**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/11/25 at 0911 hours, Resident 1 was observed sitting on her wheelchair in the hallway outside her room. Resident 1 was observed with her right hand shaking. Medical record review for Resident 1 was initiated on 6/11/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's annual H&P examination dated 7/19/24, showed Resident 1's diagnoses included paranoid Schizophrenia, psychosis, dementia, and post status stroke with left side paralysis. Resident 1 had no capacity to understand and make medical decisions. Review of Resident 1's MAR for 6/2025 showed Resident 1 was being administered Abilify 15 mg, with a start date 9/15/21, at bedtime for schizophrenia manifested by episodes of delusional thinking that people were trying to harm her. Further review of the MAR failed to show for non-pharmacological interventions were attempted prior to the administration of the Abilify medication to Resident 1. Review of Resident 1's Psychopharmaceutical Summary Sheet showed Resident 1 had episodes of delusional thinking people were trying to harm her. Review of Resident 1's plan of care revised 6/10/25, showed a care plan problem for Schizophrenia. The interventions included to administer Abilify medication as ordered, document side effects, and monitor for effectiveness. The non-pharmacological interventions included to encourage the resident to express her feelings, provide calm environment, redirect, reassure, and reorient the resident as needed. On 6/12/25 at 1630 hours, an interview was conducted with RN 4. When asked about the non-pharmacological interventions for Resident 1's Abilify medication, RN 4 checked Resident 1's MAR. RN 4 stated the non-pharmacological interventions were documented in the resident's progress notes. RN 4 was not able to find the progress notes related to the non-pharmacological interventions provided for Resident 1's Abilify medication use. On 6/13/25 at 1534 hours, an interview was conducted with the MRD. When asked where in Resident 1's medical record the staff documented the non-pharmacological interventions provided for Resident 1's Abilify medication use, the MRD stated it was documented in the resident's progress notes. When informed the progress notes failed to show the non-pharmacological interventions attempted prior to administering the Abilify medication, the MRD stated she would look for them and would provide them if found. On 06/13/25 at 1630 hours, the DON was informed of and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Residents 42) and one nonsampled resident (Resident 1) reviewed for unnecessary medications were provided with the non-pharmacological interventions for the use of psychotropic medications+. * The facility failed to ensure Resident 42 was provided with non-pharmacological interventions for the use of Remeron (antidepressant) medication. * The facility failed to ensure Resident 1 was provided with non-pharmacological interventions for the use of Abilify (antipsychotic) medication. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medications revised 1/30/25, showed it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. The Policy Explanation and Compliance Guidelines section showed the non-pharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication. Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 1/30/25, showed the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: - The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 1. On 6/10/25 at 0854 hours, Resident 42 was observed sitting in a wheelchair and just came back from physical therapy. Resident 42 stated she felt better and ready to go home. Medical record review for Resident 42 was initiated on 6/10/25. Resident 42 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 42's MDS assessment dated [DATE], showed the resident's cognition was moderately impaired. Review of Resident 42's Psychiatric Evaluation Note dated 5/21/25, showed the resident was diagnosed with MDD. Review of Resident 42's Order Summary Report dated 6/13/25, showed a physician's order dated 4/30/25, for Remeron oral tablet 15 mg (mirtazapine), give one tablet by mouth at bedtime for depression manifested by episodes of verbalization of sadness. Further medical record review for Resident 42 failed to show documented evidence the non-pharmacological interventions were provided for the use of the Remeron medication. On 6/13/25 at 1022 hours, an interview and concurrent medical record review for Resident 42 was conducted with RN 1. RN 1 verified there was no non-pharmacological intervention for Resident 42's use of the Remeron medication. RN 1 further stated the licensed nurse should document the non-pharmacological intervention on the progress notes. On 6/13/25 at 1146 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON acknowledged the above findings. The DON stated Resident 42's psycho-spiritual needs were met. The DON further stated the non-pharmacological interventions for the use of the Remeron medication were provided to Resident 42, however, was not documented. The DON stated the licensed nurse had to assess the resident's behavior and mood before giving the medication and the licensed nurse needed to listen and give emotional support if the resident expressed their feelings. The DON stated the licensed nurse should document the non-pharmacological intervention on the progress note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of one final sampled resident (Residents 608) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Resident 608. In addition, the facility failed to ensure the non-pharmacological interventions for Resident 608's pain was consistently documented prior to the administration of the Norco (narcotic pain medication) and failed to document the complete pain assessment for Resident 608's pain prior to the administration of pain medication as per Resident 608's care plan. These failures had the potential to put Resident 608 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Management revised 1/30/25, showed based upon the (pain) evaluation the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. Non-pharmacologic interventions will include but are not limited to: environmental comfort measures, loosening any constrictive bandage, clothing or device, applying splinting, physical modalities, exercise to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility, or cognitive/behavioral interventions. Pharmacologic interventions will follow a systemic approach for selecting medications and doses to treat pain. The facility staff will reassess the resident's pain management regularly for effectiveness and/or adverse consequences. If reassessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. If the pain has resolved or there is no longer an indication for pain medication the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion. Medical record review for Resident 608 was initiated on 6/9/25. Resident 608 was admitted to the facility on [DATE]. Review of Resident 608's MDS assessment dated [DATE], showed Resident 608 was cognitively intact. Review of Resident 608's Order Summary Report dated 6/11/25, showed the following physician's