the kitchen equipment to assure appropriate operating conditions, including checking for leaks, and assuring air gaps are maintained. The DSS further stated she was not aware of the active water leak observed. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2018, the P&P indicated, . All equipment shall be maintained as necessary and kept in working order . 4. Employees are to alert the FNS (Food & Nutrition Services) Director immediately to any equipment needing repair. 5. The FNS Director . will report any equipment needing repair to the maintenance man .