Based on interview and record review the facility failed to ensure one resident (Resident 10) out of 15 sampled residents was free from unnecessary psychotropic medications when Resident 10 was prescribed an order for lorazepam (a psychotropic medication that affects the brain associated with mental processes and behavior) as needed (PRN) indefinitely. This failure had the potential to cause medication interactions, confusion, and falls. Findings: A review of Resident 10's admission record indicated Resident 10 was admitted to the facility in February 2024 with diagnoses including dementia without behavioral disturbance or anxiety (a group of thinking and social symptoms that interferes with daily functioning) and recurrent depressive disorders (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 10's Order Summary Report (OSR, physician orders), Resident 10 had a physician order for lorazepam, oral tablet 0.5 mg (milligram, a unit of measurement) every 12 hours PRN for anxiety manifested by restlessness and angry outburst. During a concurrent interview and record review on 7/16/24 at 5:06 p.m. with the DON (Director of Nursing) and DCO (Director of Clinical Operations) Resident 10's OSR for lorazepam was reviewed. The DON and DCO confirmed Resident 10's lorazepam order was ordered PRN and without a stop date. The DON and DCO acknowledged as needed psychotropic medication orders should only be prescribed for 14 days and then reviewed for continued use or discontinuation. A review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, indicated, Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days.

Based on observation, interview, and record review the facility failed to ensure safe food handling and storage for food brought in by family for one resident (Resident 2) out of 15 sampled residents. This failure had the potential for Resident 2 to experience foodborne dangers, such as, nausea, vomiting and diarrhea by consuming moldy food. Findings: A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in February 2024 with diagnoses which included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a concurrent observation and interview on 7/16/24 at 9:31 a.m. with Resident 2, in Resident 2's room, a transparent plastic container with a red plastic lid was observed on Resident 2's bedside table. Indistinguishable personal food items with greenish-blue spots and fuzzy growth were observed through the container. Resident 2 stated, I'm not sure what those are, my family brought me that a while ago. During a concurrent observation and interview on 7/16/24 at 9:36 a.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 2's room, the CNA 1 opened the plastic container and confirmed the contents in the container was, old food with fuzzy mold. The CNA 1 stated, [Resident 2] could've been really sick if she had eaten that. The CNA 1 received permission from Resident 2 to discard the food and plastic container. During a concurrent observation and interview on 7/18/24 at 2:33 p.m. with DON (Director of Nursing) a photo of Resident 2's plastic container with personal food items inside was shown to the DON. The DON confirmed the personal food items, looks moldy. The DON stated, Personal food items brought in by family should have the resident's name, date, and time on the container. The food item will be refrigerated for 24 hours and then it will get thrown away. Items left out at room temperature should be thrown away after two hours. During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised March 2022, indicated, Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date .The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates.)

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for one of 15 sampled residents (Resident 11). This failure had the potential to result in unmet resident needs and delayed staff response. Findings: A review of Resident 11's admission record, indicated Resident 11 was admitted to the facility in 2016 with diagnoses that included spastic hemiplegia (uncontrolled muscle movements on one side of the body), contracture (permanent tightening of muscles which causes stiffness and prevents normal movement of a body part), polyarthritis (painful inflammation and stiffness affecting five or more joints at the same time), dementia (a loss of memory and problem-solving abilities which interfere with daily life) and a history of falling. A review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 5/1/24, indicated Resident 11 had moderate memory problems, impairments to both upper body and lower body, and was dependent on staff for mobility and care related to incontinence (unintentional passing of urine and bowel movements). During a concurrent observation and interview on 7/16/24 at 1:15 p.m. with Resident 11 in Resident's 11 room, Resident 11 was sitting up in a padded chair in her room, leaning and slumped on her left side, with a strong odor of feces coming from resident. Resident's 11 call light was tied to the resident's bed out of reach of Resident 11. Resident 11 had a grimace on her face and stated she needed staff's help but she could not reach her call light to get staff's attention. During a concurrent observation and interview on 7/16/24 at 1:19 p.m. with Certified Nurse Assistant 2 (CNA 2) in Resident 11's room, CNA 2 confirmed Resident 11 could not reach the call light that was tied to the bed while she was sitting in the chair in her room. CNA 2 acknowledged the call light is supposed to be left in reach of Resident 11 so she can call for assistance. During a concurrent observation and interview on 7/19/24 at 1:20 p.m. with Licensed Nurse 4 (LN 4) in Resident 11's room, the LN 4 confirmed Resident 11's call light was out of Resident 11's reach and confirmed staff should ensure call light is in reach of Resident 11 so she could communicate when she needs help. An interview on 7/19/24 at 8:22 a.m., the Director of Staff Development (DSD) stated she expected staff to ensure call lights are in reach and added, if the call light is not in reach the resident cannot get the attention of nurses for care needs and may try to get up on their own and fall. An interview on 7/19/24 at 11:44 a.m., the Director of Nursing (DON) stated she expected call lights be left in resident's reach and added, if call lights are not in reach residents may not be able to communicate with staff when they need help and could lead to resident becoming upset. A review of the facility's policy and procedure titled, Call System, Residents, dated September 2022, indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station .Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure baseline care plans (instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) were developed, implemented, and signed by the resident or responsible party within 48 hours of admission for two out of 15 sampled residents (Residents 260 and 261). This failure had the potential to cause residents and staff to be unaware of the residents' plan of care. Findings: A review of Resident 260's admission record indicated Resident 260 was admitted to the facility on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection) and urine retention (difficulty urinating and completely emptying the bladder). During a concurrent observation and interview on 7/16/24 at 9:07 a.m., with Resident 260 in the resident's room, Resident 260 was observed with a urinary catheter. Resident 260 stated, I was transferred here from the hospital about three days ago. I don't know how long I'm supposed to have the catheter. During an interview on 7/17/24 at 12:45 p.m. with Resident 260, in the resident's room, Resident 260 confirmed, I didn't get a copy of the baseline care plan, no one specifically spoke to me about my goals or plan of care when I was admitted . A review of Resident 261's admission record indicated Resident 261 was admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and pneumonia (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection). During a concurrent observation and interview on 7/17/24 at 9:12 a.m. with Resident 261 in the resident's room, Resident 261 was observed sitting in her wheelchair with the oxygen concentrator running at 4 L (liters, a unit of measurement) per minute through a nasal cannula (a plastic tube that delivers extra oxygen into your nose) which was laying on the bed, out of Resident 261's reach. Resident 261 stated, I'm not sure if I should be wearing the oxygen or not. Resident 261 confirmed, I didn't get a copy of the baseline care plan and no one spoke to me about my plan of care here [at the facility]. During a concurrent interview and record review on 7/18/24 at 9:24 a.m., with the DON (Director of Nursing) and the DCO (Director of Clinical Operations) Resident 260 and 261's baseline care plans were reviewed. The DON and DCO confirmed the baseline care plans were not completed within 48 hours of admission for Resident 260 and 261. The DON and DCO confirmed baseline care plans are completed within 48 hours of admission. Staff are required to provide the resident or resident's responsible party a copy of the baseline care plan by either email, mail, or a printed copy. The DON stated when a copy is provided to the resident the delivery method would be documented in a progress note and the baseline care plan would be documented as,completed. During a review of the facility's policy and procedure (P&P) titled, Care Plans - Baseline, revised March 2022, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The resident and/or representative are provided a written summary of the baseline care plan .Provision of the summary to the resident and/or resident representative is documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for four residents (Residents 1, 18, 28, and 29) of 15 sampled residents when: 1. Resident 1 was administered morphine ER (extended release, narcotic pain medication) 15 mg (milligram, a unit of measurement) and pramipexole (medication used to treat restless leg syndrome) 0.125 mg at 11:13 a.m. when it was scheduled at 8 a.m.; 2. Resident 18 was administered omeprazole (used to treat heartburn) 20 mg and gemfibrozil (medication to help lower high cholesterol and triglyceride levels in the blood) 600 mg at 8:16 a.m. instead of 30 minutes prior to the breakfast meal.; 3. Resident 28 was administered gabapentin (used to treat nerve pain) 300 mg at 10:17 a.m. when it was scheduled at 8 a.m., and a lidocaine patch 5% (pain relieving patch) at 10:17 a.m. when it was scheduled at 7 a.m.; and, 4. Resident 29 was administered cephalexin (an antibiotic) 250 mg and lisinopril (used to treat high blood pressure and heart failure) 5 mg at 10:56 a.m. when it was scheduled at 8 a.m. These failures resulted in seven medication errors being identified out of 31 opportunities during an observation of medication administration which then resulted in the facility having a medication error rate of 22.58%. Findings: 1. During a medication pass observation on 7/17/24 at 11:13 a.m. with Licensed Nurse 4 (LN 4), the LN 4 prepared one tablet of morphine extended release (ER) 15 mg and one tablet of pramipexole 0.125 mg to administer to Resident 1. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated one tablet of morphine ER 15 mg was to be administered twice a day and one tablet of pramipexole 0.125 mg was to be administered once a day. During a concurrent observation and interview on 7/17/24 at 11:13 a.m. with LN 4, the LN 4 confirmed both medications were scheduled to be administered at 8 a.m. 2. During a medication pass observation on 7/18/24 at 8:16 a.m. with LN 5, the LN 5 prepared one capsule of omeprazole 20 mg and one tablet of gemfibrozil 600 mg to administer to Resident 18. During a review of Resident 18's OSR, the OSR indicated one tablet of gemfibrozil 600 mg one time a day, 30 minutes before breakfast, and one capsule of omeprazole 20 mg were to be administered twice a day. During a concurrent observation and interview on 7/18/24 at 8:16 a.m. with LN 5, the LN 5 confirmed both medications should be administered 30 minutes before a meal. The LN 4 confirmed Resident 18 had already eaten her breakfast. 3. During a medication pass observation on 7/17/24 at 10:17 a.m. with LN 3, the LN 3 prepared one capsule of gabapentin 300 mg and a lidocaine patch to administer to Resident 28. During a review of Resident 28's OSR, the OSR indicated one capsule of gabapentin 300 mg to be administered three times a day and one lidocaine patch 5% to be administered in the morning. During a concurrent observation and interview on 7/17/24 at 10:17 a.m. with LN 3, the LN 3 confirmed the gabapentin should have been administered at 8 a.m. and the lidocaine patch was scheduled to be administered at 7 a.m. 4. During a medication pass observation on 7/17/24 at 10:56 a.m. with LN 4, the LN 4 prepared one capsule of cephalexin 250 mg and one tablet of lisinopril 5 mg. During a review of Resident 29's OSR, the OSR indicated one capsule of cephalexin 250 mg and one tablet of lisinopril 5 mg to be administered once a day at 8 a.m. During a concurrent observation and interview on 7/17/24 at 10:56 a.m. with LN 4, the LN 4 confirmed both medications should have been administered at 8 a.m. During an interview on 7/18/24 at 2:45 p.m. with the Director of Nursing (DON), the DON confirmed the LN 3, LN 4 and LN 5 did not follow physician orders when medications were administered late. The DON stated, It is important to administer medications at their prescribed times, especially antibiotics to ensure their efficacy. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated March 2018, the P&P indicated, Medications are administered in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diets (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meal on 7/17/2024 when: 1. 44 out of 44 residents with regular portion size received two scoops (eight ounces (oz.) instead of three scoops (12 oz.) of pasta entrée, 2. Five residents (Resident 6, 9, 14, 33, and 49) with pureed texture diets (diet with modified food texture that is smooth and lump-free for people with swallowing and/or chewing difficulties) received pureed garlic bread sticks instead of soaked white dinner rolls, 3. 16 residents (Resident 7, 11, 19, 21, 25, 29, 32, 38, 39, 40, 43, 46, 52, 56, 110, and 261) who were on Level 5 Minced and Moist texture diets (modified texture diet for people with swallowing and/or chewing difficulties), Heart Healthy/Cardiac diets (diet with reduced amount of fat, cholesterol, and sodium for people who are at risk of heart diseases or have heart diseases), and/or Renal diets (diet for people with chronic kidney disease) received wheat dinner rolls instead of white dinner rolls, 4. Five residents (Resident 2, 4, 29, 36, and 52) with small portion diets (diet with controlled serving size is smaller for less calories or sometimes for person's preference) were not served with the correct measured serving size because the menu spreadsheet did not include small portions for accurate measurement. These failures had the potential to result in compromising the medical and nutritional status of 50 residents for a census of 55. Findings: 1. During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that 44 residents who were on the regular portion size diets received two scoops equaling 8 oz. (2 servings of a 4-oz. scoop equals 1 cup) instead of three scoops equaling 12 oz. (equals 1 ½ cups) of pasta entree. A concurrent review of the facility document entitled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated July 2024, it showed, 1 ½ cups (12 oz.) of pasta dish for all regular portion diets, including for Regular, IDDSI (International Dysphagia Diet Standardization Initiative, describes texture modified foods and thickened liquids used in care settings) Level 5: Minced and Moist, Pureed, Consistent Carbohydrate (diet to control blood sugar level that is intended for people with diabetes), Heart Healthy/Cardiac, and/or Renal diets. During an interview with the Dietary Supervisor (DS) on 7/17/24, at 12:38 p.m., the DS acknowledged that residents with regular sized portions received two scoops (8 oz.) of the pasta dish for lunch. A concurrent review of the Diet Extensions (a spreadsheet with different therapeutic diets residents should receive according to planned food items with specific portion sizes and modified food texture) with the DS, she stated those residents should have received three scoops (12 oz.) of the pasta dish. 2. During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that five residents (Resident 6, 9, 14, 33, and 49) with puree texture diets were served a pureed texture garlic bread stick instead of a soaked white dinner roll (for pureed diets, bread items are sometimes soaked in a liquid such as milk to soften their texture). A concurrent review of the facility document titled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated 7/2024, it indicated residents with pureed texture diets should receive a soaked white dinner roll. During an interview with the DS on 7/17/24, at 12:38 p.m., the DS acknowledged that residents with pureed texture diets received pureed garlic bread sticks. After reviewing the Diet Extension, she stated those residents should have received the soaked white roll. 3. During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that 16 residents (Resident 7, 11, 19, 21, 25, 29, 32, 38, 39, 40, 43, 46, 52, 56, 110, and 261 ) who were on the IDDSI Level 5 Minced and Moist texture diet, Heart Healthy/Cardiac diet, and/or Renal diet received wheat dinner rolls instead of white dinner rolls. A concurrent review of the facility document titled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated 7/2024, it indicated a white dinner roll was to be served for the following diets: IDDSI Level 5 Minced and Moist texture diet, Heart Healthy/Cardiac diet, and/or Renal diet. During an interview with the DS on 7/17/24, at 12:38 p.m. she acknowledged that those residents with Level 5 Minced and Moist texture diets, Renal diet, and/or Heart Healthy/Cardiac diet received a wheat roll. After reviewing the Diet Extensions, she confirmed they should have received a white roll. 4. During an interview with the DS regarding the small portion on the Diet Extension on 7/16/24, at 9:05 a.m., the DS stated small portion sizes were not listed on the current menu system with the current menu company the facility was using. The previous menu company the facility used did include portion sizes for small meals on their menu/spreadsheets. The DS stated she has instructed the [NAME] and kitchen staff to give one-half amount of the regular diet for small portions. She confirmed the small portion did not have accurate measurements since the serving sizes and tools were not included on the menu/spreadsheet. During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that five residents (Resident 2, 4, 29, 36, and 52) with small portion diets were not served an accurate measured portion because the Diet Extensions did not include precise measurements for small portion size diets. During a follow up interview with the DS on 7/17/24, at 12:38 p.m., she acknowledged that those residents with small portions received one scoop (4 oz.) of pasta. She again confirmed that no portion measurements had been allotted on today's menu for small portion size diets and the portion amounts were discussed with the [NAME] and kitchen staff, and the measurement was up to the Cook's discretion. During an interview with the Registered Dietician (RD) on 7/18/24, at 10:30 a.m., she stated the current menu company did not have the portion size for diets in the menus. She stated this problem needed to be fixed right away because it could affect residents who are being monitored for weight loss. She stated they were looking for a new menu company and the menu should include portion sizes with accurate measurements. A review of facility document titled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated 7/2024, it did not indicate serving sizes (such as ounces, cups, etc.) for small portion diets. A review of facility document titled Job Description-Cook, Department: Dietary, revised 9/1/23, it showed, .Essential Job Functions: Follow recipes and prepare foods that correspond to menu cycles and recipes prepared by Dietician . A review of facility document titled, Dietary Aide-Job Duties and Responsibilities, revised 6/2020, it showed, .Food Services: Assist in checking diet trays before distribution . A review of facility policy and procedure titled, Menus, revised 10/2017, it showed, .Menus are developed and prepared to meet resident .needs while following established national guidelines for nutritional adequacy .Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutritional Board (National Research Council and National Academy of Sciences) .