orders: - dated 5/20/25, for Resident 608's pain evaluation, every shift, - dated 5/20/25, to administer hydrocodone-acetaminophen (narcotic opioid medication) 5-325 mg one tablet by mouth every four hours as needed for severe pain management (pain levels of 7 to 10, on a 0-10 pain scale with 0 = no pain and 10 = worst pain) for 30 days. Do not exceed three grams of acetaminophen per day for all sources, and - dated 5/23/25, to administer morphine sulfate Contin (narcotic opioid medication) extended-release 30 mg, one tablet by mouth every 12 hours for pain management due to breast cancer and metastatic malignant mass. Review of Resident 608's plan of care showed a care plan problem dated 5/21/25, addressing Resident 608's pain related to Resident 608's breast cancer with left mastectomy, metastatic malignant mass on Resident 608's left neck and status-post a laminectomy. The interventions included to administer the analgesia Tylenol, Norco, and morphine sulfate Contin 30 mg as per the physician's orders, to monitor/record the pain characteristics and PRN: quality (e.g. sharp, burning); severity (1 to 10 scale); anatomical location; onset; duration (e.g. continuous, intermittent); aggravating factors; relieving factors; and to provide the non-pharmacological interventions to alleviate pain (Specify: provide warm blanket when cold, provided cool drink when hot, provide extra snack when hungry, provide quiet environment when tired). a. Review of Resident 608's MAR for 5/2025 showed Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for severe pain (pain levels of 7 to 10) on the following dates, times, and pain levels: - on 5/21/25 at 1420 hours, for a pain level of 10. - on 5/22/25 at 1443 hours, for a pain level of 10. However, review of Resident 608's medical record failed to show the documentation of the non-pharmacological pain interventions attempted prior to the administration of the hydrocodone-acetaminophen pain medications for the above dates and times. On 6/11/25 at 1332 hours, an interview and concurrent medical record review for Resident 608 was conducted with LVN 1. LVN 1 stated Resident 608 complained of pain in her left chest and her back. LVN 1 stated Resident 608 was administered the morphine pain medication routinely and the Norco and the Tylenol pain medications administered as needed. LVN 1 stated when the resident reported pain, the non-pharmacological interventions were implemented and documented in the nurse's progress notes prior to the administration of the pain medications. LVN 1 further stated if the non-pharmacological pain interventions were effective, the pain medication would not need to be administered. LVN 1 reviewed resident 608's medical record and verified the above findings. b. Review of Resident 608's MARs for May and June 2025 showed Resident 608 was administered the following medications on the following dates, times, and pain levels: * Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for severe pain (pain levels of 7 to 10): - on 5/20/25 at 2305 hours, for a pain level of 10. - on 5/21/25 at 0450 hours, for a pain level of 8; at 0915 hours, for a pain level of 7; at 1420 hours, for a pain level of 10; at 1918 hours, for a pain level of 8; and at 2350 hours, for a pain level of 8. - on 5/22/25 at 0445 hours, for a pain level of 7; at 0934 hours, for a pain level of 7; at 1443 hours, for a pain level of 10; and at 2300 hours, for a pain level of 8. - on 5/23/25 at 0450 hours, for a pain level of 7; at 0900 and 1315 hours, for a pain level of 7. - on 5/24/25 at 0250 hours, for a pain level of 8. - on 5/31/25 at 1000 hours, for a pain level of 7; and at 1518 hours, for a pain level of 7. * Resident 608 was administered the morphine sulfate Contin extended release 30 mg, one tablet by mouth every 12 hours for pain management: - from 5/24 to 5/31/25 at 0900 and 2100 hours, and - from 6/1 to 6/10/25 at 0900 and 2100 hours (except on 6/6/25 at 2100 hours). Review of Resident 608's Monitor Record for May 2025 for the monitoring of Resident 608's pain evaluation every shift, showed the licensed nurses documented Resident 608's pain level as follows for the following dates and shifts (when the hydrocodone-acetaminophen pain medication was administered for severe pain, pain level of 7 to 10): - on 5/20/25 for the 2300 to 0700 hours shift, the pain evaluation was documented as 2, - on 5/21/25, for the 0700 to 1500 hours shift and the 1500 to 2300 hours shift, the pain evaluation was documented as 0; and for the 2300 to 0700 hours shift, the pain evaluation was documented as 1. - on 5/22/25, for the 0700 to 1500 hours shift, the pain evaluation was documented as 0. - on 5/23/25, for the 0700 to 1500 hours shift, the pain evaluation was documented as 1, and for the 2300 to 0700 hours shift, the pain evaluation was documented as 1. - on 5/31/25, for the 0700 to 1500 hours shift and the 1500 to 2300 hours shift, the pain evaluation was documented as 0. Review of Resident 608's medical record failed to show documentation the licensed nurses assessed Resident 608's pain (including the pain location, level, quality, characteristics, and alleviating/aggravating factors) prior to the administration of the morphine sulfate pain medication. On 6/16/25 at 0838 hours, an interview and concurrent medical record review for Resident 608 was conducted with the DON. The DON stated when the resident had reported pain, the licensed nurse should assess the resident's pain, and implement and document the non-pharmacologic pain interventions and its effectiveness in the nursing progress notes. The DON stated if the non-pharmacologic pain interventions for pain were not effective, the licensed nurse would administer the pharmacological pain intervention, per the physician's order, and evaluate its effectiveness. The DON stated the facility was responsible for the monitoring of the resident's pain, which included the tracking and trending of the resident's pain. The DON stated the monitoring of the resident's pain each shift would assist in determining if there was a pattern for the resident's pain, and would also assist in determining when the pain medications would no longer be needed. The DON stated the licensed nurses were responsible for monitoring and documenting the resident's pain level every shift. The DON stated the pain evaluation should be documented at the end of shift, to accurately reflect the resident's highest level of pain during the shift. The DON further stated, if the PRN pain medications were administered to the resident during the shift for the pain levels of 5 out of 10 and 8 out of 10, when documenting the monitoring of pain for that shift, the licensed nurse was expected to document the pain level of eight for that shift because that was the resident's highest level of pain. The DON reviewed Resident 608's medical record and verified the above findings. The DON stated for the administration of the routine pain medications, the resident's pain should be assessed and documented in the progress notes. c. Review of Resident 608's Progress Notes, showed the following licensed nurses entry documentation: - dated 5/27/25 at 0043 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/28/25 