The facility failed to ensure the appropriate food texture for five residents (Resident 6, 9, 14, 33, and 49) who were on a puree texture diet and received pureed ziti with cheese with chunks of pasta and tomato. The total census was 55. This deficient practice had the potential to increase risk to the residents with swallowing and/or chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway). Findings: A concurrent observation and interview on 7/17/24, at 10:27 a.m. with [NAME] (C)1 were conducted during puree preparation for the lunch meal. C1 stated the texture for the puree pasta (ziti with cheese) should be smooth, like mashed potatoes. A concurrent observation and interview on 7/17/24, at 12:38 p.m., with the Dietary Supervisor (DS), were conducted during food sampling of the puree pasta for the test meal tray. The texture of the puree pasta and cheese entrée had a bulky, lumpy consistency when sampling. After tasting, the DS stated the pureed pasta texture was lumpy with noticeable chunks of pasta and tomato, and stated the texture was not correct. The DS stated the texture should have been a smooth consistency. She added that residents who have swallowing difficulties might have increased risk for choking on the food chunks. During an interview with the Registered Dietician (RD) on 7/18/24, at 10:30 a.m., she stated, I was very disappointed with yesterday's puree. I was very surprised because normally they do a very good with the purees. The RD disclosed she observed the puree pasta ziti with cheese when she performed dining observation on 7/17/24 lunch meal. She acknowledged the puree ziti with cheese had lumps and stated the kitchen staff and the cook needed more training for that issue. A review of the facility's pureed pasta procedure titled PU4 Pasta Ziti Baked with Cheese [2] (PU4 Baked Ziti with Cheese), dated 5/2024, it showed, Blend [in food processor] until smooth .Final product must not be sticky or gummy. Pureed foods are classified as Level 4 as established by the IDDSI Framework (International Dysphagia Diet Standardization Initiative, describes texture modified foods and thickened liquids for care settings). A review of a facility document titled [Company name] Menu Solutions: Standards of Professional Practice-Diet Guide, updated 3/19/2021, under the section of IDDSI Level 4: Pureed Food indicated, .Description - This diet is used in the dietary management of dysphagia with food texture modification described as foods that are smooth and lump-free, not firm or sticky .

Based on observations, interviews and record reviews the facility failed to develop and implement person-centered comprehensive care plans for four (4) residents (Resident 2, Resident 36, Resident 10, and Resident 56,) of 15 sampled residents when: 1. Resident 2 and Resident 36 did not have a care plan for the use of psychotropic (medication that affects the brain associated with mental processes and behavior) medications; 2. Resident 10 did not have a care plan for the use of a Wander/Elopement Alarm (WEA, a wearable device that alerts when the wearer wanders or elopes out of the building); 3. Nursing staff did not implement Resident 56's care plan when there was no WEA on him. These failures decreased the facility's potential to provide appropriate interventions and person-centered care. Findings: 1. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in February 2024 with diagnoses which included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 2's Order Summary Report (OSR, physician orders), the OSR indicated Resident 2 was prescribed sertraline (a psychotropic medication) for depression manifested by feelings of sadness and loneliness. During a review of Resident 2's care plans on 7/17/24, there was no care plan for the use of Resident 2's psychotropic medication, sertraline. A review of Resident 36's admission record indicated Resident 36 was admitted to the facility in March 2024 with diagnoses including chronic kidney disease (a gradual loss of kidney function over time) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36's OSR, the OSR indicated Resident 36 was prescribed seroquel (a psychotropic medication used to treat schizophrenia, bipolar disorder, and depression). During a review of Resident 36's care plans on 7/17/24, there was no care plan for the use of Resident 36's psychotropic medication, seroquel. 2. A review of Resident 10's admission record indicated Resident 10 was admitted to the facility in February 2024 with diagnoses including dementia without behavioral disturbance or anxiety (a group of thinking and social symptoms that interferes with daily functioning) and recurrent depressive disorders (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 10's OSR, the OSR indicated Resident 10 had an order for a WEA. A review of Resident 10's care plans on 7/17/24, there was no care plan for the use of Resident 10's WEA. During a concurrent interview and record review on 7/18/24 at 8:51 a.m. with the DON (Director of Nursing), Resident 2's and Resident 36's care plans were reviewed. The DON confirmed there were no care plans for Resident 2's and Resident 36's psychotropic medications. Resident 10's care plan was also reviewed, and the DON confirmed there was no care plan for the use of Resident 10's WEA. The DON stated comprehensive person-centered care plans should be completed within 21 days and are reviewed or updated as applicable and they should include specific orders from the physician. 3. Resident 56's admission record was reviewed and indicated the resident was admitted to the facility with diagnoses of disorientation, apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), history of falling, and dementia. In an observation on 7/16/24 at 8:45 a.m., Resident 56 was in bed asleep and had bruises around the right eye and face. A WEA was wrapped around her right ankle. During an interview with the Licensed Nurse 3 (LN 3) on 7/16/24 at 8:37 a.m. the LN 3 stated Resident 56 fell last week and sustained bruising to her face and right eye. The LN 3 confirmed Resident 56 had a WEA on her right ankle. During a review of Resident 56's care plans indicated there were no comprehensive care plans written for the use of a WEA device. During an interview and record review with the DCO on 7/18 at 8:33 a.m., the DCO reviewed Resident 56's care plans and confirmed there were no care plans for the use of use of a WEA. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, revised March 2019, the P&P stated, If identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident.

Based on observations, interviews, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for seven residents (Residents 2, 36, 19, 10, 34, 56, and 110) out of 15 sampled residents when: 1. Psychotropic medications (medication that affects the brain associated with mental processes and behavior) were prescribed for Resident 2 and 36 without appropriate indications, manifestations or monitoring of behaviors. 2. Resident 19, 14 and 110 nasal cannulas (a plastic tube that delivers extra oxygen into your nose) and humidifiers (devices used to humidify supplemental oxygen) were not labeled or dated, and oxygen was not provided per the physician order. 3. Resident 10 and Resident 34 had incomplete monitoring orders for a Wander/Elopement Alarm (WEA, a wearable device that alerts when the wearer wanders or elopes out of the building) 4. Resident 56 had a WEA on without a physician's order. These failures decreased the facility's potential to prevent worsening of the residents' clinical condition. Findings: 1. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in February 2024 with diagnoses which included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 2's Order Summary Report (OSR, physician orders), Resident 2 had an order for sertraline (a psychotropic medication) for depression manifested by feelings of sadness and loneliness. There was not an order for the monitoring of Resident 2's feelings of sadness or loneliness noted on the OSR. A review of Resident 36's admission record indicated Resident 36 was admitted to the facility in March 2024 with diagnoses including chronic kidney disease (a gradual loss of kidney function over time) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36's OSR, the OSR indicated Resident 36 was prescribed quetiapine (a psychotropic medication used to treat schizophrenia, bipolar disorder, and depression) for depression. The OSR for these psychotropic medications did not include indications, manifestations of behaviors for the use of these medications or orders to monitor behaviors identified. During an interview on 7/18/24 at 9:24 a.m. with the Director of Nursing (DON), the DON stated, Orders for psychotropic medications need to identify the specific indication or behavior for the use of the medication for the resident .there needs to be an order to monitor those behaviors. A review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, indicated, Psychotropic medication management includes: indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. 2. A review of Resident 19's admission record indicated admission to the facility in June 2024 with diagnoses including acute respiratory failure (not enough oxygen in the tissues in your body) and chronic bronchitis (long term inflammation of the airways that carry air to the lungs). During an observation on 7/16/24 at 8:47 a.m. in Resident 19's room, Resident 19 was observed laying in bed with oxygen running at 2 L (liters, a unit of measurement) per minute through a nasal cannula connected to a concentrator (a machine that takes air from your surroundings, extracts oxygen and filters it into purified oxygen for you to breathe) with a humidifier. The nasal cannula and humidifier were not dated and initialed. During a concurrent observation, interview and record review on 7/16/24 at 11:11 a.m. with Licensed Nurse 4 (LN 4), in Resident 19's room, the LN 4 confirmed Resident 19's humidifier was not labeled with an open date and time and the nasal cannula was not labeled or dated. Resident 19's OSR was reviewed, the oxygen order indicated continuous oxygen due to chronic respiratory failure at 1 L per minute through a nasal cannula. The LN 4 confirmed Resident 19's oxygen was running at 2 L per minute instead of 1 L. The LN 4 acknowledged the importance of following physician orders, and the goal was to wean Resident 19 off from the supplemental oxygen. During a record review of Resident 14's facesheet, indicated Resident 14 was admitted with diagnoses of Idiopathic (relating to or denoting any disease or condition which arises spontaneously or for which the cause is unknown) Sleep Related Non-Obstructive Alveolar (the the tiny air sacs in the lungs), Asthma (chronic lung disease caused by inflammation and muscle tightening around the airways, which makes it harder to breathe). During the initial pool tour 7/16/24 at 9:44 a.m., Resident 14 was observed in her room and was receiving oxygen at 2 LPM nasal cannula via an oxygen concentrator machine. In an During an interview with the LN3 on, 07/16/24 at 9:44 a.m., he confirmed the Resident 14 was on oxygen and the oxygen cannula did not have a date when it was applied. The LN3 stated the facility practice and expectations were all oxygen tubings must be labeled and the oxygen tubing changed once every week on Friday. The LN3 stated the nasal cannula had no date on the tubing and the humidifier that would indicate when it was first used and when it was due to be changed. The LN 3 stated he will label and change the oxygen NC tubing now. Review of Resident 14's SRO indicated on 1/16/24: . Supplemental oxygen via NC (Nasal Cannula) or oxymask to keep SpO2 (blood oxygen level above or equal 90% . A review of Resident 110's admission record indicated she was admitted to the facility with diagnoses of chronic respiratory failure with hypoxia (Insufficient oxygen level at the tissue level), chronic respiratory failure with hypercapnea (excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration), and unspecified asthma (a long-term condition that affects the airways in the lungs). During an observation and interview on 7/16/24 at 9:44 a.m. the LN 3 confirmed Resident 110 was receiving oxygen via oxygen concentrator. Further observation by LN3, he stated the oxygen cannula was not dated when it was applied. The LN 3 stated the facility practice was all oxygen tubes must be labeled and per protocol the cannula was changed once every week on Friday. The LN3 stated he will label and change the oxygen cannula now. During a record review of Resident 110's OSR dated 7/9/24 indicated : .Change humidifier bottle and O2 (oxygen) tubing q FRI (every Friday) on noc (night shift) and PRN (abbreviation for as necessary) every night shift every Friday . During an interview on 7/16/24 at 5:06 p.m. with the Director of Nursing (DON) and the Director of Clinical Operations (DCO), the DON and DCO both stated the oxygen tubing and the humidifier should be labeled with the date and time it was applied. The DCO confirmed the expectations were that all oxygen tubings would be labeled and changed every Friday. A review of the facility's P&P titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, indicated, Distilled water used in respiratory therapy must be dated and initialed when opened and discarded after twenty-four (24) hours. 3. A review of Resident 10's admission record indicated admission to the facility with diagnoses including dementia without behavioral disturbance or anxiety (a group of thinking and social symptoms that interferes with daily functioning) and recurrent depressive disorders (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During an observation on 7/16/24 at 11:27 a.m. in the dining room, Resident 10 was observed sitting in her wheelchair. During an observation on 7/17/24 at 9:29 a.m. in the hallway, Resident 10 was observed sitting in her wheelchair. During concurrent observation and attempted interview on 7/18/24 at 11:57 a.m. in the dining room with Resident 10, Resident 10 was observed wearing a WEA on the left ankle. Resident 10 did not engage in conversation about the WEA. During a review of Resident 10's OSR, the OSR indicated Resident 10 had an order for a WEA with a start date of 4/10/24. There were no orders to monitor the placement, functional status or behaviors that would warrant the use of a WEA. A review of Resident 34's admission record, indicated Resident 34 was admitted to the facility in August 2023 with diagnoses that included adjustment disorder (emotional or behavioral reaction to change) with anxiety (worry and fear). A review of Resident 34's Minimum Data Set (MDS, an assessment tool), dated 4/23/24, indicated Resident 34 has severe memory problems, used a wheelchair independently, and used a WEA. A review of Resident 34's OSR, dated 7/19/24 indicated an active order for [WEA] to R [right] side of wheelchair to alert staff of attempts to leave building unassisted . with a start date of 3/1/24. The OSR did not indicate any orders for monitoring placement or functional status of the WEA. During an interview on 7/18/24 at 2:37 p.m., the DON stated, Prior to the placement of a [WEA] staff would need to contact the physician to discuss if the [WEA] is appropriate and there should be a lot of documented attempts to exit the building. During an interview on 7/19/24 at 10:10 a.m. with the DON and DCO, the DON and DCO confirmed orders for WEAs should include monitoring the placement and function of the WEA. During a review of the P&P titled, Wandering and Elopements, revised March 2019, the P&P stated, If identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A P&P for the use of wander/elopement alarms was requested on 7/19/24 at 10:10 a.m. from the DON and DCO. The facility was unable to provide a P&P for the use of WEAs. 4. Resident 56 facesheet was reviewed and indicated the resident was admitted to the facility with diagnoses of disorientation, apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), history of falling, and dementia. Resident 56 was seen on 7/16/24 at 8:45 a.m. during an initial pool tour of the facility. The Resident was in bed asleep and observed that Resident 56 has bruising around her right eye and face. Resident 56 was observed to have a WEA in place on her right ankle. During an interview with the LVN 3 on 07/16/24 at 8:37 a.m. he indicated the resident dad a fall last week and sustained bruising on her face and right eye. The LVN 3 confirmed that the resident has a WEA on her right ankle. The LN3 stated the resident was confused and was exit seeking from the building when she fell. The Resident's bed was observed to be in a low position and a falls mat was in place at the bedside. Review of Resident 56's nursing notes 7/12/24 indicated the resident fell and sustained bruises and a laceration by the right eye. Neuro checks were on going. Further review of the nursing notes from 7/12/24 through 7/18/24, there were no notation that indicated a WEA was applied to the resident's right ankle. Further review of Resident 56's OSR dated 7/16/24, there were no physician's orders obtained for the use of a WEA. During a record review of the resident 56's clinical records indicated there were no care plans in place for the use and monitor of a WEA. During an interview with the Director of Clinical Operations (DCO) on 7/18 at 8:33 a.m. The DCO stated after reviewing the clinical record, that Resident 56 wore a WEA and there were no physician's orders nor care plans in place for the use of a WEA. The DCO stated the MD must be notified and must order for the use of a WEA. During a record review of the facility policy and procedure Wandering and Elopements revised March 2019 indicated: .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .1. If identified at risk for wandering, elopement, or other safety issues, the resident's care plan will include startegies and interventions to maintain the resident's safety. During a record review of facility policy Goals and Objectives, Care Plans revised April 2009 indicated: .Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .1. Care plan goals and objectives are defined as the desired outcome for a specific reisdent problem .3. Care plan goals and objectives are derived fro information contained in the resident's comprehensive assessment and: a. are resident oriented b. are behaviorally stated c. are measurable, and d. contain timetable to meet the resident's needs in accordance with the comprehensive assessment . 5. Goals and objectives are reviewed and/or revised: a. whne there has been a significant change in the resident's condition. b. when the desired outcome has not been achieved c. when the resident has been readmitted to the facility from a hospital/rehabilitatioon stay; and d. at least quarterly .

Based on observation, interview and record review, the facility failed to ensure the Dietary Supervisor (DS) met the state's education qualification requirements, as required per federal regulation, to be the DS to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultations with the DS to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (cross reference F803), modified food texture accuracy (cross reference F805), and safe food handling and sanitation (cross reference F812), which lacked the benefit of a qualified DS responsible for the day-to-day food service operation for the skilled nursing facility. In addition, the facility lacked the benefit of the expertise of the RD input when there was not sufficient oversight over the food service operations via frequently scheduled consultation to the DS by the RD, when the job description and the contract of the RD was essentially based on clinical nutrition. There was a total of 53 out of 55 residents receiving meals from the facility kitchen. Findings: During the annual recertifications survey from 7/16/24 to 7/19/24, multiple issues surrounding the delivery of dietetic services were identified: 1. Meal distribution accuracy - the menu/spreadsheet (a tool helps the kitchen staff to identify food items, portion sizes and utensils (such as scoops, ladles, etc.) for different therapeutic diets) were not followed, and the portion size of food items were not served correctly; 2. Puree food texture was not prepared appropriately to meet residents' needs, and 3. Safe food handling and sanitation: a. Cooked chicken leftovers were found without temperature monitoring before being stored in the refrigerator for the cool down procedure; b .A cook did not practice ambient (room temperature) food cool down procedures when preparing ambient foods (such as tuna salad, egg salad, chicken salad, etc.); c. Bags of bread (English muffins and raisin bread) passed the used-by date were not discarded; d. Several sizes metal pans were found stacked wet, and few metal pans with brown and white substances on the food contact surfaces were stored at the clean and ready-to-use storage areas; e. The interior of the microwave was found dirty with food debris and liquid splashes; f. Several cutting boards were found with deep gouges, black substances and strong rancid odor; g. Employee's personal beverage containers were found at the resident's food/beverage preparation area, and h. The ice machines located in the kitchen and nourishment room (at nurse station) were not clean. During an initial kitchen tour and concurrent interview with the Dietary Supervisor (DS) on 7/16/24, at 9:13 a.m., the DS stated she started the position since in September last year (2023). She stated she was not certified as a Dietary Services Supervisor (DSS) or Certified Dietary Manager (CDM), and she added she was still taking courses to be a CDM. She stated there were two Registered Dietitians (RD) contracted to the facility and they visited the facility around 16 hours per week. The DS stated the RDs were responsible for clinical and monthly kitchen sanitation audit, but no in-services for the kitchen staff. She stated she was responsible for the in-services for the staff, but she only did one so far since she started working in the facility. During an interview with the Regional Operations Director (ROD) on 7/17/24, at 2:14 p.m., he was aware the DS was not qualified for the current position. A concurrent review of the federal regulations with the ROD indicated the qualified personnel for the Dietary Manager position should meet one of the criteria from the state standards, Health and Safety Code 1265.4. The ROD acknowledged the requirements after he reviewed the state standards. During an interview with the RD on 7/17/24, at 2:45 p.m., she stated she and the other dietitian visited the facility twice per week (around 16 hours per week) per contract. She stated she and the other dietitian were majorly responsible for clinical work (such as nutrition assessments, monitoring resident's weight and attending weight meeting, and consultations) and monthly kitchen sanitation audit. She stated she usually spent one to two hours for the kitchen sanitation audit monthly. She stated she did some meal tray monitoring and in-services for the staff last year but did not do any this year. She stated she spent approximately 80 percent of her visit time for clinical and 20 percent for foodservice operation (kitchen). During a follow up interview with the RD on 7/18/24, at 10:30 a.m., she stated she was not aware the DS was not qualified for the position and did not meet the state standards. She stated she was aware that the DS still taking the courses to be CDM certified. RD stated she and the other dietitian covered the full-time position due to the previous dietary supervisor not being qualified. She stated the dietitians' hours cut back to part time since the new company took over and the new supervisor, DS, was on board for the position. A review of the DS's employee file indicated the DS was hired by the facility on 3/22/24 for the full-time position as Dietary Manager. The file indicated DS had three associate degrees with management, business management and recreational management but no indication of any type of professional registration nor certification. The file included ServSafe certification (a certification provided after the completion of training and an examination of the knowledge of safe food handling), but this certification was not one of the requirements of the state standards. A review of DS's job description (JD) provided by the facility, revised 6/2020, it did not indicate any education and experience requirements for the dietary supervisor position. A review of the state's qualifying pathways to be a dietary manager as listed in the Health and Safety Code (H & SC) 1265.4, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. A review of the RD's JD, revised 11/2017, it indicated the RD majorly was responsible for clinical work for the facility. A review of the facility-RD contract titled, [Consulting Company Name] - Consulting Agreement, contracted started 4/1/2024, it indicated the scope of the RD's duties as consultant basis and responsible for clinical work for the facility. It also indicated the RD or RDs were contracted to work in the facility and did not exceed a maximum of 20 hours per week. The contract also indicated work days and hours were flexible and allowed the RD or RDs to be complete remotely for documentation and charting through the electronic medical record system 50 percent of the time.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1) Cool down process was not performed for meat leftovers (any food that was prepared for service but was not served), 2) Procedure for cooling down method for ambient (room temperature) food was not being followed, 3) Metal serving pans had brown and white substances on the inside surface; serving pans were found stacked wet, 4) Expired bread had not been discarded, 5) Microwave had food debris on upper interior surface, 6) Several cutting boards had gouges, black smudges, and rancid odor, 7) Employees' beverage containers were stored in residents' food and drink preparation area, and 8) Ice machines in kitchen and nourishment rooms were not clean. These failures had the potential to lead to foodborne illness for a total of 53 out of 55 residents who received facility prepared foods. Findings: 1. During an inspection in the walk-in refrigerator on 7/16/24, at 10:28 a.m., a bucket of cooked leftover chicken breasts (cooked on 7/15/24) was found that did not have temperature monitoring and without the cool down process done before being stored in the refrigerator. In a concurrent interview with the Dietary Supervisor (DS), she reviewed the weekly menu for the week and stated the chicken was prepared for the Asian Chicken salad for dinner on 7/15/24. When the DS was asked whether the cook performed a cool down process for the chicken pieces, she reviewed the Food Cooling Log and stated there was no entry for the chicken breasts for 7/15/24. She stated the cook who placed the chicken breasts in the refrigerator would return to work on 7/18/24. During a follow up interview on 7/17/24, at 9:05 a.m. with the DS, she stated [NAME] (C) 2 was the one who cooked the chicken in the walk-in refrigerator, and he would be in to work that morning at 10:30 a.m. During an interview with C 2 on 7/17/24, at 10:54 a.m., he stated someone else cooked the chicken breasts, but he was the one who put them in the refrigerator that evening (7/15/24) without taking the temperature of the chicken or following the cool down process. He stated, It was a mistake, and specified that because he didn't perform the cooling down method, he wouldn't know whether the temperature of the food was within safe food parameters. During an interview with the Registered Dietitian (RD) on 7/18/24, at 10:30 a.m., she stated the cook should have done the cool down procedure for the leftovers before storing them in the refrigerator for food safety. She said, We need to do the in-service, and we need to get a log for the process. A review of facility's Food Preparation and Service, revised Nov. 2022, it showed, .Potentially hazardous food (PHF) including meats, poultry .Rapid Cooling: PHF are cooled rapidly. This is defined as cooling from 135 degrees Fahrenheit (F) to 70 F within two hours and then to a temperature of 41 F or below within the next 4 hours. The total cooling time between 135 F and 41 F is not to exceed 6 hours . A review of facility policy and procedure titled, Use of Leftovers (2013), it showed, Leftovers must be cooled to 70 F within 2 hours and then down to 41 F within another 4 hours . 2. During a concurrent observation and interview on 7/17/24 at 3:55 p.m., C 2 was preparing chicken salad for the evening meal, chicken salad sandwiches. C 2 stated there was no system for cooling ambient foods, nor was he practicing it. He verbalized the process of ambient food (such as tuna or egg salad) cool down with prompting. He stated he would put the made salads in the refrigerator but not take any temperature nor using the cool down log for monitoring. C 2 also stated he never practiced or had been told to do the ambient food temperature monitoring and cool down process. During an interview with the DS on 7/18/24, at 2:55 p.m., she stated the kitchen did not have a policy and procedure for ambient foods, and the kitchen staff were not practicing the ambient cool down process. During a follow up interview with the DS on 7/19/24, at 9:12 a.m., she changed her answer and stated the kitchen had a cool down process for ambient foods. However, she stated the staff were not monitoring the temperature after the cold salads were prepared. She confirmed that the staff should be monitoring the temperature and practicing the ambient food cooling down process. A review of undated facility's policy and procedure titled, Addendum to Food Preparation, it showed, Ambient food being used for cold food preparation will be pulled from the shelf 24 hours in advance and placed in the refrigerator. Once pulled from the refrigerator, and opened, food items will be temped [temperature taken] to assure temperatures are 41 degrees or below. Once the preparation of the food is completed, the item will then be temped again to assure food temperature has not exceeded 41 degrees .Ambient food prepared using ingredients from room temperature items for cold production must be cooled to 41 degrees within four hours .Will maintain cooling logs for ambient food. 3. During a concurrent observation and interview on 7/16/24, at 9:53 a.m. and 10:12 a.m., there were several metal pans found having issues stored in the clean and ready-to-use areas as follows: -9 of 1/3 sheet pans (stacked wet) -3 of 1/2 sheet pans (stacked wet) -4 of full sheet pans (stacked wet) -2 of full sheet pans (had brown and white substances on the inside surfaces) The Assistant Dietary Supervisor (ADS) stated the pans should be dried. She also stated the pans should be clean and the staff should check them before being stored away. During an interview with the RD on 7/18/24, at 10:30 a.m., she stated the pans should be fully dried and clean before being stored away. The RD stated she would talk with the dishwasher about completely air drying the pans. A review of facility's policy and procedure titled, Sanitation: Dish Machine Usage and Testing, dated 10/01/2021, it showed, .Air dry: Place equipment or utensils onto a clean surface to air dry. Do not dry with a towel or other method .Return to storage: Once equipment and utensils are completely air dried, they can be returned to storage . A review of the facility's policy and procedure titled, Sanitation, dated 10/2008, it indicated all food contact surfaces and utensils must be washed to remove the soil completely before manual or machine wash, then sanitized. 4. During a concurrent observation and interview on 7/16/24, at 10:18 a.m., there was a tray of four bags of English Muffins with a label written, Pulled 6/24/24, Use by 7/14/24. There was another tray of three bags of raisin bread with a label written, Pulled 6/29/24, Use by 7/13/24. The ADS confirmed and stated those breads were past the use by date and should be discarded. She added the breads stored in the freezer are pulled out for thawing at room temperature. She stated it was everybody's responsibility to check the bread. During an interview on 7/19/24, at 9:05 a.m. with the DS, she stated the bread was received frozen from the supplier and kept in the walk-in freezer. She stated the kitchen followed the dry storage guidelines for the bread, which could keep for five to seven days unopened or opened on the shelf. A concurrent review of facility policy and procedure, Food Receiving and Storage Policy and Procedure, dated 11/2022, with the DS, under the Refrigerated/Frozen Storage section, which stated that refrigerated foods should be eaten by their 'use by' date, or else need to be frozen or discarded. The DS confirmed that she would follow that section of the guidance for the dry foods which would be discarded if past the use by date. During an interview with the RD on 7/18/24, at 10:30 a.m., she stated the kitchen staff need more training. She stated she planned to talk to the staff more about putting correct dates on labels. The RD stated, There's no excuse. They shouldn't have them (expired bread items) there. She stated she had a prior discussion with kitchen staff about doing a daily walkthrough of food items and discarding expired food. A review of facility's document titled, Dry Goods Storage Guidelines, dated 2023, it indicated that the bread should be stored, 5-7 days unopened on shelf .5-7 days opened on shelf .This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise. A review of facility policy and procedure titled, Food Receiving and Storage, revised Nov. 2022, it showed, .Refrigerated/Frozen Storage: Refrigerated foods are labeled, dated and monitored so they are used by their 'use by' date, frozen or discarded . (The DS stated this guidance also applied to the dry food, which needed to be discarded when past the use-by date.) 5. An observation of the microwave oven cleanliness and concurrent interview was conducted on 7/16/24, at 10:09 a.m. The interior top portion of the microwave was found with food residue and liquid splash spots. Dietary Aide (DA) 1 confirmed and stated the microwave was dirty and that she cleans the oven every day. She stated the microwave was scheduled to be cleaned daily. During an interview with the RD on 7/18/24, at 10:30 a.m., she acknowledged and agreed the microwave should be cleaned daily. A review of facility's policy and procedure titled, Sanitization, revised 10/2008, it showed, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . 6. A concurrent observation of the cleanliness of cutting boards and interview was conducted with the ADS on 7/17/24, at 9:24 a.m. There were seven plastic cutting boards found with deep gouges, dark brownish black splotches on the surfaces, and a rancid odor. The ADS confirmed and stated the cutting boards were in bad condition and agreed they smelled. She also stated she would discard them. During an interview with the RD on 7/18/24, at 10:30 a.m., she stated she was aware of the issues with the cutting boards. She stated she recommended they do a chorine wash, and she had also instructed the staff to discard marred or stained cutting boards. She stated the cutting boards should have smooth surfaces to be easily cleaned. A review of the facility's policy and procedure titled, Sanitization, revised 10/2008, it showed, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/chemical sanitizing solutions .Cutting boards (acrylic or hardwood) will be washed and sanitized between uses . 7. During an initial kitchen tour on 7/16/24, at 9:00 a.m., an observation of the food preparation area and interview was conducted with the ASD. There were personal beverage containers found on the resident's food and drink preparation area. The ASD confirmed the beverage containers belonged to the kitchen staff. She stated there was no designated area for the staff's drink containers. In a follow up interview with the DS at 9:20 a.m., she confirmed that staff's drinks were in the food preparation area and agreed there should be a designated area for staff's belongings. During an interview with the RD on 7/18/24, at 10:30 a.m., she stated staff's personal items and drinks were not allowed in the food/beverage prep area and these items should be in a designated area. A review of the undated facility's policy and procedure titled, Employee Health and Hygiene: Personal Items, Food and Drink, it showed, .Designate area within the facility for associates to store beverages-ideally 3 feet from any food preparation or storage area. Beverages should not be stored in and around cook areas or utility rooms .Observe food preparation areas to ensure no food, drink .are stored outside of their designated area . 8. During an inspection of the ice machine in the kitchen on 7/16/24, at 11:20 a.m., the Dietary Aide (DA) 2 stated he was responsible for the monthly cleaning and sanitizing for the ice storage bin. He dissembled the top part (machinery part) of the ice machine. DA 2 stated he was also responsible for rinsing the water curtain (a plastic cover rest on the ice making panel of the top machinery component, the function is to prevent ice shooting out and redirect the ice to the ice storage bin) and the water trough (a component that holds the water before it is frozen during the ice making process) with hot water only. He stated he did not touch anything else other than the ice storage bin, water curtain and water trough. During an interview with the Maintenance Supervisor (MS) on 7/16/24, at 11:40 a.m., he stated that the facility hired outside vendor and sent their technician to the facility and performed the deep clean (clean and sanitize the machinery part (top part) of the machine and the ice storage bin with the chemical solutions) of the ice machine every six months. Upon removing the ice machine's top access panel, the water curtain and the water trough, there were pink and slimy substances found. This was covering some portion outside of the water curtain and inside of the water trough and was easily removed when wiping with paper towel. There were significant black substances found at the bottom of the evaporator unit (a part where the water condenses and makes ice) and was easily wiped off with the paper towel. The MS stated the last deep clean was done on 3/25/24 and the water filter would be changed every year with the last change on 3/25/24. The MS confirmed the pink and black substances and stated maybe the ice machine was not scrubbed enough. During an inspection of the ice machine in the nourishment room located at the nurse station on 7/16/24, at 11:43 a.m., the MS stated he was responsible to clean the ice storage bin and rinse the water curtain and water trough with hot water and clean the ice dispenser nostril monthly. When the MS removed the top access of the machinery part of the ice machine, there were pink slimy substances found on the water curtain and inside the water trough, and on the top and bottom rims of the ice making panel. The pink slimy substances were easily wiped off with paper towel. In addition, there were significant black substances found on the bottom of the evaporator unit and the black substances were easily wiped of with paper towel and felt the surface was not smooth when touched. The MS stated the outside vendor was responsible to do deep clean for the ice machine every six months and the last service was done on 3/25/24. The MS confirmed the pink and black substances were found and stated maybe the outside vendor technician did not scrub enough when cleaning the ice machine. During an interview with the outside vender technician (OVT) on 7/16/24, at 3:35 p.m., he stated the previous technician may not be scrubbing the parts of the ice machine enough and the calcium deposits accumulated for both ice machines (kitchen and nourishment room). He stated the calcium deposits took times to be soften and clean better. During an interview with the Registered Dietitian (RD) on 7/18/24, at 10:30 a.m., she stated the ice machine should be clean. She stated she checked the ice machine monthly during the monthly kitchen sanitation audit, but she did not check the top (machinery) part. A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, The food service area shall be maintained in a clean and sanitary manner . ice machine and ice storage containers will be drained, cleaned and sanitizer per manufacturer's instructions . A review of the undated kitchen ice machine manual titled, [Manufacturer's brand] Ice Machines Installation, Operation and Maintenance Manual, indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual. CLEANING/SANITIZING PROCEDURE This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized . Removes mineral deposits from areas or surfaces that are in direct contact with water. PREVENTATIVE MAINTENANCE CLEANING PROCEDURE . This procedure cleans all components in the water flow path, and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure without removing the ice from the bin/dispenser . A review of the undated nourishment room ice machine manual titled, [Manufacturer's brand] Dispensers Installation, Use & Care Manual, indicated all removable and disassembled parts of the ice machine should be clean and sanitize with the cleaning and sanitizing solutions monthly. According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like 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 (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). In addition, on Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse 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 for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits .

Based on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one of one garbage dumpster, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview on 7/16/24, at 10:52 a.m., it was observed one out of one outside dumpster was covered with its two lids. However, the dumpster lids were bowed away from the midline where they converged, leaving a two-inch gap in between. The deformed lids lacked the integrity to securely cover the bin. The Dietary Supervisor (DS) confirmed the condition of the dumpster lids and agreed that either the lids needed to be fixed or the facility needed a new trash bin. During an interview with the Director of Clinical Operations (DCO) on 7/19/24, at 9:35 a.m., she stated the facility did not have a policy and procedure regarding dumpster conditions. The DCO stated the maintenance department called a waste management company and had to purchase new lids for the dumpsters. According to the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.15 Outside Receptacle, referenced 7/23/24, (A) Receptacles and waste handling units for refuse .used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one Certified Nursing Assistant (CNA), CNA 2, of five sampled CNAs had a valid CNA license. This failure had the potential to result in all 55 residents in the facility to receive care from an unqualified person. Findings: During a concurrent interview and record review on [DATE] at 11:44 a.m. with the Director of Nursing (DON), the CNA 2's license verification was reviewed. The DON confirmed CNA 2's license verification indicated an expiration date on [DATE]. The DON stated she expected CNAs who worked at the facility to have a valid CNA license. During a concurrent observation and interview on [DATE] at 11:48 a.m. with the Director of Staff Development (DSD) in the facility's dining room, CNA 2 was assisting residents with their lunch meal. The DSD stated she was aware CNA 2's license was getting close to expiration, CNA 2 had not yet submitted an updated CNA license and confirmed CNA 2 was currently working a CNA shift. An interview on [DATE] at 11:53 a.m., CNA 2 confirmed she has not received a CNA license renewal yet and her CNA license was expired. A review of the facility's policy and procedure titled Competency of Nursing Staff revised [DATE], indicated, .all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law . A review of California Health and Safety Code, Division 2. Licensing Provisions, Chapter 2. Health Facilities Article 9, Section 1337.6, effective date [DATE], indicated, .The department shall give written notice to a certificate holder 90 days in advance of the renewal date and, 90 days in advance of the expiration of the fourth year that a renewal application has not been submitted, and shall give written notice informing the certificate holder, in general terms, of the provisions of this article. Nonreceipt of the renewal notice does not relieve the certificate holder of the obligation to make a timely renewal. Failure to make a timely renewal shall result in expiration of the certificate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain an infection control program for a census of 55 residents when: 1. Facility staff were observed not performing hand sanitation when entering and exiting resident's rooms; 2. Soiled linens were processed without adequate use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses); and, 3. The washing machine's water temperature was not monitored. These failures decreased the facility's potential to prevent the spread of disease and infections among residents. Findings: 1. During an observation and concurrent interview with Environmental Service 1 (EVS 1) on 7/18/24 10:32 a.m., the EVS 1 was observed entering and exiting resident rooms 24, 25, 12, and 13 without performing hand sanitation. The EVS 1 was observed to push her cart near room [ROOM NUMBER], entered room [ROOM NUMBER] with gloved hands without sanitizing her hands. The EVS 1 was observed to exit room [ROOM NUMBER], removed her gloves, and donned a new pair of disposable gloves without sanitizing her hands with the intention of entering room [ROOM NUMBER]. The EVS 1 confirmed she had been trained in handwashing and hand sanitation practices, but was rushing and trying to save time to complete her work. During an observation and concurrent interview on 7/18/24 at 11:05 a.m., the EVS 2 was observed to exit room [ROOM NUMBER] holding towels with ungloved hands. The EVS 2 proceeded to open the lid of the hamper with her bare hands and tossed the dirty towels into the linen hamper. The EVS 2 immediately re-entered room [ROOM NUMBER] without sanitizing her hands. The EVS 2 then touched the resident's clean blanket and began to rearrange it. The EVS 2 stated the towels were from the patient's bathroom sink in and confirmed the towels were dirty and needed to be placed in the dirty laundry hamper. The EVS 2 she confirmed she should have worn gloves. The EVS 2 stated she was in a hurry. The EVS 2 also confirmed she should have washed her hands before going into the resident's room and tidying up the resident's blanket. During an observation and concurrent interview on 7/18/24 11:20 a.m., the Certified Nursing Assistant 3 (CNA 3) was observed to enter and exit rooms [ROOM NUMBER] without using any of the alcohol-based hand sanitizers located throughout the hallway to sanitize her hands. The CNA 3 confirmed she had not sanitized her hands and should have done so before entering the residents' rooms. During an observation on 7/18/24 at 11:25 a.m. resident rooms [ROOM NUMBER] were observed to have faucets and sinks with soap dispensers available for use to wash hands. 2. During an inspection of the facility laundry department was performed on 7/19/24 at 9:12 a.m. accompanied by the Infection Preventionist (IP). The laundry department was divided into two sections: one room for storage of dirty linens and the other room was for storage of clean linens. The dirty linens section was observed to have one box of disposable gloves but no other PPE equipment was accessible in the dirty linens room. During an observation of the clean linens section of the laundry room on 7/19/24 at 9:15 a.m. the Linen Room Technician (LRT) was observed folding clothes and linens. In a concurrent interview the LRT stated she was folding the washed and clean linens. The LRT was asked to demonstrate how she processed the dirty linens to be washed. The LRT entered the dirty linens room and stated she donned disposable gloves. The LRT stated she transported the dirty linen hamper into the laundry room and the dirty linens were placed into the washing machines to be washed. The LRT stated she would then remove the disposable gloves from her hands and would sanitize her hands. The LRT confirmed she had never worn a cover gown or faceshield when processing dirty linens, she wore only disposable gloves. The LRT further stated she had not been trained to use a gown or face shield when processing dirty linens. In an interview with the IP on 7/19/24 at 9:30 a.m., the IP confirmed there were no other PPE in the dirty linens room except for the gloves. Concurrent interview the IP, she stated the LRT staff should be wearing gloves, a gown, and face shield when processing and handling dirty linens. In a further tour of the clean linen section of the laundry department with the IP and LRT on 7/19/24 at 9:45 a.m., the LRT confirmed there were two washing machines and two dryers in the department. The LRT stated she did not know if the washing machines or dryers were high or low temperature machines. The LRT further stated she did not knowwhat the water temperatures should be in the the washing machines, nor what the dryer machine temperatures were supposed to be when drying the clothes. The LRT stated she had not been monitoring temperatures for either the washing or dryer machines. The only log she kept was for cleaning the lint screens of the dryers. The LRT further indicated the washing machines were supplied from a dedicated hot water line. She pointed to a tankless water heater and had a digital readout which indicated 131 degrees Fahrenheit (a unit of measurement that is used to measure temperature). The LRT was not aware of what the minimum temperatures should be when washing the dirty linens. In an interview with the Maintenance Supervisor (MS) on 7/19/24 at 9:50 a.m., the dryer temperature was checked with a heat gun and indicated 139 degrees Fahrenheit (F). The MS stated he did not know what the optimal temperature range the dryers and the washing machines were supposed to operate within. The MS confirmed he was in charge of the Laundry Department. The MS stated the hot water supply for the washing machines came from a tankless water heater and the temperature reading from a digital thermometer was 131 degrees F. The MS stated he was unaware the temperatures were needed to be monitored on the washing machines and the dryers. There were no other temperature measuring tools to indicate how hot the water temperatures gets with the washing cycles, nor the dryers temperature when in operation. A review of an electronic mail addressed to the MS by the laundry company dated 7/19/24 at 11:46 a.m. indicated, .The washer does not have an internal water heater. However water temps [temperatures] on a Hot fill setting should be around 150 degrees F .The dryers are as follows .Low heat temp= 140 degrees, Medium heat temp= 160 degrees, High heat temp= 185-190 degrees . A review of the facility policy and procedure titled Laundry and Bedding soiled revised September 2022 indicated, .Soiled laundry/bedding shall be handled, transported and processed according to the best practices for infection prevention and control. Handling .All used laundry is handled as potentially contaminated using standard precautions (e.g. gloves and gowns when sorting .Onsite Laundry Processing .Laundry processed in hot water temperatures is 160 degrees F for 25 minutes. A review of an undated facility procedure titled Isolation Laundry Procedures indicated, .Procedures .Wear rubber gloves and gown/apron .Set booster water heater according to instructions to highest setting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, implement, and monitor an infection control program with the use of antibiotics when: 1. The Infection Prevention and Control Program (IPCP) failed to monitor the laboratory indications on the use of antibiotics. 2. There were inadequate tracking tools in use for tracking of residents on antibiotics and the indications for the use of antibiotics 3. There were inadequate infection control inservices for the facility staff on handwashing. These failures had the potential for residents to be exposed and acquire infectious diseases causing illness. Findings: 1. During an interview with the Infection Preventionist (IP) on 7/18/24 02:35 PM the IP was asked to provide the tracking tool she used to monitor residents who were using antibiotics. The IP was further asked aside from the tracking tool she used what were the clinical indications for the use of the antibiotics. The IP provided a map of the facility which she stated she used to monitor residents that were having Urinary Tract infections (UTI) which were rooms 11, 23, 24, 25, 26. The IP was asked how she verified and confirmed the specific residents in rooms 11, 23, 24, 25, 26 who had a UTI. The IP was not able to answer who were the specific residents in the room that had UTI, nor the confirming laboratory indicators of a urinalysis (a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes), urine culture and sensitivity (C/S A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection and antibiotics that the germs may be resistant). She was not using any other tool to track antibiotic use. The IP was asked who were the current residents she had that were on antibiotic treatment. The IP state for Resident 35 (3 A), the Medical Doctor (MD) prescribed Ciprofloxacin, an antibiotic for the treatment of UTI. The IP was asked what was the laboratory indication for the use of the antibiotic, she stated she had not checked for the urinalysis and the C/S indication. She was asked to check the lab of Resident 35 and the culture result dated 7/18/24 result was urogenital flora (normal). Concurrent interview with the Director of Clinical Operations she was was asked to verify the laboratory findings, and she stated it was normal and the resident had no indications for use of the antibiotic. The DCO stated she will clarify with the MD if not to discontinue the medication. Further interview with the IP on 7/18/24 at 2:55 p.m. the IP was asked to verify if Resident 29 in room [ROOM NUMBER] was on antibiotics. The IP was not aware if resident 29 was on antibiotics. The MD orders were reviewed with the IP and she confirmed that Resident 29 was on antibiotic Cephalexin 250 mg (milligrams, a dosage) by mouth was ordered on 5/31/24. Further interview with the IP she stated the Cephalexin was ordered to be given 1 capsule once a day for Prophylaxis (preventative) related to Urinary Tract infection. The IP was asked to verify if the resident had any urinalysis or culture and sensitivity labs done to indicate the Resident had any UTI. The IP confirmed there were no laboratory examinations ordered. Further interview with the IP the antibiotic Cephalexin was started on 5/31/24 and as of 7/18/24 Resident 29 had been on antibiotics a total of 48 days for the prevention of UTI. Concurrent interview with the DCO she stated the used of Cephalexin antibiotic for UTI prophylaxis was not normal clinical indications for usage. The DCO stated she will clarify with the MD if not discontinue the medication. 2. During an interview with the Infection Preventionist (IP) on 7/18/24 02:35 PM the IP was asked to provide the tracking tool she used to monitor residents who were using antibiotics. The IP was further asked aside from the tracking tool she used what were the clinical indications for the use of the antibiotics. The IP provided a map of the facility which she stated she used to monitor residents that were having Urinary Tract infections (UTI). The IP was asked how she verified and confirmed the rooms 11, 23, 24, 25, 26 had UTI. The IP was not able to answer who were the residents in the room that had UTI nor the confirming laboratory indicators of a urinalysis (a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes), urine culture and sensitivity (C/S A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection and antibiotics that the germs may be resistant). She was not using any other tool to track antibiotic use. Concurrent interview with the DCO she stated there were tracking tools for the IP to use in the Electronic Health Records (EHR). The DCO stated it was still in development and not yet active. The DCO confirmed there were no other tools in used for monitoring infections and for the use of antibiotics. 3. During an interview with the IP on 07/18/24 at 2:42 PM The IP was asked about staff infection control in-services specifically hand washing. The IP was made aware of observations made on staff who were not performing hand hygiene when going in and out of residents rooms. The IP stated in-services were done on handwashing, and she confirmed all employees whether they are clinical or non clinical employees are expected to attend handwashing inservices. The IP was asked to provide the staff in-services attendance sheets on handwashing from January 2024 to current date of 7/18 /24. The IP stated that ALL staff must attend handwashing in-services whether they are clinical or non-clinical employees. The IP stated and verified total number of employees were 82. The breakdown were Fulltime employees were 59, Part time were 15, on call were eight (8). The IP provided the In-service Training attendance on Handwashing and the sign in attendance sheets dated 2/6/24 for in-service times of 6:30 a.m. and 2:10 p.m. total staff who attended were six (6) staff members. The IP confirmed that was all the inservices she had on file. Review of some of the Infection Prevention Nurse job description indicated: .Plan, develop, organize, implement evaluate, coordinate, and direct our infection control program in accordance with the current rules, regulations, and guidelines that govern such requirement .Interpret infection control policies and procedures as necessary .Assist the supervisor of laundry services in developing infection control procedures for the handling of clean and soiled laundry and linen, equipment cleaning .Ensure that all nursing service personnel follow established isolation precautions to include standard/universal precautions .