at 0912 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/29/25 at 1007 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/30/25 at 0933 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/1/25 at 0556 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/2/25 at 1400 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/3/25 at 1101 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/4/25 at 0913 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/5/25 at 0929 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/6/25 at 1039 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/7/25 at 1346 hours, the licensed nurse documented Resident 608's pain score was 7, non-medication interventions did not provided relief, PRN medication provided. See MAR for details. However, review of Resident 608's MARs for May and June 2025 failed to show Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg one tablet every four hours as needed for severe pain, pain level of 7 to 10. On 6/16/25 at 1134 hours, an interview and concurrent medical record review for Resident 608 was conducted with the DON. The DON reviewed Resident 608's medical record and verified the above findings. On 6/16/25 at 1350 hours, the Administrator and the DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/11/25 at 1116 hours, sn observation and concurrent interview was conducted with the DON. When asked about the facility's process for the disposition of controlled substances, the DON showed a drawer used to store the controlled substances to be destroyed with the pharmacist. According to the DON, the pharmacist and DON conducted disposition of the controlled substances on a monthly basis. During the observation of the drawer containing controlled substances for the disposal, one used patch without a pharmacy label was observed stored inside the drawer. The DON stated the patch was a Fentanyl (opioid) patch. When asked about the patch was missing a pharmacy label, the DON stated she knew who the patch was used for. On 6/13/25 at 1050 hours, a follow-up observation and concurrent interview was conducted with the DON. Two used Fentanyl patches without the pharmacy labels were observed inside the drawer used to store controlled substances to be disposed of. When asked about the facility's process for keeping a record for the accurate reconciliation of the Fentanyl patches stored inside the drawer, at all times, the DON verified she did not have the documentation. The DON stated she would obtain the Controlled Drug Record for the Fentanyl from the licensed staff when the pharmacist came to the facility on a monthly basis to do the medication destruction. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure Resident 12's BP was taken in appropriate time when administering the medications for hypertension. * LVN 1 failed to administer Resident 12's docusate sodium (stool softener) as ordered by the physician. * The facility failed to establish a system of records for Fentanyl patches that were already used and ready to be disposed. These failures had the potential to negatively affect the residents' health condition for possible complications. Findings: 1.a. Review of the facility's P&P titled Medication Administration revised 1/30/25, showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section showed to compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. On 6/11/25 at 0846 hours, a medication administration observation for Resident 12 was conducted with LVN 1. LVN 1 prepared and administered the following medications to Resident 12: - one tablet of amlodipine besylate (medication to treat high blood pressure and chest pain) 2.5 mg; - one tablet of losartan (medication to treat high blood pressure) 50 mg; - one tablet of docusate sodium (stool softener) 100 mg; - two tablets of acetaminophen (pain reliever) 500 mg; - two tablets of cranberry (supplement) 450 mg; - two capsules of Fish Oil (supplement) 500 mg; and - 60 cc of Boost nutritional drink. Medical record review for Resident 12 was initiated on 6/11/25. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident 12's Order Summary Report dated 6/11/25, showed the following physician's orders: - dated 12/23/22, to administer amlodipine besylate tablet 2.5 mg. Give one tablet by mouth in the morning for hypertension; and - dated 1/6/22, to administer losartan potassium tablet 50 mg. Give one tablet by mouth one time a day for hypertension. Review of Resident 12's Weights and Vitals Summary dated 6/12/25, showed the resident's blood pressure of 126/76 mmHg was taken on 6/11/25 at 0652 hours. On 6/11/25 at 0901 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 1. LVN 1 verified Resident 12's BP was taken at 0652 hours and she administered the amlodipine besylate and losartan potassium medications at 0846 hours. LVN 1 acknowledged she did not take Resident 12's BP just before giving the medications for hypertension. LVN 1 stated Resident 12 had been taking the hypertension medication for a long time and did not need to have the BP taken. On 6/13/25 at 1130 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have taken Resident 12's BP before giving the medication because the BP could change. b. Review of Resident 12's Order Summary Report dated 6/11/25, showed a physician's order dated 12/2/21, to administer docusate sodium (stool softener) capsule 250 mg. Give one capsule by mouth in the morning for bowel management. Hold if with loose stool. On 6/11/25 at 1139 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 1. LVN 1 verified she administered 100 mg tablet instead of 250 mg capsule of docusate sodium to Resident 12. LVN 1 stated she got confused with the dosage when she gave the docusate sodium medication to Resident 12. On 6/13/25 at 1123 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have checked the physician's order and checked the medication before giving to Resident 12.

Based on observation, interview, facility P&P review, and facility document review: * The facility failed to ensure the food item in the residents' refrigerator was properly labeled, dated, and discarded by the use-by date. * The facility failed to ensure the visitors and staff were educated on safe food handling of outside food brought in to the facility. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family and Visitors revised 1/30/25, showed it was the right of the residents to have food brought in by family or other visitors, however the food must be handled in a way to ensure the safety of the residents. All food items brought in that are manufactured and do not require refrigeration may be kept in the resident room inside a lock tight container that is provided by the resident and consumed prior to the expiration date. Any expired food must be discarded. 