Based on interview, observation, and record review, the facility failed to ensure the required in-service trainings for three of four sampled Contracted Certified Nursing Assistants (CCNA 1, CCNA 2, and CCNA3) and three of five sampled facility employed Certified Nursing Assistants (CNA 2, CNA 3, and CNA 4), when the facility was unable to provide documentation to demonstrate the CCNAs and CNAs had no less than 12 hours per year of continuing competencies including dementia (a loss of memory and problem-solving abilities which interfere with daily life) management and abuse prevention. These failures had the potential to result in CCNAs and CNAs not identifying and reporting abuse nor being able to effectively care for residents with dementia. Findings: In an interview on 7/18/24 at 2:59 p.m., the Director of Clinical Operations (DCO) stated the facility used contracted staff through staffing agencies and she expected those staffing agencies to provide CCNAs mandatory training documentation for facility to review before scheduling the CCNAs to perform patient care. During a concurrent interview and observation on 7/18/24 at 3:04 p.m., the Staffing Coordinator (SC) stated the facility used three staffing agencies for the CCNAs and the staffing agencies send over documentation to demonstrate the CCNAs completed the mandatory annual trainings. The SC logged onto two of the three staffing agency's online portals to look for documentation to demonstrate the CCNAs had completed the abuse prevention and dementia management trainings. The SC confirmed she could not find any documentation to support the CCNAs had completed any of the mandatory annual trainings. During a concurrent interview and observation on 7/19/24 at 8:22 a.m., the Director of Staff Development (DSD) stated she did not have a specific training plan for the CCNAs, she would encourage them to attend any in-service trainings hosted by the facility if they were present when trainings occurred, and she believed the staffing agencies provided the CCNAs with annual mandatory trainings including abuse prevention and dementia management. During a concurrent record review and interview on 7/19/24 at 1:53 p.m. with the Regional Operations Director (ROD) and the DCO. All three staffing agency contracts were reviewed. The ROD confirmed two of the contracts indicated the facility was responsible to provide contracted staff with trainings and the third contract did not indicate who was responsible for trainings. The DCO confirmed the facility was responsible to ensure the CCNAs completed annual trainings prior to working in the facility. The ROD stated he would follow up with the staffing agencies to request training documents for contracted staff who have worked in the facility. A review of CCNA employee records conducted on 7/19/24 indicated the following: -CCNA 1 worked in the facility on 7/10/24 and 7/13/24. There was no documented evidence to support CCNA 1 completed dementia management training or completed at least 12 hours of training within the last year or prior to working in the facility. -CCNA 2 worked in the facility 21 times since 6/6/24. There was no documented evidence to support CCNA 2 completed dementia management training or completed at least 12 hours of training within the last year or prior to working in the facility. -CCNA 3 worked in the facility on 7/14/24. There was no documented evidence to support CCNA 3 completed dementia management training or completed at least 12 hours of training within the last year or prior to working in the facility. In an interview on 7/19/24 at 3:29 p.m., the ROD stated he reviewed the available CCNA training records and confirmed the facility could not show complete mandatory annual training records for CCNAs. A review of CNA employee records conducted on 7/19/24 indicated no documented evidence to support CNA 2, CNA 3, and CNA 4 completed training for dementia management and abuse prevention, or completed at least 12 hours of training within the last year. In an interview on 7/19/24 at 3:53 p.m., the ROD stated he reviewed the CNA training documents for CNA 2, CNA 3, and CNA 4 and confirmed the facility did not have documentation to support the CNAs completed mandatory annual trainings as required. In an interview on 7/19/24 at 4:14 p.m., the DCO stated she reviewed the CNA training documents for CNA 2, CNA 3, and CNA 4 and confirmed the facility did not have the documentation to support the CNAs completed mandatory annual trainings as required. A review of the facility policy and procedure Competency of Nursing Staff, revised May 2019, indicated, .nursing assistants employed (or contracted) by the facility will: participate in facility-specific, competency-based staff development and training program and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents .The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population .The type and amount of this training is based on the facility assessment . A review of the Facility Assessment Tool, dated 6/25/24, indicated, .Our resident profile .common diagnosis .Alzheimer's disease (a progressive disease that destroys memory and other important mental functions which interfere with activities of daily living), non-Alzheimer's dementia .staff training/education and competencies .Required in-service training for nurse aides. In-service must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of 13 sampled residents was free of a significant medication error when she received insulin glargine (a long-acting insulin, medication to lower blood sugar level) 10 times (doses) past the expiration date. This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident. Findings: During a concurrent observation and interview on [DATE] at 11:03 a.m. with Licensed Nurse 1 (LN 1), an inspection of Medication Cart 2 identified one opened insulin glargine 100 units/milliliter (u/ml, a unit of measurement) vial, expired on [DATE], for Resident 1. LN 1 confirmed the finding and stated it should have been removed from the cart and not available for use. A review of Resident 1's medical record indicated a physicians' order, dated [DATE], for insulin glargine 100 u/ml, give 10 units sub-q (under the skin) once daily at bedtime. During a concurrent interview and record review on [DATE] at 11:10 a.m. with LN 1, Resident 1's Medication Administration Record (MAR), dated [DATE] and [DATE] was reviewed. The MARs indicated Resident 1 was administered expired insulin glargine on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. LN 1 stated insulin glargine expired 28 days after first use and Resident 1 was administered a total of 10 doses of expired insulin. He confirmed it was important to check expiration dates on medications before administering them to a resident. During an interview on [DATE] at 1:50 p.m. with LN 2, LN 2 stated she would check the expiration dates on medications before administering them and, The ones I worry about the most is insulin . Somehow those get missed. During an interview on [DATE] at 2:58 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to check the expiration dates of medication before administering them to a resident, especially insulin. DON stated after expiring, insulin was potentially no longer effective. During an interview on [DATE] at 9:05 a.m. with Consultant Pharmacist (CP), CP confirmed insulin glargine was stable for 28 days once opened and beyond that, it should not have been used. He stated, My concern [with expired Brand Name insulin glargine] would be erratic blood sugar levels .Possibly contamination from being opened too long. During a review of the product labeling from the manufacturer of insulin glargine, revised [DATE], the labeling indicated, Do not use [Brand Name insulin glargine] . 28 days after you first use it. According to Consumermedsafety.org (a nationally recognized medication safety organization), it indicated, 6 Important Storage tips for all insulin .Never use insulin if expired .You must throw away after 28 days since out of the fridge. (https://www.consumermedsafety.org/insulin-safety-center/insulin-basics/storage-of-insulin; accessed [DATE]) During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated [DATE], the P&P indicated, Policy Interpretation and Implementation .The expiration/beyond use date on the medication label must be checked prior to administering . During a review of the facility's P&P titled, Storage of Medications, dated [DATE], the P&P indicated, Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for one of 13 sampled residents (Resident 1) when hand hygiene was not performed during medication administration and an eye drop was not handled with infection control precautions. These failures had the potential to result in transmission of infection in the facility for all 29 residents. Findings: During a medication pass observation on 9/5/23 at 9:16 a.m. with Licensed Nurse 1 (LN 1), the LN 1 was observed preparing to administer medications to Resident 1, including a Brand Name eye lubricant eye drop. The LN 1 put on a pair of gloves, opened a binder that contained medical records and flipped through multiple pages before closing it. With the same gloves, LN 1 picked up Resident 1's medications and entered the resident's room. LN 1 removed the cap from the eye drop bottle and placed it directly on Resident 1's bedside table, next to her breakfast tray. LN 1 then administered two drops into each of Resident 1's eyes, all without changing gloves or performing hand hygiene. During an interview on 9/5/23 at 11:06 a.m. with LN 1, LN 1 stated nursing staff were expected to wash their hands or use hand sanitizer between medication administration. He stated it was acceptable to use the same gloves used to review medical records in the binder to administer medication because, Everything on the [medication] cart is considered clean. He stated he believed the bedside table was a clean enough surface to place the eye drop cap on, because we put [the resident's] food on it. LN 1 stated it would have been better nursing measures to have placed the cap on a napkin or to have held onto it. During an interview on 9/5/23 at 2:56 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to perform hand hygiene anytime they touched a resident. She stated gloves were to be changed after touching medical records and before performing direct resident care. DON stated nursing staff were to wash their hands and wear new gloves before administering an eye drop. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Eye Drops, dated October 2007, the P&P indicated, Procedures .Perform hand hygiene .Remove the cap . place cap on a clean, dry surface (such as a tissue or gauze). During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated August 2015, the P&P indicated, Policy Interpretation and Implementation .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before and after direct contact with residents .Before preparing or handling medications .Before donning sterile gloves .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene .

Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition and good repair when one reach-in freezer had a torn gasket and ice buildup. This failure had the potential to result in the freezer not holding proper temperatures for frozen foods stored inside. Findings: During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., the reach-in freezer was found to have a torn gasket (a seal around the door that helps keep the cold air in and warm air out) and ice buildup (an accumulation of ice that occurs when warm or humid air flows into a freezer). During a concurrent observation and interview on 9/5/23 at 10:56 a.m., the Front of House Supervisor (FOHS) confirmed the reach-in freezer had a torn gasket and ice buildup. The FOHS added, the torn gasket made the freezer door not shut properly and could negatively affect the frozen food. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager stated the reach-in freezer gasket needed to be replaced to prevent ice buildup and maintain freezer temperature. A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .equipment shall be kept clean, maintained in good repair and shall be free from breaks .open seams .seals .will be kept in good repair .

Based on observation, interview, and record review, the facility failed to ensure staffing requirements were met when the facility did not employ a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time (40 hours per week) basis. This failure resulted in a lack of administrative oversight and supervision and has the potential to affect the quality of care delivered to all residents by nursing staff. Findings: During a record review on 9/5/23, of the facility's staffing records for the month of August 2023, it was noted the DON was not present in the facility on Thursdays and Fridays. During an interview on 9/6/23 at 3:22 p.m. with DON, DON stated, she works three days a week, Monday, Tuesday and Wednesday, eight hours a day. This has been her schedule for the last two years. DON stated she understood the DON position should be full-time, but she can only work part-time. During an interview on 9/7/23 at 11:00 a.m. with Administrator (ADM), ADM confirmed the DON doesn't work full-time at the facility. ADM stated the DON position should be full-time. During a record review of the Facility Assessment Tool (FAT), dated May 2023-May 2024, the FAT indicated, Staffing Plan .DON: 1 DON RN full-time Days.

Based on observation, interview, and record review, the facility failed to ensure: -Opened multi-dose inhalers and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date; and -Expired medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date. Findings: During a concurrent observation and interview on 9/5/23 at 10:13 a.m. with Licensed Nurse 2 (LN 2), an inspection of Medication Cart 1 (Med Cart 1) identified one Brand Name (an inhaler to treat asthma) 200 microgram/25 microgram (mcg, a unit of measurement) inhaler and one Brand Name Inhub (an inhaler to treat asthma) 500 mcg/50 mcg inhaler, both opened and unlabeled with an open date. LN 2 reviewed the manufacturer's specifications on the outside of the Brand Name and Brand Name Inhub inhalers. LN 2 stated the manufacturer's specifications indicated both had shorter expirations after first use and should have been labeled with an open date. During a concurrent observation and interview on 9/5/23 at 11:03 a.m. with LN 1, an inspection of Med Cart 2 identified one vial Brand Name test strips (used to test blood sugar levels) opened and unlabeled with an open date. LN 1 confirmed the finding and reviewed the manufacturer's specifications on the side of the vial. LN 1 confirmed the manufacturer indicated the test strips expired three months once opened and should have been marked with an open date. Inspection of the med cart also identified one opened insulin glargine (a long-acting insulin to treat diabetes) 100 units/milliliter vial, expired 8/25/23. LN 1 confirmed it should have been removed and not available for use. During an interview on 9/5/23 at 2:58 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to check the expiration date of a medication before administering it to a resident. She stated the med carts were inspected for expired drugs once a month as part of the facility's quality assurance program. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated December 2012, the P&P indicated, Policy Interpretation and Implementation .When opening a multi-dose container, the date opened shall be recorded on the container. During a review of the facility's P&P titled, Storage of Medications, dated April 2007, the P&P indicated, Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure: 1. The Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulation, to be the DM to carry out the functions of the food and nutrition services; and, 2. The Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. These failures resulted in lapses in the delivery of food and nutrition services associated with meal distribution, safe food handling, sanitation, and insufficient oversight of food service operations for a census of 29 residents who received meals from the facility kitchen. Findings: During the annual recertification survey from 9/5/23 to 9/8/2023, multiple issues surrounding the delivery of dietetic services were identified: 1. Meal distribution accuracy - The menu/recipes were not followed and the portion size of food items were not served correctly, and 2. Safe food handling and sanitation: a. The ice machines in the kitchen and nourishment room (located in nursing station) were not clean; b. Improper labeling and dating of food items in the dry storage, walk-in refrigerator, and dry storage room; c. Improper storage of opened food packages in the dry storage, walk-in refrigerator, and dry storage room; d. Expired food items were found in the dry storage room and walk-in refrigerator; e. Improper storage of trays of prepared food were uncovered, unlabeled, and undated in the walk-in and reach-in refrigerators; f. The [NAME] was unable to verbalize the proper cool down process of food and did not practice safe food handling while preparing food; g. Clean and ready-to-use food serving utensils stored in two drawers that were dirty and not well maintained; h. The reach-in freezer had ice buildup and the gasket was torn; i. The juice dispenser was not cleaned per the manufacturer's instruction, and j. One dietary aide did not appropriately record the sanitizer concentrations in the log. During an initial kitchen tour and concurrent interview with the Front of House Supervisor (FOHS) on 9/5/23, at 9:04 a.m., the FOHS stated the DM was usually off on Friday, Saturday, Sunday, and Monday. The FOHS stated she would help to supervise the kitchen when the DM was not in the facility. She stated her usual responsibility was as a dietary aide. She stated the RD visited the facility once a week and seldom saw her in the kitchen. During an interview with the DM on 9/7/23, at 10:30 a.m., the DM stated he was a resource chef manager for the outsourcing company which contracted with the facility. The DM stated he has been covering for the facility's Dietary Manager position for the past four months. The DM stated he was not certified as a Dietary Services Supervisor or was a Certified Dietary Manager. He added he was not aware he needed to meet the requirements to be in the DM position. He stated the RD would not visit the facility this week and he was not aware she took the time off. During a phone interview with the RD on 9/7/23, at 1:30 p.m., the RD stated she visited the facility once a week per her contract. She stated she mostly did clinical workload, performed a monthly kitchen sanitation audit, and provided a copy to the DM. She stated she would communicate with the DM once every two weeks. The RD stated she did not spend much time in or oversee the kitchen. A review of the DM's employee file confirmed the DM was contracted with an outsourced company and did not indicate a hire date. The file included ServSafe Certification (a certification provided after trained and examined the knowledge of safe food handling) and other certifications provided by the outsourcing company training. A review of the undated DM's job description (JD), it stated, .The Dining Service Director .Education and Experience: .Minimum 3 years related experience and/or training at the Dining Services Director level or equivalent .Bachelor's degree in Food Science, Nutrition, Culinary Arts or Hotel/Restaurant Management .having completed Certified Dietary Management Program preferred . A review of the state's qualifying pathways to be a dietary manager as listed in the Health and Safety Code (H&SC) 1265.4, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. A review of the facility organizational chart indicated the DM was supposed to supervise the dietary service department and its staff; the RD was not included in the chart. A review of an undated RD's JD indicated the RD's major responsibility was to perform clinical work in the facility. A review of the facility's contract titled RD .Consulting Agreement, signed on 3/12/22, indicated the scope of the RD's duties was consultant based and as a clinical dietitian. It also indicated the RD's hours of work in the facility did not exceed a maximum of eight hours per week.