1. On 6/9/25 at 0848 hours, a concurrent observation and interview was conducted with the Activities Director in the dining room. The refrigerator in the dining room was observed with an opened bottle of coconut water labeled 27-A, without a resident's name or identifier. The manufacturer's label showed best if used by 1/16/25, to refrigerate after opening, and to consume within two days. The Activities Director verified the above findings. When asked, the Activities Director stated she did not know when the coconut water was opened. The Activities Director further stated the bottle should be labeled with the resident's name and the opened date. The Activities Director stated the coconut water should have been discarded. On 6/11/25 at 1045 hours, an interview was conducted with the DSD. The DSD stated the food brought from the outside may be refrigerated if the food was appropriate for the resident's ordered diet. The DSD stated the food would be stored in the refrigerator and should be labeled with the resident's name, room number, and the date the item entered the refrigerator. 2. On 6/11/25 at 1014 hours, an interview was conducted with CNA 3. CNA 3 stated food brought from the outside was stored in the refrigerator in the dining room and labeled with the resident's name, room number, and the date the food was brought in. CNA 3 stated the food would be kept in the refrigerator for three days and reheated for the residents. CNA 3 was asked if she had received any safe-food handling education. CNA 3 stated she did not recall any in-services provided regarding the safe-food handling practices of the food brought from outside. CNA 3 further stated she was only provided with in-services on the storage and labeling of the food brought from the outside. On 6/11/25 at 1020 hours, an interview was conducted with CNA 4. CNA 4 stated food brought from outside for the residents was stored in the refrigerator in the dining room. CNA 4 stated if the food needed to be reheated, she would use the microwave located in the dining room. CNA 4 was asked if she had received any education on safe food handling when reheating and serving the food to the residents. CNA 4 stated no. On 6/11/25 at 1036 hours, an interview was conducted with the IP. The IP stated the food brought from the outside for the residents would be checked for the appropriate diet and texture and stored in the refrigerator in the dining room. The IP further stated the food would be kept in the refrigerator and reheated in the microwave located in the dining room. The IP stated the food would be discarded after three days. The IP stated she did not provide information or education to the residents' family or visitors about the food handling practices when they bring in food from the outside for the residents. On 6/11/25 at 1041 hours, an interview was conducted with LVN 1. LVN 1 was asked if she had received any safe food handling education and if she provided information about safe food handling to the visitors when they bring food from the outside. LVN 1 stated she did not recall receiving any education on safe-food handling and she had only received in-services on ensuring the food brought from the outside were the correct diet and texture, on how to label the food, and where to store the food. On 6/11/25 at 1122 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD reviewed the in-services provided to the facility staff regarding the food brought from the outside and verified the in-services she provided to the facility staff did not cover safe food handling practices of food brought from the outside. On 6/11/25 at 1358 hours, a follow-up interview was conducted with the DSD. The DSD stated the reheating of the food stored in the resident refrigerator was done by the CNAs or licensed nurses. The DSD stated she had not provided any in-services/education to the facility staff about safe food handling practices and the facility did not provide education to the visitors regarding the safe food handling practices of the food brought to the facility. On 6/16/25 at 1325 hours, the Administrator, DON, CDM, and DSS were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the arbitration agreement was explained in a form, manner, and language the residents or their representatives understood for two of three residents reviewed for the arbitration agreements (one nonsampled resident (Resident 23) and one final sampled resident (Resident 41). This failure posed the risk for the residents to not have a clear understanding of the arbitration process they signed. Findings: Review of the facility's P&P titled Binding Arbitration Agreements revised 1/30/25, showed when explaining the arbitration agreement to the resident or their responsible party, the facility shall explain the form in a manner that he or she understands, including in a language they understand, ensure the resident or their responsible party understands, and that it is their right not to sign the agreement. 1. Medical record review for Resident 41 was initiated on 6/12/25. Resident was admitted to the facility on [DATE]. Review of Resident 41's H&P examination dated 5/2/25, showed the resident had the capacity to understand and make medical decisions. Review of Resident 41's Arbitration Agreement dated 5/8/25, showed the form was signed by the resident and the resident's legal representative. The agreement showed by signing the agreement, the resident was giving up the right to dispute allegations of medical malpractice in the court of law, and must use arbitration (where disputing parties use a third party to make a final decision about their dispute). The agreement also showed it was binding for all the parties including the resident, their heirs, representative, executors, family members, successors, and administrators. On 6/12/25 at 0932 hours, an interview was conducted with Resident 41. Resident 41 stated she did not know what an Arbitration Agreement was and did not understand what the arbitration process was. Resident 41's signature was on the arbitration agreement as well as her representative. On 6/12/25 at 1125 hours, a telephone interview was conducted with Resident 41's responsible party on his understanding of the arbitration agreement and process. Resident 41's responsible party stated he did not recall being told about the arbitration agreement or what the arbitration process was. Resident 41's responsible party stated had they knew what the arbitration meant and it was presented in an understandable manner, he would not have signed the Arbitration Agreement. 2. Medical record review for Resident 23 was initiated on 6/12/25. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 2/1/25, showed the resident had fluctuating capacity to understand and make decisions. Review of Resident 23's Arbitration Agreement dated 1/31/25, showed the form was signed by Resident 23. The agreement showed by signing the agreement, the resident was giving up the right to dispute allegations of medical malpractice in the court of law, and must use arbitration (where disputing parties use a third party to make a final decision about their dispute). The agreement also showed it was binding for all the parties including the resident, their heirs, representative, executors, family members, successors, and administrators. On 6/12/25 at 0950 hours, an interview was conducted with Resident 23. Resident 23 stated she did not know what the arbitration was and did not understand the process of the arbitration. When Resident 23 was provided with an explanation of the arbitration process, Resident 23 did not verbalize understanding.

Based on observation, interview, medical record reviews, facility document review, and facility P&P review , the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection surveillance program for January and February 2025. Specifically, the Infection Surveillance Monthly Report did not match the data recorded in the facility's Infection Control Summaries for those months. These failures posed a risk of unrecognized resident infections and increased the potential for transmission of communicable diseases throughout the facility. Findings: Review of the facility's P&P titled Antibiotic Stewardship Program dated 1/30/25, showed antibitiotic used shall measure by monthly prevalence, antibiotic starts and/or antibiotic days of the therapy. Data obtained from antibotic stewardship monitoring activityes is dicussed in the facility's QAPI meetings. 1. On 6/12/25 at 1000 hours, a concurrent interview, medical record review, and facility document review was conducted with the IP. The IP was asked what was discussed during the quarterly infection control meeting held in 4/2025. The IP stated they reviewed the antibiotic usage by presenting the infection control summary data for the CAIs and HAIs meeting the McGeer's criteria, and HAIs not meeting the McGeer's criteria for January, February, and March 2025. When asked about the criteria used to identify and track the HAIs, the IP explained the facility used the McGeer's criteria. The infection assessment was generated automatically in Point Click Care when the staff completed the associated questionnaire form. The IP was then asked to provide the infection control surveillance program for January and February 2025 . a. Review of the Infection Control Summary for 1/2025 showed four residents were classified as HAI meeting the McGeer's criteria and four residents did not met the McGeer's criteria. However, the Infection Surveillance Monthly Report Log for January 2025 showed three residents were classified as HAI meeting the McGeer's and five residents as not meeting the McGeer's criteria. For example: For Resident 15, the infection was documented as meeting McGeer's criteria in the Infection Surveillance Monthly Report, however, should have been classified as HAI not meeting the McGeer's criteria. b. Review of the Infection Control Summary for 2/2025 showed: eight residents with CAIs, four residents with HAIs meeting the McGeer's, and nine residents with HAIs not meeting the McGeer's criteria. However, the Infection Surveillance Monthly Report Log for 2/2025 showed there were 11 residents with CAIs, three residents with HAIs meeting the McGeer's, and seven residents with HAIs not meeting the McGeer's criteria. For example: For Resident 51, the infection was listed as CAI in the monthly report, however, was listed as HAI not meeting the McGeer's criteria in the Summary Report. The Infection Surveillance Monthly Report log report was inconsistent with the Infection Control Summary report. For Resident 360, the infection was similarly classified as CAI in the report, however, was listed as HAI not meeting the McGeer's criteria in the Summary Report. The Infection Surveillance Monthly Report log report was inconsistent with the Infection Control Summary report. The IP confirmed the discrepancies identified and stated Resident 15's infection should have been categorized as HAI not meeting the McGeer's criteria. In addition, Residents 51 and 360 should have been classified as CAI and not included in the HAI category. The IP verified the Infection Control Summaries did not match the corresponding Infection Surveillance Monthly Report Logs.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the opened food items in the freezer were properly stored, dated, and labeled. * The facility failed to discard the items in the refrigerator that were past the use-by date, as per the facility's P&P. * The facility failed to ensure the juice boxes and thickener (for the juice dispenser) were properly labeled and discarded. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure the plastic cup was not stored inside the flour container. * The facility failed to air dry the kitchen equipment. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 61 residents who received food prepared in the kitchen. Findings: Review of the facility's document titled Diet Type Report dated 6/9/25, showed 61 of 61 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Review of Sanitation revised 9/26/18, showed all the food stored should be dated when it is placed in the storeroom, refrigerator, or freezer. The food in all the refrigerators should have a use-by-date. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. On 6/9/25 at 0750 hours, an observation of Freezer 1 was conducted with the DSS. The following were observed: - an opened bag of the frozen hashbrowns. The bag was not observed labeled with the opened date or stored inside a sealed bag. - an opened blue bag containing the frozen Danishes. The label showed received on 5/28/25. The label was not observed with the opened dated or stored inside a sealed bag. - an opened bag of the frozen cinnamon rolls. The bag was not observed stored inside a sealed bag and two cinnamon rolls were observed outside of the bag and touching the other items nearby. The DSS verified the above findings. The DSS stated the opened bags should be stored inside a closed Ziplock bag after it was opened and before placing in the freezer. The DSS further stated the bags should be labeled with the opened date when it was first opened, to determine when the items should be discarded. 2. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall be discarded accordingly. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed the refrigerated storage- foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: iv. labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen/discarded. On 6/9/25 at 0750 hours, an observation of Refrigerator 1 was conducted with the DSS. The following were observed: - a clear plastic container was observed with limes, cucumbers, oranges, and lemons. The label on the plastic container showed items: lime, cucumber, orange, lemon; received on 5/28/25, and to use-by 6/6/25. - a clear plastic container with carrots inside. The label showed: carrots, prepped on 5/26/25, and use-by 6/7/25. The DSS verified the above findings. The DSS stated the items in the plastic containers should have been removed from the refrigerator and discarded by the use-by date. The DSS stated the kitchen aide was responsible for removing the expired items in the refrigerator, once a week and the evening cook was responsible for checking the refrigerators and freezers during their shift and removing the expired items. 3. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking of the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - a bag of the cranberry juice connected to the juice dispenser. The bag of juice was not observed labeled with the opened date. The DSS stated she did not know when the juice was opened. - a box of the blush grape juice concentrate connected to juice dispenser. The label on the box showed the opened date of 4/29/25, and the use-by date of 5/29/25. - a box of the apple juice concentrate connected to juice dispenser. The label showed the received date 5/20/25, however the label was undated with the opened or use-by date. The DSS stated she did not know when the juice was opened. - a box of the orange juice concentrate connected to the juice dispenser. The label showed the received date of 5/30/25, however the label was undated with the opened or use-by date. The DSS stated she did not know when the juice was opened. - a bag of thickener liquid connected to the juice dispenser. The bag was not observed labeled with the opened date. The DSS stated did not know when the bag was opened. The DSS verified the above findings. The DSS stated the juices should be discarded after one month of opening. 4. According to the US FDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the US FDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: e. equipment used in the handling of food, including dishes, utensils, mixers. grinders, and other equipment that comes in contact with food. All the equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. Review of the facility's P&P titled Can Opener revised 8/31/18, showed to sanitize the can open after each meal and more frequently if needed. To scrub the shank, paying special attention to the blade and moving parts. To use the sanitizing solution and brush or run through the dish machine. To scrub the base plate (attached to the table). On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - two clear plastic containers containing clean cooking utensils were observed with multiple dry particles and debris at the bottom of the bins. - a blue-handled rice scooper observed with yellow colored food residue. - a white-handled rice scooper observed with light brown colored dry food residue. - a portion server observed with dried, white-colored residue. - a stationary can opener observed with dry yellow colored sticky residue on the blade and brownish black colored residue on the can opener gear (the spinning part of the can opener, behind the blade) - multiple steam pans in the dry storage room, observed with dry, white particles on the pans. The DSS verified the above findings. The DSS stated the cooking utensils should be clean and completely dry before placed in the bin. The DSS stated the bins storing the clean kitchen utensils should be completely closed when not in use and the bins should be clean. 