Based on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the [NAME] 1 (CK 1) was unable to verbalize the process of properly cooling down cooked food and was unable to practice safe food handling while preparing food for a census of 29 residents who received food from the facility kitchen. These failures had the potential to cause food borne illness in a potentially compromised population. Findings: During an interview with the CK 1 on 9/6/23, at 9 a.m., the CK 1 explained the cooling down process of the cooked food. The CK 1 stated he would put the cooked meat in the refrigerator to cool down in order to slice the meat easier. He then stated he would reheat the meat to 150 degrees Fahrenheit (F, a unit to measure temperature). In a concurrent review of the cooling log (a log to verify the effectiveness of the cooling process from 140 degrees F to at least 41 degrees F within the maximum cooling period of six hours), the CK 1 stated he had never seen the log and stated he had not followed the cooling process nor used the cooling log since he started working in the facility. During an interview with the Front of House Supervisor (FOHS) on 9/6/23 at 9:08 a.m., the FOHS stated she expected the Cooks to use the cooling log when cooling hot cooked food and expected the Cooks to have the knowledge to reheat the food temperature to 165 degrees F for a minimum of 15 seconds. During an observation of CK 1 making puree food on 9/6/23 at 10:27 a.m., CK 1 used the same soiled dry towel during the following actions: wiped the surface of the food contact counter, removed cooked food from the oven, wiped his gloved hands, wiped the inner sides of a cooking pan with cooked food in it, grabbed a tray of cooked food and touched the surface of the cooked pork slices that were ready for making pork puree. During a follow up observation of CK 1 during the lunch meal distribution on 9/6/23, starting at 11:24 am., CK 1 used the same soiled dry towel (which he placed on the food prep table) and wiped the thermometer probe after he pierced the pork to take its temperature. Then he placed the used thermometer with the ready-to-use clean utensils without properly cleaning it. When CK 1 placed the food on the plate, CK 1 was observed to have used the same towel to wipe off the extra gravy from the plate several times. During an interview with the Dietary Manager (DM) on 9/7/23, at 12:52 p.m., the DM acknowledged CK 1's practices and stated CK 1 lacked food safety knowledge and needed more training. He stated the dietary department only did one in-service about handwashing for the dietary staff. During a concurrent interview and review of CK 1's employee file with the DM on 9/7/23, at 2:05 p.m., the file indicated CK 1's hire date on 3/28/23 and there was no competency or skill set evaluation on file. The DM stated there was no competency or evaluation done for CK 1. He stated CK 1 only had one in-service regarding handwashing. During a follow up interview with the DM on 9/7/23, at 3:55 p.m., the DM stated kitchen staff needed to follow the sanitization policy and the towel should either be in a sanitizer bucket soaked with sanitizer solution or it was in use. The DM confirmed Cooks should know and perform food safety and sanitization practices because it could lead to cross contamination and illness. A review of the undated departmental policy and procedure, titled .Food Safety & Quality Assurance Standards Manual, indicated, PREVENTING TEMPERATURE ABUSE .COOLING .Cooling is the process of rapidly bring the temperature of a hot TCS [time/temperature control for safety] food down, through the temperature danger zone, to a safe cold temperature. Inadequate cooling of TCS foods has been consistently identified as on of the leading contributing factors to foodborne illness .cooked TCS foods must be rapidly cooled with 2 hours, from 135 F to 70 F, and within and additional 4 hours from 70 F to 41 F. The cooling process must be documented for each TCS food item cooled .monitor TCS food during the cooling process to ensure that critical limits are not exceeded. Check the food temperature throughout the process. Record cooling times/temperatures on the .cooling log (or equivalent). Retain log for a minimum of 30 days . A review of the undated departmental policy and procedure, titled .Food Safety & Quality Assurance Standards Manual, indicated, PREVENTING TEMPERATURE ABUSE .REHEATING .Reheating is the process of bring TCS foods that were cooked and cooled, back to a temperature that is safe to be served and consumed .TCS foods that are cooked, cooled and then reheated for hot holding or immediate service must be reheated so that all parts of the food reach a minimum internal temperature of 165 F .record final internal temperature of reheated TCS foods onto the TCS food cooking and cooling log (or equivalent) and maintain logs for a minimum of 30 days . A review of the undated departmental policy and procedure, titled .Food Safety & Quality Assurance Standards Manual, indicated, PREVENTING TEMPERATURE ABUSE .THERMOMETERS .MEASURING TEMPERATURE .Clean and sanitize thermometer probes just as you would any other small ware. They should be washed, rinsed, and sanitized after each use. A Sani-Wipe may also be used in lieu of the wash, rinse sanitize process. A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .the food service area shall be maintained in a clean and sanitary manner .between uses, cloths and towel used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution . A review of the undated Cook's job description indicated, .Essential Functions and Key Tasks .prepare large quantities of food, following .sanitation standards .maintains basic food recipes, preparation, and service and storage sanitation principles . A review of facility contract agreement with the outsourcing company, titled, Dining Service Management Agreement, signed on 4/3/20, indicated, .Service Standards .[outsourcing company's name] shall comply with all applicable food safety and other federal, state and local laws and regulations. [outsourcing company name] shall maintain high standards of sanitation in provision of Dining Services .Training: [outsourcing company name] shall provide all Dining Services related training to Dining Services personnel .

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician.) during the lunch meal on 9/6/23 when: 1. Six residents (Residents: 4, 6, 11, 23, 27, and 29) with small portion and/or consistent carbohydrate (CCHO, a diet to help keep blood sugar levels stable) received half of a white roll instead of a whole white roll; 2. Nine residents (Residents: 3, 5, 9, 11, 15, 20, 21, 25, and 29) with mechanical soft texture diets (chopped or ground food prescribed to those who have trouble chewing and swallowing) received whole spears of asparagus and sweet potato with the peel instead of diced asparagus and sweet potato without the peel; 3. 14 residents (Residents: 1, 2, 6, 7, 8, 13, 16, 17, 18, 19, 22, 24, 26, and 28) who were not on CCHO and/or small portion diets got two ounces (oz, a unit of measurement) of tapioca pudding instead of four oz.; 4. Three residents (Resident 10, 12, and 14) with small portion puree texture diets (blended smooth and prescribed for people who have trouble chewing or swallowing) got four oz. pureed sweet potato and four oz. of pureed asparagus instead of two oz. of pureed sweet potato and pureed asparagus; and, 5. One resident (Resident 19) with an ordered pureed texture diet got a bowl of regular texture salad. These failures decreased the facility's potential to ensure residents received the nutrition they needed in a safe manner for a census of 29 residents. Findings: 1. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the Diet Aide (DA) served six residents with prescribed small portion and/or CCHO diets half of a white roll. A concurrent review of the facility's prescribed diet menu titled, Extensions: Wednesday, Week 1 . 2023, to be served on 9/6/23, indicated a white roll should have been served to residents with CCHO and small portion diets. 2. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the [NAME] (CK 1) served nine residents with prescribed mechanical soft texture diets whole spears of asparagus and sweet potato with the peel. A review of the facility's prescribed diet menu titled, Extensions: Wednesday, Week 1 .2023, to be served on on 9/6/23, indicated diced steamed asparagus and baked sweet potato without the peel should have been served to residents with mechanical soft diets. 3. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the DA served 14 residents two oz of tapioca pudding who were not on CCHO and/or small portion diets. A review of the facility's prescribed diet menu, titled Extensions: Wednesday, Week 1 .2023, to be served on 9/6/2023, indicated diets that were not CCHO and/or small portion should be served four oz. of tapioca pudding. During an interview on 9/6/23 at 11:58 a.m., the DA stated she had prepared only two oz. portions instead of four oz. portions of tapioca pudding for the 9/6/23 lunch service, because there was not enough tapioca pudding to make the four oz. sized portions. 4. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the CK 1 served three residents four oz. puree sweet potato and four oz. of puree asparagus with use of a #8 scoop (a four oz. serving utensil) who were prescribed small portion puree texture diets. A review of the facility's prescribed diet menu, titled Extensions: Wednesday, Week 1 .2023, to be served on 9/6/2023, indicated small portion puree texture diets should have been served two oz. puree sweet potato and two oz. puree asparagus. 5. A review of Resident 19's quarterly Minimum Data Set (an assessment tool), dated 7/25/23, indicated Resident 19 was admitted to the facility in October of 2018 and diagnosed with Parkinson's disease (causes uncontrollable movements and difficulty with coordination) and dysphasia (difficulty swallowing). A review of Resident 19's lunch tray ticket dated 9/6/23, indicated, .Do Not Serve .Salad Garden . During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., Resident 19 received a bowl of regular texture salad. During an interview on 9/6/23 at 12:12 p.m., the Dining Services Director (DSDS) stated small portion and CCHO diets should have had one whole roll per the menu extension. The DSDS also stated the kitchen staff needed to follow the menu, menu extensions, and resident tray tickets (the ticket on the meal tray which indicate the resident's prescribed diet order, likes, dislikes, and allergies) to give the correct foods and to ensure residents received the correct portions because it affected the residents' nutritional intake. The DSDS also acknowledged Resident 19 was prescribed a puree texture diet and received a regular texture salad. The DSD stated she went to Resident 19's room and saw Resident 19 had taken a bite of the salad. The DSD added kitchen staff needed to follow the menu and tray ticket to ensure the residents received the correct form of food to prevent choking. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager (DM) stated the cooks and kitchen staff needed to follow the menu and menu extensions for compliance with the diet orders, portions, and food textures for each resident. A review of the undated facility document titled, Diet Aide Job Description, indicated, .The Diet Aide assembles meals and serves food under the direction of the [DSDS] or manager .Essential Functions and Key Tasks .Assembles snacks and nourishments according to .client orders . A review of the undated facility document titled, Cook Job Description, indicated, .As the cook you will have responsibility of food production in the kitchen operations .Essential Functions and Key Tasks .Prepare large quantities of food, following standardized recipes .Maintains basic food recipes, preparation and service .

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when: 1. Food items were found with missing or incorrect labels and dates; 2. Food items found expired and available for use; 3. A food item was found opened and uncovered to prevent cross contamination (the unintentional transfer of bacteria and substances from one food to another); 4. Trays of prepared food were found uncovered, unlabeled and/or undated; 5. Drawers which stored clean ready-to-use utensils were dirty and one was broken; 6. Ice machines in the kitchen and in the nourishment room were not clean; 7. A juice dispenser was not cleaned per the manufacturer's instruction; 8. One Dishwasher did not perform the sanitizer concentration recording appropriately; and, 9. One [NAME] was unable to verbalize the proper cooling down process and did not perform safe food handling practices during food preparation. These failures decreased the facility's potential to prevent food-borne illness in a highly susceptible population for a census of 29 residents who received food from the kitchen. Findings: 1. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., the following food items were found opened and without labels (stickers on the packages to indicate the opened date and expiration date): -a bag of shredded Mozzarella cheese, -a block of cream cheese, -a bag of macaroni noodles, -a bag of spaghetti noodles, -a bag of penne pasta, -a bag of egg noodles, -a bin of chocolate chips, -a jar of red chili in oil, -a box of tofu, -a jar of ranch dressing, he -a package of wonton wrappers, and, -a bottle of fish sauce. During a concurrent observation and interview on 9/5/23, at 10:56 a.m., the Front of House Supervisor (FOHS) inspected all the opened packages listed above and confirmed all the items were opened and were missing a label. The FOHS added per their policy all opened packages of food products should be labeled with the date they were opened. In an interview on 9/7/23 at 3:55 p.m., the Dietary Manager (DM) stated he expected kitchen staff to label all opened food products with: the name of the product, the date the item was opened/prepared, and to refer to the food storage chart and mark the date the product will expire. A review of the facility's policy titled, CULINARY & SUPPLY CHAIN, revised December 2020, indicated, .Cover, label and date unused portions and open packages .products are good through the close of business on the date noted on the label .refer to the food storage chart in this policy to determine discard dates for food items . 2. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m. the following expired food items were available for use in the dry storage room and reach-in freezer: -a bin of oatmeal labeled with an expiration date of 8/15/23, -a bin of flour labeled with an expiration date of 2/11/23, -a bin of sweetened coconut labeled with an expiration date of 2/6/23, and -a tray of mango sorbet labeled with an expiration date of 8/24/23. During a concurrent observation and interview on 9/5/23 at 10:56 a.m., the FOHS inspected all the expired packages listed above and confirmed all of the items were expired. The FOHS stated those items should not be available for use and added, if someone ate expired food, they could get sick. During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected kitchen staff to discard expired foods and ensure no expired foods were in food storage areas. A review of the facility's policy titled, CULINARY & SUPPLY CHAIN, revised December 2020, indicated, .discard food past the 'use by', 'sell-by', 'best-by', or 'enjoy by' date .Cover, label and date unused portions and open packages . products are good through the close of business on the date noted on the label . 3. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., an opened package of butter was found on the shelf in the reach-in refrigerator. The butter was not fully wrapped and had a brown substance on it. During a concurrent follow up observation and interview on 9/5/23 at 2:55 p.m., the FOHS confirmed the butter was not properly wrapped and had evidence of cross contamination. During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected kitchen staff to put opened packages of food in a closed container and to have followed policies on covering foods to prevent cross contamination. 4. During a kitchen tour on 9/5/23 starting at 8:58 a.m., the following food items were found prepared, uncovered, unlabeled, and/or undated: -a tray of cups filled with red liquid without a label or date, -a tray of plastic containers filled with a white creamy substance was uncovered and without a label or date, and -four trays of brown triangular shaped food were not covered and without a label or date. During a concurrent observation and interview on 9/5/23, at 9:36 a.m., the FOHS inspected the tray of cups with red liquid and stated they were prepared soup to be served to the skilled nursing residents. The FOHS confirmed they were not labeled or dated. During a concurrent observation and interview on 9/5/23 at 9:40 a.m., the FOHS inspected the tray of plastic containers filled with a white creamy substance and stated they were prepared ranch dressing and confirmed they were uncovered, unlabeled, and undated. During a concurrent observation and interview on 9/5/23 at 9:36 a.m., the [NAME] 1 (CK 1) inspected four trays of brown triangular shaped food and stated they were prepared, breaded frozen tilapia . pulled from the freezer this morning. The CK 1 confirmed the prepared tilapia was not covered, unlabeled, and undated. The CK 1 added, they should have cover, label and sticker with date. During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected the kitchen staff to follow the policy to either cover the entire rack or individual trays of prepared food to prevent cross contamination that could lead to illness. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, .PREVENTING CONTAMINATION .FOOD STORAGE .All food shall be stored in such a manner as to prevent contamination and maintain the safety and a wholesomeness of the food for human consumption .Foods that have been opened or processed must be stored in NFS [National Sanitation Foundation] approved containers with tight-fitting lids (where appropriate) or covered or otherwise protected from overhead/environmental contamination . A review of the facility's policy and procedure titled, CULINARY & SUPPLY CHAIN, revised December 2020, indicated, .Cover, label and date unused portions and open packages . 5. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., there were two drawers which stored clean and ready-to-use food serving utensils. Both drawers were dirty with food debris and one of the drawers was broken with two holes in the bottom. During an interview on 9/7/23 at 3:55 p.m., the DM confirmed the utensil drawers with debris and holes in the bottom were not acceptable per policy due to the risk of cross contamination. A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .The food service area shall be maintained in a clean and sanitary manner .all utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks . 6. During an inspection of the ice machine in the kitchen on 9/5/23, at 11:09 a.m., the Maintenance Director (MD) removed the ice machine's top access panel to reveal the water curtain (a white plastic cover to direct the ice into the storage bin). Upon removal of the water curtain, there were orange-pink and black gelatinous substances covering a large portion inside of the curtain. During a concurrent interview, the MD stated the facility hired an outside vendor who sent their technician to deep clean (sanitize the machinery and the storage bin) the ice machine, but he was not sure how often the outside vendor's technician was scheduled to clean it. The MD added, he needed to wait until the technician came to dissemble other parts of the ice machine. During a concurrent observation and interview on 9/5/23 at 11:12 a.m., at the kitchen ice machine, the FOHS confirmed the presence of the substances found on the water curtain and stated the ice machine was not kept in clean and sanitary condition. She also stated the kitchen staff were not responsible for cleaning the ice machine. During an interview on 9/5/23 at 11:15 a.m., the FOHS stated there was another ice machine located in the nourishment room at the nursing station, and the facility maintenance was responsible for maintaining and cleaning it. During an inspection of the ice machine in the nourishment room on 9/5/23, at 3:42 p.m., the MD acknowledged there was an orange, slimy substance, which could easily be wiped off with a paper towel from the chute (the passage through which ice dispenses) of the ice machine. The MD removed the ice machine's top access panel to reveal the water curtain and stated he could not remove the water curtain because he thought he would break it if he tried. The water curtain was able to be pulled forward while still attached and a black substance was visualized on the inside of the water curtain and on the water trough (a component that holds the water before it is frozen during the ice making process). The MD stated the facility's maintenance staff were responsible for monthly cleaning of the exterior of the ice machine and an outside vendor performs the interior cleaning cycles. The MD added, he was not able to say if the ice machine was clean or not. During a follow up inspection of the ice machine in the nourishment room on 9/6/23 at 8:36 a.m., the Outside Vendor Technician (OVT) removed: the ice machine's top access panel, water curtain, and water trough. The water curtain and water trough had significant amounts of a black gelatinous substance, both sides and bottom of the evaporator plate (the cold surfaces within the ice maker where ice is formed) had an orange-pink slimy substance. During a follow up inspection of the ice machine in the kitchen on 9/6/23, at 8:50 a.m., the OVT removed the water trough to reveal significant black gelatinous substance, which could be easily wiped off with a paper towel, on the bottom of the ice evaporator unit and on the bottom of the water trough. During an interview on 9/6/23 at 10:20 a.m., the OVT stated the outside vendor company has a contract with the facility to perform ice machine cleaning every six months. During an interview on 9/7/23, at 3:55 p.m., the DM stated the pink and black substances were mold and the ice machines, were not being cleaned as often as they should be. A review of the undated kitchen ice machine manual titled, [Manufacturer's brand] Ice Machines Installation, Operation and Maintenance Manual, indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual. CLEANING/SANITIZING PROCEDURE .must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized .Remove mineral deposits from areas or surfaces that are in direct contact with water. PREVENTATIVE MAINTENANCE CLEANING PROCEDURE .This procedure cleans all components in the water flow path, and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure without removing the ice from the bin/dispenser . A review of the nourishment room ice machine manual titled, [Manufacturer's brand] Ice Machines Installation, Operation and Maintenance Manual, dated June 2017, indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual .Cleaning /sanitizing procedure .must be performed a minimum of once every six months. The ice machine and bin must be disassembled cleaned and sanitized .remove mineral deposits from areas of surfaces that are in direct contact with water. Preventative maintenance cleaning procedure .This procedure cleans all components in the water flow path, and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure . A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, The food service area shall be maintained in a clean and sanitary manner . ice machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions . 7. During a concurrent observation, interview, and machine instruction review on 9/5/23, at 11:23 a.m., the FOHS opened the juice dispenser machine to reveal the dispenser nozzles with built-up orange and pink substances on them and a panel with written instructions for cleaning the juice dispenser. The FOHS stated the juice dispenser nozzles were removed and cleaned once a week. The FOHS then looked at the written instructions on the inside panel of the juice dispenser that indicated the nozzles should be removed and cleaned daily and stated the machine is not being cleaned per manufacturer's directions. During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected kitchen staff to clean the juice dispenser nozzles daily per the manufacturer instructions to prevent buildup but acknowledged the juice dispenser was not included on the assigned cleaning schedules. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, SANITATION .MAINTAINING SANITARY CONDITION .Effective sanitation prevents the growth of microorganisms .equipment, food-contact surfaces, and utensils must be clean to sight and touch .non-food contact surfaces must be kept free of an accumulations of dust, dirt, food residue and other debris .must be cleaned as often as necessary to keep them clean .clean food and non-food contact surfaces that have an accumulation of soils outside of their proper cleaning frequency 8. During a concurrent observation and interview on 9/5/23 at 10:25 a.m., the dishwasher (DW) stated the test strips to test the sanitizer concentration, went missing a couple of days ago .I didn't test the sanitizer today. I went off what it was before as he pointed to the September sanitizer test log hanging on the wall. The log had been filled out for 9/5/23 for the 5:30 a.m., 12 p.m., and 2 p.m. time slots. Each time slot was documented with a sanitizer level of 200 ppm (part per million: a unit of measure for the sanitizer concentration). During an interview on 9/5/23, at 10:38 a.m., the FOHS stated the sanitizer log should be filled out after testing the sanitizer solution with the test strips, the sanitizer log should not be filled out ahead of time, and, if you don't have a way to test it, you can't log it. During an interview on 9/7/23, at 10:45 a.m., the DM stated the sanitizer log should be filled out three times daily when the sanitizer buckets were prepared and tested. The DM also stated he expected kitchen staff to have documented not tested on the log if the sanitizer was not tested. The DM confirmed the sanitizer log should not have been prefilled out on 9/5/23. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, SANITATION .SANITIZER BUCKETS/BOTTLES WIPING CLOTHS .wet wiping cloths must be stored at all times in an approved quat [quaternary ammonium compound] within the effective range .between 200-400 ppm .test sanitizer concentration .throughout the day to ensure they are maintained at the effective concentrations . 9. During a concurrent observation and interview on 9/6/23, at 9 a.m., CK 1 explained the cooling down process of cooked foods. CK 1 stated he cooked meats in the mornings then would take the meat from the oven and put it in the refrigerator to cool it down to room temperature or colder, he would then remove the cooled meat from the refrigerator to slice, and then would reheat the meat to 150 degrees Fahrenheit (F: a unit of measure for temperature) to serve for lunch. CK 1 reviewed a binder on a prep station that had instruction for cooling foods and a cooling log and stated, First time I have seen a cooling log and that he had not followed or used a cooling log while working in the facility. During an interview on 9/6/23, at 9:08 a.m., the FOHS stated she expected the cooks to use cooling logs when cooling hot foods and expected reheated meats/foods to be heated to 165 F for a minimum of 15 seconds. During an observation of the puree food making on 9/6/23, at 10:27 a.m. CK 1 used the same soiled dry towel to: wipe the surface of a food contact counter, take out cooked food from the oven, wipe his gloved hands, wipe the inner sides of a cooking pan that touched food, grab the tray of cooked food and the soiled dry towel touched the surface of cooked pork slices that were ready for making pork puree. During a follow up observation in the kitchen on 9/6/23 starting at 11:24 a.m. CK 1 checked the temperature of the pork. He pierced the pork with the thermometer probe and then wiped the thermometer probe with a dry towel that had been sitting on the prep table (not in a bucket of sanitizer solution) and then put the thermometer with other ready to use cooking utensils. While serving lunch plates, CK 1 wiped off gravy from the plate of a lunch meal with the same dry towel he used to wipe the thermometer with. During an interview on 9/7/23, at 3:55 p.m., the DM stated kitchen staff were expected to follow the sanitization policy, towels were expected to be either in a sanitizer bucket soaked in sanitizer solution or actively in use. The DM also stated, cooks specifically should know and perform food safety and sanitization practices to prevent cross contamination and illness. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, PREVENTING TEMPERATURE ABUSE .COOLING .Cooling is the process of rapidly bring the temperature of a hot TCS [time/temperature control for safety] food down, through the temperature danger zone, to a safe cold temperature. Inadequate cooling of TCS foods has been consistently identified as one of the leading contributing factors to foodborne illness .cooked TCS foods must be rapidly cooled within 2 hours, from 135 F to 70 F, and within and additional 4 hours from 70 F to 41 F. The cooling process must be documented for each TCS food item cooled .monitor TCS food during the cooling process to ensure that critical limits are not exceeded. Check the food temperature throughout the process. Record cooling times/temperatures on the .cooling log (or equivalent). Retain log for a minimum of 30 days . A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, PREVENTING TEMPERATURE ABUSE .REHEATING .Reheating is the process of bring TCS foods that were cooked and cooled, back to a temperature that is safe to be served and consumed .TCS foods that are cooked, cooled and then reheated for hot holding or immediate service must be reheated so that all parts of the food reach a minimum internal temperature of 165 F .record final internal temperature of reheated TCS foods onto the TCS food cooking and cooling log (or equivalent) and maintain logs for a minimum of 30 days . A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, undated, indicated, PREVENTING TEMPERATURE ABUSE .THERMOMETERS MEASURING TEMPERATURE .Clean and sanitize thermometer probes just as you would any other small ware. They should be washed, rinsed, and sanitized after each use. A Sani-Wipe may also be used in lieu of the wash, rinse sanitize process . A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .the food service area shall be maintained in a clean and sanitary manner .between uses, cloths and towel used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution .

Based on observation, interview, and record review, the facility failed to provide a clean environment for the residents and visitors when one of one garbage dumpsters, located outside the facility, were not secure with the dumpster lids closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview on 9/6/23 at 9:15 a.m., the facility's outside garbage dumpster lids were open, there were bags of garbage in the dumpster bin and trash was scattered on the ground around the dumpster bin. The Front of House Supervisor (FOHS) stated. [the dumpster] is supposed to be closed at all times to keep pests out of it. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager (DM) stated he expected the dumpster area to be kept clean and dumpsters should have been closed with tight fitting covers per their policy and to prevent pest and rodent activity. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, FACILITY DESIGN & MATERIALS MANAGEMENT .GARBAGE, UTILITY SINK & SEWAGE DISPOSAL .Garbage and refuse storage containers, including dumpsters, must have tight-fitting lids or covers . A review of 2022 Federal Food Code, dated 1/18/2023, indicated, .Outside Receptacles .Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a comprehensive assessment for one resident (Resident 29) of 14 sampled residents within 14 days of a significant change in condition, when Resident 29 entered hospice care on [DATE]. This failure had the potential to result in an unrecognized change in status. Findings: Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia, muscle wasting and weakness. A review of the clinical record for Resident 29 indicated: An initial physician's order dated [DATE] for a hospice referral. A subsequent physician's verbal order for hospice dated [DATE], which documented the resident's initial enrollment in the hospice program. A social services progress note dated [DATE] indicated Resident 29 started on hospice care on [DATE], continued with a general decline, and expired on [DATE]. A review of Minimum Data Sets (MDS, an assessment tool), between [DATE] and [DATE], indicated no significant change MDS was completed within 14 days after hospice care started. During an interview on [DATE] at 4:15 p.m., the MDS Coordinator (MDSC) stated she did not complete a MDS assessment for a significant change for Resident 29. During an interview on [DATE] at 12:15 p.m., the Director of Nursing (DON) stated, .A Significant Change of Condition Assessment has to be done by MDSC when resident goes Hospice. MDSC should have done another Significant Change of Condition Assessment [when resident started hospice care] . A review of the facility's policy and procedure titled MDS Completion and Submission Timeframes, revised [DATE], indicated, Our facility will conduct and submit resident assessments in accordance with current federal .submission timeframes .Timeframes for completion .of assessments is based on the current .Resident Assessment Instrument Manual. A review of the facility's policy and procedure titled Frequency of Conducting Resident Assessments, revised [DATE], indicated, Resident assessments shall be developed .timely .Conduct timely resident assessments .when there has been a significant change in resident's condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete the Minimum Data Set (MDS, an assessment tool) in a timely manner for two residents (Resident 6, Resident 429) out of 14 sampled residents. These failures reduced the facility's potential to provide residents appropriate care and services. Findings: A review of a face sheet indicated Resident 6 was admitted to the facility on [DATE]. A review of Resident 6's MDS, dated [DATE], indicated an Assessment Reference Date (ARD, the last day of the assessment period) of 5/31/22 which meant the MDS was completed 29 days after the ARD. Resident 429 was admitted to the facility in 2/5/18 with multiple diagnoses which included contracture of muscle, left hand. A review of Resident 429's MDS, dated [DATE], indicated an ARD of 6/8/22 which meant the MDS was completed 84 days after the ARD. During an interview on 9/2/22 at 8:45 a.m., the Director of Nursing (DON) stated, [The MDS] .should be completed in 14 days .the MDS is related to resident care. If not done timely, it is an issue . A review of the facility's policy and procedure titled Frequency of Conducting Resident Assessments, revised October 2001, indicated, Resident assessments shall be developed .on a timely bases. A review of the facility's policy and procedure titled MDS Completion and Submission Timeframes, revised July 2017, indicated, Our facility will conduct .resident assessments in accordance with current federal .timeframes .Timeframes for completion .of assessments is based on .the Resident Assessment Instrument manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, a comprehensive assessment tool used for designing plans of care) for two residents (Resident 2, Resident 29) of 14 sampled residents, when the MDS did not identify the signs and symptoms of Resident 21's verbal behavior directed toward others. This deficient practice decreased the facility's ability to provide necessary care to ensure the safety of all residents. Findings: A review of Resident 21's medical records on 8/31/22, indicated Resident 21 was admitted on [DATE] with diagnoses which included dementia (a loss of memory and problem-solving abilities which interfere with daily life), anxiety, and depression. A review of a MDS, dated [DATE], indicated Resident 21 displayed verbal behavioral symptoms directed towards others four to six days during the observation period. The MDS did not indicate the impact these behavioral symptoms had on Resident 21 or other residents. A review of a care plan, last reviewed July 2022, indicated Resident 21 had the following behavioral disturbances: inappropriate sexual comments, foul language and yelling at others, stating there are dead babies everywhere, allegations of pornographic films were being made in the facility, and striking out at others. A review of a physician's order sheet dated August 2022 indicated Resident 21 had a physician's order for staff to monitor behaviors for: yelling out at residents and visitors since 10/12/21; episodes of demanding immediate attention since 11/5/20; and episodes of constant complaints to residents and visitor since 11/5/20. In a concurrent record review and interview on 8/31/22 at 2:42 p.m., the Minimum Data Set Nurse/Assistant Director of Nursing (MDS/ADON) stated, .The behavioral symptoms of [Resident 21] were not reflected in the appropriate MDS Sections. The MDS and Care Plan of every resident should be consistent with the Physician's order to ensure proper care of residents and accurate reporting to government entities. In an interview on 8/31/2022 at 4:15 p.m., the Director of Nursing (DON) stated, Every MDS of every resident should be complete and accurate. The DON confirmed Resident 21's MDS was not complete. A review of the facility's policy and procedure titled MDS Assessment Coordinator, revised November 2019, indicated, Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment . A review of the facility's policy and procedure titled MDS completion and Submission Timeframes, revised July 2017, indicated, Our facility will conduct and submit resident assessments in accordance with .current federal .guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 16) of 14 sampled residents' activity care plan interventions were reassessed and revised for effectiveness and quality care outcome. This failure decreased the facility's potential to ensure Resident 16's psychosocial needs. Findings: A review of Resident 16's clinical record indicated he was admitted in early 2018 with diagnoses which included major depressive disorder. A review of Resident 16's minimum data set (MDS, an assessment tool) dated 6/26/22 indicated his memory was intact and his history and physical (H&P) dated 10/25/21 indicated he had the capacity to make decisions related to his medical care. A review of Resident 16's physicians order dated 2/3/22 indicated, Fluoxetine, [an antidepressant] 10 mg [milligram, a unit of measurement], give 1 [tablet] by mouth once daily for depression manifested by verbalization of sadness such as wanting to die, to be with his wife. A review of counseling service progress notes dated 4/14/22 through 4/21/22 indicated Resident 16's short term goal included increased socialization while his long term objectives indicated decreased depression. A review of Resident 16's mood interview assessment dated [DATE] indicated he had been bothered by the following: feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy and thoughts that he would be better off dead, or of hurting self on some way. Resident 16's activity preference assessment dated [DATE] indicated participation in religious services or practices and listening to music were noted as very important. There was no documented evidence Resident 16's very important activity preference were incorporated in the activity care plan. A review of Resident 16's activities participation form for the months of May, July, and August 2022 indicated there was no documented evidence religious services or practices and listening to music were provided. During several observations on 9/1/22 from 9:28 a.m. through 5:03 p.m., Resident 16 remained in his room with no activity encouragement or involvement and or no activities provided. During an interview and record review on 9/1/22 at 4:35 p.m., the Activity Assistant (AA) stated the last time Resident 16 was encouraged to come out of his room was May 2022. The AA validated it should have been best to encourage Resident 16 to come out of his room daily and participate with activities but he was not. During an interview and record review of the activities participation form on 9/1/22 at 5:03 p.m., the Activity Director (AD) stated Resident 16 loved live music but validated there was no documented evidence live music was provided. The AD also validated spiritual/religious activities and music were not provided to Resident 16. The AD admitted he and his assistant had less frequent interactions and had missed the opportunity to help Resident 16 achieve his goal to increase his socialization. The AD stated the activity unit should have pursued Resident 16's activity preference and the AD should have been persistent with the activity interventions but he did not. The AD also validated Resident 16's care plan should have been revised, reassessed and updated for effectiveness to align with Resident 16's ability to participate but it was not. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/16 indicated, .each resident's comprehensive person-centered care plan will be consistent with the residents rights to participate in the development and implementation of his or her plan of care, including the right to request revisions of the plan of care.