5. According to the US FDA Food Code 2022, Section 4-201.11, Equipment and Utensils- Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. Equipment and utensils must be designed and constructed so that parts do not break and end up in food as foreign objects or present injury hazards to consumers. According to the US FDA Food Code 2022, Section 4-202.11, Food-Contact Surfaces, the purpose of the requirements for multi-use food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor or foodborne pathogenic organism. Surfaces which have imperfections such as cracks, chips, or pits allow microorganism to attach and form biofilms. Once established, these biofilms can release pathogens to food. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - one white slotted portion scooper observed with a melted handle. - one white silicone spatula observed chipped and cracked. The DSS verified the above findings and stated the spatula and the portion scooper should be removed and replaced. 6. According to the US FDA Food Code 2022, 3-304.11, Food Contact with Equipment and Utensils, food shall only contact surfaces of: a. equipment and utensils that are cleaned as specified under Part 4-6 of this Code and Sanitized as specified under Part 4-7 of this code; b. single-service and single-use articles. According to the US FDA Food Code 2022, 3-304.12, In-Use Utensils, Between-Use Storage, during pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon; (C) On a clean portion of the food preparation table or cooking equipment only if the in-use utensil and the food-contact surface of the food preparation table or cooking equipment are cleaned and sanitized at a frequency specified under §§ 4-602.11 and 4-702.11; (D) In running water of sufficient velocity to flush particulates to the drain, if used with moist food such as ice cream or mashed potatoes; (E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food; or (F) In a container of water if the water is maintained at a temperature of at least 57 degrees Celcius (135 degrees F) and the container is cleaned at a frequency specified under Subparagraph 4-602.11(D)(7). On 6/9/25 at 0750 hours, during the initial tour of the kitchen, a clear container labeled flour was observed in the emergency food storage room. A plastic cup was observed inside the flour container. The DSS verified the above finding and stated the scoops/cups used to scoop the flour should be kept outside of the container, and not inside. 7. According to the US FDA Food Code 2022, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - a green-handled rice scooper observed stored wet inside the clean kitchen utensils container. - a 4-oz stainless steel measuring cup observed stored wet inside the clean kitchen utensils container. - a stainless-steel spatula observed stored wet inside the clean kitchen utensils container. - three blenders observed stored on the shelf, upright and wet. - one blender lid observed wet, with food particles on the lid. - two steam pans observed stacked, upside down and wet. The DSS verified the above findings and stated the kitchen equipment should be clean and completely dry before stored. On 6/16/25 at 1325 hours, the Administrator, DON, CDM, and DSS were informed and acknowledged the above findings.

Based on interview, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurately completed for 1 (Resident #30) of 2 sampled residents reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #30's Level I PASARR Screening reflected the presence of a serious diagnosed mental disorder. Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, revised 12/18/2023, specified, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine if the individual may have a serious mental illness and benefit from specialized services. Question 10. Diagnosed Mental Illness *Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? *If yes, there will be a text box question [to] provide the type of mental illness. An admission Record revealed the facility admitted Resident #30 on 06/11/2024. According to the admission Record, the resident's admitting diagnoses included major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/2024, revealed Resident #30 had severely impaired cognitive skills for daily decision making and had short- and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated Resident #30 had an active diagnosis of depression. Resident #30's undated Care Plan Detail included a focus area that indicated Resident #30 had depression. Resident #30's History and Physical Exam, dated 06/13/2024, indicated Resident #30 had a diagnosis of major depressive disorder. Resident #30's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/10/2024, revealed Section III- Serious Mental Illness Screen, question #10 was answered No, and did not reflect the resident's diagnosis of major depressive disorder. This resulted in a Negative Level I Screening, and a Level II evaluation was not required. During an interview on 07/17/2024 at 2:05 PM, the Director of Nursing (DON) stated when residents were admitted to the facility, facility staff reviewed their Level I Screenings, and if they were not correct, they were updated the next day. The DON said they had noticed the hospitals were not filling the Level I Screenings out accurately. The DON confirmed Resident #30's Level I Screening was not correct and should have been redone. She said she was not sure how it was missed. During an interview on 07/17/2024 at 2:18 PM, the Administrator stated she expected PASARRs to be correct. She stated Resident #30's diagnosis of major depressive disorder should have been reflected on their PASARR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light was kept within reach for one of 18 final sampled residents (Resident 46). This failure had the potential for the resident to not be able to use the call light to summon assistance. Findings: Review of the facility's P&P titled Answering the Call Light revised October 2010 showed under the section for General Guidelines, Number five showed when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. On 12/12/22 at 0928 hours, Resident 46 was observed in bed with the call light button attached to the headboard of the bed. The call light was situated between the bed and the wall, out of reach for Resident 46. On 12/12/22 at 1032 hours, a concurrent observation and interview was conducted with CNA 2. Resident 46 was observed in bed with the call light attached to the headboard of the bed and out of reach. CNA 2 verified Resident 46's call light was out of reach for Resident 46. CNA 2 further stated Resident 46 calls for help from staff by using the call light. On 12/15/22 at 1408 hours, Resident 46's call light was observed on the floor on the left side of the bed. On 12/15/22 at 1410 hours, an interview was conducted with the help of a Korean translator with Resident 46. When asked how Resident 46 called for help, Resident 46 was observed activating the call light. When Resident 46 was asked why they activated the call light, Resident 46 responded, when I press the button, someone will come and help me. On 12/15/22 at 1427 hours, a concurrent interview and observation was conducted with CNA 3. CNA 3 was asked to come to Resident 46's room. CNA 3 verified Resident 46's call light was on the floor, out of reach for Resident 46. CNA 3 stated Resident 46 used the call light when the resident required help from the staff. Medical record review for Resident 46 was initiated on 12/15/22. Resident 46 was admitted to the facility on [DATE]. Review of Resident 46's care plan dated 10/24/21 and revised 7/27/22, showed under focus, the resident was at risk for falls related to impaired cognition,self-care deficits, and history of repeated falls. The careplan interventions included to place the resident's call light within reach and encourage the resident to use it for assistance as needed, and the resident needed prompt responses to all requests for assistance.

3a. During an observation on 12/12/22 at 1200 hours, a laptop computer on the medication cart was left open at Nursing Station 2. The laptop computer screen faced the hallway where other residents were observed and displayed a resident's personal information including diagnoses, allergies, and picture. On 12/12/22 at 1208 hours, a concurrent observation and interview was made with the DSD. The DSD verified the laptop computer was left unattended and showed resident information. The DSD acknowledged the laptop computer should not be left unattended with visible resident identifier information because it was a privacy concern. b. During an observation on 12/15/22 at 1444 hours, a computer monitor displayed with resident information was left unattended at Nursing Station 1. The computer monitor displayed resident pictures, dates of birth, diagnoses, and allergy information. On 12/15/22 at 1448 hours, a concurrent observation and interview was conducted with RN 1. RN 1 verified the computer was left unattended and stated anyone could have accessed the resident's information. RN 1 stated the computer monitor with resident information should not be left unattended. Based on observation, interview, and record review, the facility failed to ensure the personal privacy for two of 18 final sampled residents (Residents 48 and 66) when: * Resident 48's curtain was not completely closed while the G tube medications were being administered. * Resident 66's room had a Hard of Hearing posting stapled above the head of bed. * Personal health information (PHI) on a computer terminal was left unattended with visible resident identifier information. These failures had the potential to negatively affect the dignity of the residents and violate privacy. Findings: Review of the facility's P&P titled Confidentiality/Security of Information revised 9/20/09, showed all information, both automated and manual, regarding specific residents, applicants for admission or related health information pertaining to a resident, is protected by law and must be secured against loss, destruction and unauthorized access or use. According to the P&P, automated and manual resident's records/information systems are subject to the same degree of management control, protections, integrity, reliability, accessibility, verification of accuracy and security. The objectives of information security are designed to ensure residents' privacy and protection of health information/data; protection of communications (manual or automated systems) as they relate to a resident, facility, or the organization. Review of the facility's P&P titled Health Information/Record Manual-Confidentiality/Security of Information revised 9/20/09, under Policy, Number one showed all information, both automated and manual regarding specific residents, applicants for admission or related health information pertaining to a resident is protected by law and must be secured against loss, destruction and unauthorized access or use. 1. On 12/14/22 at 0828 hours, a medication administration observation was conducted with RN 2 in Resident 48's room. RN 2 checked Resident 48's G tube placement and residual. RN 2 did not pull Resident 48's privacy curtain prior to accessing the resident's G tube site for medication administration. On 12/14/22 at 0908 hours, an interview was conducted with RN 2. RN 2 was asked about Resident 48's privacy curtain. RN 2 confirmed she did not pull the curtain all the way around the resident to ensure the privacy. RN 2 verified the privacy curtains should have been pulled around Resident 48's bed right away to provide sufficient privacy. 2. On 12/12/22 at 1043 hours, an observation of Resident 66 was conducted in the resident's room. Resident 66 was observed in bed and awake. A Hard of Hearing posting was observed stapled above Resident 66's head of the bed, indicating the resident was hard of hearing. The posting was not covered. On 12/12/22 at 1047 hours, an interview was conducted with RN 1. RN 1 stated the posting indicated Resident 66 was hard of hearing and verified it violated HIPAA. On 12/13/22 at 1606 hours, an interview was conducted with the DON. The DON stated Resident 66's posting should have been covered to protect privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 50) received care in accordance with standards of practice. * Resident 50 received dialysis treatment (process of removing waste products and excess fluid from the body). The facility failed to place a dressing on Resident 50's tunneled dialysis catheter (a thin flexible hollow tube that is tunneled under the skin before entering a large vein) insertion site. This failure had to potential for Resident 50 to develop a central line-associated bloodstream infection (CLABSI, a serious infection that occurs when germs enter the bloodstream through the central line) Findings: According to the facility's P&P titled Central Venous Catheter Dressing Change dated 6/2018 under the section for Policy, Letter A, the P&P showed a transparent dressing (a thin, clear sterile dressing that keeps out water, dirt and germs) is the preferred dressing. If the resident is allergic to the transparent dressing, a gauze and tape dressing may be used. Medical record review for Resident 50 was initiated on 12/13/22. Resident 50 was admitted to the facility on [DATE]. Resident 50 had a diagnosis of end stage renal disease (ESRD, last stage of chronic kidney disease when the kidneys fail and stopped working well enough to survive) and was on hemodialysis. Review of Resident 50's MDS dated [DATE], showed the resident had severe impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decisions making. The MDS also showed the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of Resident 50's Order Summary Report dated 12/14/22, showed an order dated 12/10/22, to monitor the hemodialysis access site on the right upper chest tunneled catheter for signs/symptoms of infection. On 12/14/22 at 1500 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 confirmed the tunneled dialysis catheter on Resident 50's right upper chest was open to air with no dressing applied to the insertion site. LVN 2 stated the tunneled dialysis catheter should have a dressing applied to the insertion site due to the risk of infection. On 12/15/22 at 0914 hours, an interview was conducted with RN 1. RN 1 stated tunneled dialysis catheters should be covered with an occlusive dressing (a thin, clear dressings that usually have an adhesive side that faces the wound). When asked why it was important to keep central lines covered, RN 1 stated because of the risk of infection.