Based on observation, interview, and record review, the facility failed to provide treatment in accordance with current professional standards when one resident (Resident 7) of 14 sampled residents did not receive metformin ER (an anti-diabetic medication) with a meal, as ordered and specified by the manufacturer, to decrease GI (gastrointestinal) upset. This failure had the potential to expose Resident 7 to unwanted side effects of the medication, causing discomfort and decreasing the resident's overall well-being. Findings: On 8/31/22, a review of Resident 7's clinical record indicated the resident was admitted to the facility with diagnoses including diabetes. Her medications included metformin extended-release (ER) 500 milligrams (mg, unit of measure) 1 tablet twice daily with breakfast and dinner, dated 12/16/19. During a medication pass observation on 8/31/22, at 3:53 p.m., with Licensed Nurse 1 (LN 1), LN 1 was observed preparing four medications, including a metformin ER 500 mg tablet for Resident 7. Resident 7 took the metformin ER tablet with sips of water. During an interview on 8/31/22, at 3:57 p.m., the LN 1 confirmed metformin ER was to be administered with the resident's dinner. When asked when the meal would be served, LN 1 stated, Dinner is coming in about 45 minutes. LN 1 acknowledged and agreed administering metformin ER 45 minutes before the meal was too early and not considered given to the resident with dinner. During an interview on 8/31/22, at 4:32 p.m., the Director of Nursing (DON) confirmed dinner was served daily to the residents at 5 p.m. The DON stated if a medication order indicated to be given with dinner, it was to be given at the same time as when the meal was served. She agreed and confirmed it was not appropriate to administer metformin ER 45 minutes before the meal was served and stated, It's too early. A review of Lexi-comp, a nationally recognized drug information resource, indicated more than 10% of those who take metformin ER experience side effects that include but are not limited to diarrhea, gas, nausea, vomiting and to, Administer with a meal (to decrease GI upset). During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, (undated), the P&P indicated, Medications are administered in accordance with written orders of the prescriber . Medications to be given with meals are to be scheduled for administration at the resident's meal times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 16) of 14 sampled residents' activity preference was implemented for quality of life. This failure decreased the facility's potential to prevent Resident 16's risk of depression to worsen. Findings: A review of Resident 16's clinical record indicated he was admitted in early 2018 with diagnoses which included major depressive disorder. A review of Resident 16's minimum data set (MDS, an assessment tool) dated 6/26/22 indicated his memory was intact and his history and physical (H&P) dated 10/25/21 indicated he had the capacity to make decisions related to his medical care. A review of Resident 16's physicians order dated 2/3/22 indicated, Fluoxetine, [an antidepressant] 10 mg [milligram, a unit of measurement], give 1 [tablet] by mouth once daily for depression manifested by verbalization of sadness such as wanting to die, to be with his wife. A review of counseling service progress notes dated 4/14/22 through 4/21/22 indicated Resident 16's short term goal included increased socialization while his long term objectives indicated decreased depression. A review of Resident 16's mood interview assessment dated [DATE] indicated he had been bothered by the following: feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy and thoughts that he would be better off dead, or of hurting self on some way. Resident 16's activity preference assessment dated [DATE] indicated participation in religious services or practices and listening to music were noted as very important. There was no documented evidence Resident 16's very important activity preference were incorporated in the activity care plan. A review of Resident 16's activities participation form for the months of May, July, and August 2022 indicated there was no documented evidence religious services or practices and listening to music were provided. During several observations on 9/1/22 from 9:28 a.m. through 5:03 p.m., Resident 16 remained in his room with no activity encouragement or involvement and or no activities provided. During an interview and record review on 9/1/22 at 4:35 p.m., the Activity Assistant (AA) stated the last time Resident 16 was encouraged to come out of his room was May 2022. The AA validated it should have been best to encourage Resident 16 to come out of his room daily and participate with activities but he was not. During an interview and record review of the activities participation form on 9/1/22 at 5:03 p.m., the Activity Director (AD) stated Resident 16 loved live music but validated there was no documented evidence live music was provided. The AD also validated spiritual/religious activities and music were not provided to Resident 16. The AD admitted he and his assistant had less frequent interactions and had missed the opportunity to help Resident 16 achieve his goal to increase his socialization. The AD stated the activity unit should have pursued Resident 16's activity preference and the AD should have been persistent with the activity interventions but he did not. The AD also validated Resident 16's care plan should have been revised, reassessed and updated for effectiveness to align with Resident 16's ability to participate but it was not. A review of the facility's policy and procedure titled Activity Evaluation, revised May 2013, indicated, The resident's activity evaluation is to be conducted by Activity Department personnel in conjunction with other staff who will evaluate related factors such as functional level, cognition, and medical conditions that may affect activities participation. The resident's lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences will be included in the evaluation.

Based on observation, interview and document review, the facility failed to provide a comparable nutrient alternative to the main entrée for those residents who did not eat fish/seafood (Residents 4, 5, 10, 26, and 28 ). This failure had the potential to limit intake of protein for these 5 out of 31 residents which could lead to malnutrition, weight loss, and/or poor wound healing. Findings: An observation of the lunch tray plating occurred on 8/20/22 at 11:45 a.m. The menu consisted of cod, vegetable brown rice, orange ginger carrots, a dinner roll, and peanut butter cake. A dietary aide started the lunch plating process by calling out the type of diet to be served along with the food preferences. The main entrée was served by the Dietary Manager (DM) who noted there was not a prepared alternative for residents who had requested no fish or seafood. She proceeded to make a cheese sandwich (which consisted of two slices of bread, two slices of cheese, with mayonnaise) when a tray ticket requested no fish. The protein content of the 4 ounces of cod was 29 grams per the daily nutrient analysis provided by the facility. The cheese sandwich provided approximately 14 grams of protein (2.7 grams per slice of bread, and 4 grams per slice of cheese per food labels).

Based on observation, interview, and record review, the facility failed to protect resident personal and medical information when dietary tray tickets were thrown into the general trash. This failure had the potential of personal information being seen by non-facility persons for the 31 residents receiving facility prepared meals. Findings: During a tour of the dietary department on 8/31/22 starting at 11:30 a.m. the Dietary Aide 2 (DA 2) removed trays from the dirty carts in preparation for washing. He sorted the tray contents, threw napkins and tray tickets into the trash can and food into a compost collection bin. In a subsequent interview with the Registered Dietitian (RD) on 8/31/22 at 11:35 a.m., she stated other places she had worked kept the tray tickets on the nursing floor to be destroyed and would have to investigate the process for this facility. During an interview with the Director of Nursing (DON) on 9/1/22 at 11:55 a.m., she stated the tray tickets are returned to the kitchen on the meal trays but she thought they were being destroyed as personal information should be kept secured. A review of tray tickets include resident name, room number, name of facility and level of nursing care, diet order and texture, food likes/dislikes, and food allergies. A review of a facility provided policy titled Protected Health Information (PHI), Authorization for Use or Disclosure of, revised March 2014, indicated, All uses and disclosures of protected health information (PHI) beyond those otherwise permitted by current HIPAA [Health Insurance Portability and Accountability Act] law require a signed authorization. A review of a facility provided policy titled Resident Rights, revised December 2016, indicated, .privacy and confidentiality .The unauthorized .disclosure of resident information is prohibited. All release .or disclosure of resident information must be in accordance with current laws governing privacy of information issues . A review of a facility provided policy titled Release of Information, revised November 2009, indicated, Our facility maintains the confidentially of each resident's personal and protected health information.

Based on observation, interview, and record review, the facility failed to store and prepare foods according to professional standards for food safety when: 1) The back panel inside the microwave and the waffle maker stand was dirty; 2) One white and one red cutting board were badly stained with black markings; 3) There was an unidentified brown item around 1.5 inches by 1 inch in size on the clean grated sheets; 4) There was a dirty electric fan in the food preparation area; 5) There were expired, improperly labeled and/or undated food in the kitchen; 6) There were opened and unlabeled packages of foods left open in the kitchen and in the freezer; 7) There was a dented can of sauerkraut in the canned food rack; 8) There were five expired bottles of improperly labeled protein drink in the resident's refrigerator; and, 9) The kitchen staff did not change gloves in between tasks in the kitchen during tray line. These failures had the potential to increase the risk of foodborne illnesses for a total of 31 residents who received food from the kitchen. Findings: 1) During the initial kitchen tour on 8/30/22 at 8:32 a.m., accompanied by the Dietary Manager (DM) the DM acknowledged the microwave had brown drips and spots on the inside back panel and the waffle maker stand below the microwave had brown drips. The DM stated, It's [the microwave] disgusting and should be cleaned. A review of a facility Policy and Procedure (P&P) titled, Safety and Sanitation, revised 1/29/19, indicated, All food contact surfaces .must be cleaned and sanitized .once every 4 hour .any build up reflects failure to clean and sanitize at the proper frequency . A review of the Food and Drug Administration (FDA) document titled Food Code dated 2017, section 4-602.11 Equipment Food-Contact Surfaces and Utensils, indicated, .It is the standard of practice to ensure food contact surfaces of equipment shall be cleaned at any time during the operation when contamination may have occurred . 2) During the initial kitchen tour on 8/30/22 at 8:32 a.m., the DM acknowledged the white and red cutting boards were badly stained with black markings covering over half of its surface. The DM stated the black markings could lead to cross contamination. A review of the FDA document titled Food Code, dated 2017, section 4-501.12 Equipment Cutting Surfaces, indicated, .Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced . 3) During the initial kitchen tour on 8/30/22 at 8:32 a.m., there was an unidentified brown item around 1.5 inches by 1 inch was on a stack of clean grates for sheet pans. The DM stated it looked like, hamburger and proceeded to throw it out but did not remove the grates to be rewashed. A review of a facility P&P titled Storage of Food and Supplies, revised 12/7/20, indicated, All food, non-food items and supplies .used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . 4) During a concurrent observation and interview on 8/30/22 at 9:05 a.m., the DM acknowledged the electric fan in the preparation area had a gray/black build up on the vents with orange drips on the base of the fan. The DM stated staff are supposed to wipe the outside nightly, but the staff did not know how to clean the vents inside the fan. A review of the FDA document titled Food Code, dated 2017, section 4-601.11 Equipment, Food-Contact Surfaces, Non-food contact Surfaces, and Utensils, indicated, .Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . A review of the FDA document titled Food Code, dated 2017, section 4-602.13 Nonfood-Contact Surfaces, indicated, .Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues . 5) During the initial kitchen tour on 8/30/22 at 8:32 a.m., the DM acknowledged there was an opened container of pepper flakes which was improperly labeled with 11/11 (without a year), an opened container of baking soda with use by date of 6/24/22, an opened container of seafood and poultry seasoning with a use by date of 6/21/22, and an opened container of unlabeled all-purpose seasoning in the kitchen preparation area. The DM was observed removing the expired items from the kitchen preparation area. During a concurrent observation and interview on 8/30/22 at 9:10 a.m., in the kitchen dry storage room, the DM acknowledged there was a can of all vegetable shortening with a best by date of 1/15/21. The DM proceeded to remove it from the dry storage and discard. During a concurrent observation and interview on 8/30/22 at 9:10 a.m., in the refrigerator, the DM acknowledged there was a container of Swiss cheese with the discard date of 8/27/22, an unlabeled container of American cheese, and an unlabeled container of cut cucumbers. During an interview on 9/1/22 at 2:18 p.m., the DM stated spices past the best by dates should be discarded to follow the FDA recommendations and to avoid the possibility of bacterial growth. The DM further stated the purpose of labeling food is to assure the food is safe to be served. A review of a facility P&P titled Storage of Food and Supplies, revised 12/7/20, indicated, Cover, label and date unused portions and opened packages .discard food past the use by, sell-by, or best by date . 6) During a concurrent observation and interview on 8/30/22 at 8:33 a.m., in the kitchen, the DM acknowledged there was an opened package of bread in the shelves which was exposed to air. The DM stated it should be closed with the original tie to keep it fresh and reduce the chance of the bread developing mold or bugs getting into the product. During a concurrent observation and interview on 8/30/22 at 9:30 a.m., in the kitchen walk- in freezer, the DM confirmed there was an opened and unlabeled bag of pork sausage patties noted to have the beginning of ice buildup. The DM stated it was supposed to be labeled as well as closed to avoid cross contamination and maintain the quality of the food. A review of a facility P&P titled Storage of Food and Supplies, revised 12/7/20, indicated, All food .used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Freezer Foods .Wrap food tightly to prevent cross contamination . 7) During a concurrent observation and interview on 8/30/22 at 8:33 a.m., in the kitchen dry storage room, a dented can of sauerkraut was noted in the storage along with other canned goods. The DM removed the can and stated dented cans are supposed to be kept in her office and returned to the food supply company. During an interview on 9/1/22 at 2:18 p.m., the DM stated dented cans are removed from the storage room because, it could cause botulism [a potentially fatal disease caused by consumption of improperly processed food]. A review of a facility P&P titled Storage of Food and Supplies, revised 12/7/20, indicated, Maintain designated area for items that are damaged (such as dented cans) . 8) During a concurrent observation and interview on 8/31/22 at 9:40 a.m., with Licensed Nurse 2 (LN 2) in the nursing station, the resident's refrigerator was inspected. Five bottles of a protein drink were found in the refrigerator and were beyond the best by date. The LN 2 acknowledged the five bottles of protein drink should have been thrown away. These bottles were observed to be labeled only with the resident's room number and no other identifier. During an interview on 9/1/22 at 12 p.m., the Director of Nursing (DON) stated outside food should be labeled with a received date and the resident's name. The DON further stated food and drinks should not be labeled with the resident's room as residents might move to a different room. The DON also stated expired food should be thrown out because it could be, bad for the resident. A review of a facility P&P titled Food Receiving and Storage, revised October 2017, indicated, All foods belonging to residents .labeled with resident's name .and the use by date . 9) During an observation on 8/30/22 11:47 a.m., in the kitchen during trayline (a system of food preparation in which trays move along in assembly line), the Dietary Aide 1 (DA 1) was observed plating rice and vegetables with gloved hands. The DA 1 went to take a cup of soup from the reach-in refrigerator with gloved hands and proceeded to put the soup inside the microwave. The DA 1 then returned to tray line and was observed with same gloved hands, touching a wheat roll and continued to place food on trays without changing gloves and washing hands. During an interview on 9/1/22 at 2 p.m., the Infection Preventionist (IP) stated she expected kitchen staff to wash their hands before putting on gloves and to change gloves when other surfaces were touched. During an interview on 9/1/22 at 2:18 p.m., the DM stated it is expected kitchen staff wash hands and change gloves anytime they change tasks. A review of a facility P&P titled Safety and Sanitation, revised September 2013, indicated, .one of the methods to prevent food borne illness is insuring [sic] that all team members practice .washing their hands .after handling dirty equipment or raw food product .

2. During the initial kitchen tour on 8/30/22 at 8:32 a.m., the Dietary Manager (DM) was observed not wearing a mask and three other kitchen staff were observed not wearing masks while performing kitchen tasks. During an observation on 8/30/22 at 11:45 a.m., in the kitchen, during trayline (a system of food preparation in which trays move along in assembly line) four kitchen staff were observed not wearing masks while preparing food trays. During an observation on 8/31/22 at 8:36 a.m., in the kitchen, the Dietary Aide 2 (DA 2) was observed washing dishes without a mask on. The [NAME] 1 (CK 1) was also observed cooking shrimp without a mask on. Three other kitchen staff were further observed not wearing masks while performing kitchen tasks. During an observation on 9/1/22 at 9:31 a.m., in the kitchen, the CK 2 was observed preparing pureed foods without a mask on. Four other kitchen staff were also observed not wearing masks, while one staff member was wearing a mask below the nose which only covered her mouth while performing kitchen tasks. During an interview on 9/1/22 at 2 p.m., the IP stated kitchen staff are expected to wear a mask due to the risk of contaminating food by expelling germs over it. During an interview on 9/1/22 at 2:18 p.m., the DM stated staff were not wearing masks inside the kitchen when she took the job over. During an interview on 9/1/22 at 3:05 p.m., the ADM stated the facility did not have a specific policy regarding wearing masks in the kitchen. A review of the facility's policy and procedure titled Personal Protective Equipment - Using Face Masks, revised September 2010, indicated, .Purpose .The use of masks .To prevent transmission of infectious agents .To prevent transmission of infections that are spread by direct contact with mucous membranes . Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were performed for a census of 31, when; 1. Staff did not follow manufacturer's instruction regarding disinfectant contact time; and, 2. Kitchen staff did not wear masks for source control during meal preparation and during tray line. These failures reduced the facility's potential to prevent a spread of infection. Findings: 1. During a concurrent observation and interview on 9/1/22 at 2:45 p.m., in the hallway across the nursing station, the Housekeeper 1 (HK 1) was holding a spraying bottle and sprayed the table surface rendering the surface wet. Within 10 seconds, the HK 1 grabbed a clean rag from the cart and wiped the surface rendering the surface dry. The HK 1 stated, We use this spray to disinfect all surfaces like .tables .doors bed rails .After I spray, I wipe it [surface] right away with the rag . A review of the spray bottle's label with the Assistant Director of Nursing (ADON), indicated, .[Brand Name] Five 16 Concentrate .One Step Disinfectant Cleaner .Use DIRECTIONS: .Allow to remain wet for 5 minutes . During an interview on 9/1/22 at 2:47 p.m., the ADON stated, [Staff are supposed to] .Observe wet time [contact time] of 5 minutes [per manufacturer's instruction] before wiping the surface. During an interview on 9/1/22 at 2:49 p.m., the Housekeeping Supervisor (HSK) acknowledged the HK 1 should have followed the manufacturer's instruction to observe a 5 minute wet time prior to wiping the surface. During an interview on 9/1/22 at 3 p.m. the Infection Preventionist (IP) stated, .[The HK 1] should have followed the wet time of 5 minutes per manufacturer's instructions. The IP confirmed it was an infection control issue. A review of an undated facility policy and procedure titled, .Policy for Cleaning Surfaces . indicated, .Use .on all surfaces .There is a 5 minute dwell time for this product [Brand Name Five 16].