Based on observation and interview, the facility failed to ensure a stored medication bottle was properly labeled to include an expiration date. This failure had the potential for the residents at the facility to receive expired medications. Findings: On 12/15/22 at 1450 hours, an inspection of Medication Cart A and concurrent interview was conducted with RN 2. Medication Cart A was observed to have a bottle of Geri-Tussin DM (also known as dextromethorphan-guaifenesin, a combination medication used to relive coughs) with an expiration date of 09/ with the year crossed out. RN 2 confirmed she could not determine the medication's expiration date and stated the Central Supply Personnel was responsible for encircling the expiration date. On 12/15/22 at 1502 hours, an interview was conducted with the Central Supply Personnel. The Central Supply Personnel confirmed she was responsible for encircling the expiration dates on the medication bottles. The Central Supply Personnel verified the expiration date labeled on the Geri-Tussin DM bottle was circled with a black marker, thus covering the year of expiration. The Central Supply Personnel stated she made a mistake. When asked if she knew when the bottle of Geri-Tussin DM expired, the Central Supply Personnel stated no. On 12/15/22 at 1506 hours, a follow-up interview was conducted with RN 2. When asked if the Geri-Tussin DM should be administered without knowing the correct expiration date, RN 2 stated no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 2017 showed in most situation, the preferred method of hand hygiene was with an alcohol-based hand rub. If hands were not visibly soiled, use alcohol-based hand rub containing 60-95% ethanol or isopropanol for situations including before and after contact with the residents. On 12/15/22 at 0951 hours, LVN 1 was observed entering Room A without performing hand hygiene. LVN 1 was observed touching Resident 18A on her shoulder. LVN 1 was then observed coming out of the Room A without performing any hand hygiene after touching Resident 18A. LVN 1 was then observed to touch Resident 422 (who was in a wheelchair in a hallway) on her hand and shoulder. LVN 1 was not observed performing hand hygiene before touching Resident 422. On 12/15/22 at 0955 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above observation. LVN 1 acknowledged the observation and stated she should have performed hand hygiene before entering and exiting the room of the residents and in between touching residents. On 12/15/22 at 1018 hours, an interview was conducted with the IP. The IP acknowledged the above findings. The IP stated staff should perform hand hygiene before and after contact with the residents. The IP stated not performing hand hygiene before and after contact with residents may lead to transmission of infection to other residents. Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices to prevent the spread of infection as evidenced by: * The facility failed to follow the proper doffing practices before exiting a room on isolation precautions. * The facility failed to ensure the staff performed hand hygiene before and after contact in between residents. These failures had the potential for cross-contamination and spread of infectious organisms in the facility. Findings: 1. According to the CDC, under Precautions to Prevent Transmission of Infectious Agents reviewed 7/2019, healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient ' s environment. Donning the PPE (personal protective equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination On 12/14/22 at 0906 hours, an observation was conducted for Room B. Room B was observed with an isolation signage indicating contact precautions should be observed. CNA 1 was observed walking out of Room B into the hallway wearing an isolation gown while carrying bed linen in her arms. CNA 1 was next observed disposing of the bed linen in the dirty clothes bin. CNA 1 walked to the clean linen cart, removed the protective cover, put her hand inside the cart, and removed a clean linen. CNA 1 was then observed to walk back into room [ROOM NUMBER] while the CNA was still wearing the same isolation gown. On 12/14/22 at 0909 hours, an interview was conducted with CNA 1. CNA 1 verified she exited the room while donning an isolation gown. When asked where the staff was expected to remove the isolation gowns, CNA 1 stated inside of the room by the door entrance. On 12/14/22 at 0947 hours, an interview was conducted with the IP. When asked if they would have a concern if a staff walked out of a room wearing an isolation gown and carrying dirty linen, the IP answered the staff was not to leave the resident's room in an isolation gown. When asked if there would be a concern if a staff member reached into the clean linen cart wearing an isolation gown, the IP stated yes. When asked to elaborate on the concern, the IP. stated it could cause a spread of infection.

Based on observation and interview, the facility failed to ensure the food was prepared and served in accordance with professional standards for food safety as evidence by:. * The facility failed to ensure the food which was prepared to be served to the residents from the kitchen was free from chemical contamination. * The facility failed to maintain the temperatures of the milk were appropriate when served to the residents. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 form completed by the facility dated 12/12/22, showed 63 residents received the food prepared in their dietary department. 1. On 12/14/22 at 1109 hours, an observation of [NAME] 1 during the puree preparation was conducted. [NAME] 1 was observed washing the items used for puree in the sink. Then with gloved hands [NAME] 1 was observed moving the items to the section of the sink filled with fluid, which appeared light pink in color. [NAME] 1 then took a knife from another kitchen staff member and begun cutting a food item which [NAME] 1 identified the food item as a sheet of chocolate peanut butter bars. Fluid from the outside of [NAME] 1's gloves was observed dripping from the gloves and onto the food as the cook cut the chocolate peanut butter bars. [NAME] 1 then scooped several of the cut chocolate peanut butter bars from the tray and placed them into the blender. When asked, [NAME] 1 verified he was going to blend the chocolate peanut butter bars to serve to the residents. During a concurrent interview with the Dietary Supervisor, the Dietary Supervisor was asked if she observed the liquid on the sheets of chocolate peanut butter bars, the Dietary Supervisor stated yes. When asked what the fluid was, the Dietary Supervisor stated it was condensation. When asked if the Dietary Supervisor could observe fluid on the outside of [NAME] 1's gloves, the Dietary Supervisor stated yes. When asked if there should be fluid on the outside of [NAME] 1's gloves, the Dietary Supervisor stated no. When asked why it was a concern, the Dietary Supervisor stated the concern was for chemical and sanitation contamination of the food. 2. Review of the facility document titled Lunch Milk Beverage Production List dated 12/14/22, showed the following: * three residents was to receive 4 oz of soy milk * three resident was to receive 4 oz of whole milk * four residents was to receive 8 oz of soy milk * four resident was to receive 8 oz of whole milk * one resident was to receive 8 oz of nectar thickened soy milk * two residents was to receive 4 oz of two percent milk * one resident was to receive 2 cups of 8 oz soy milk * one resident was to receive 4 oz of nectar thickened soy milk On 12/14/22 at 1212 hours, an observation and concurrent interview was conducted with the Dietary Supervisor. When asked if the cups filled with liquid were prepared for the lunch trays and ready to be served, the Dietary Supervisor stated yes. When asked if the kitchen was serving the drinks, the Dietary Supervisor stated yes. When asked what temperature of the milk should be served at, the Dietary Supervisor stated at 41 degrees Fahrenheit or below. During a concurrent observation and interview, measurement of the temperatures of cold serviced fluids was conducted and showed the following: - Temperature measuring of the first glass of fluid labeled milk showed the temperature was at 43 degrees Farenheit. - Temperature measurement of the second glass of fluid labeled soy milk showed the temperature was at 43 degrees Fahrenheit. 3. Temperature measurement of the third glass of fluid labeled milk showed the temperature was at 43 degrees Fahrenheit . The Dietary Supervisor verified the above findings. When asked if the milk was safe to serve, the Dietary supervisor stated no. When asked, the Dietary Supervisor stated there were eight residents who were to receive whole milk, eight residents who were to receive soy milk, two residents who were to receive nectar thick milk, and two residents who were to receive two percent milk.