Based on interview, record review, document review, and facility policy review, the facility failed to act upon the Consultant Pharmacist's recommendation for 2 (Resident #2 and Resident #32) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Consultant Pharmacist Reports, effective date 06/2021, revealed, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. 1. An admission Record revealed the facility admitted Resident #2 on 11/15/2023. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #2's Order Summary Report with active orders as of 06/19/2024, revealed an order dated 11/30/2023 for mometasone furoate inhalation aerosol 200 micrograms per actuation 2 puffs inhale orally twice daily for asthma. The Consultant Pharmacist's Medication Regimen Review, for recommendations created between 05/01/2024 and 05/05/2024, revealed please add to Resident #2 order for mometasone rinse mouth with water after use, do not swallow the water. 2. An admission Record revealed the facility admitted Resident #32 on 01/17/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Resident #32's Order Summary Report with active orders as of 06/20/2024, revealed an order dated 03/05/2024 for Eliquis oral tablet 2.5 milligrams (mg) (apixaban) give one tablet by mouth two times a day for deep vein thrombosis prophylaxis. The Consultant Pharmacist's Medication Regimen Review, for recommendations created between 05/01/2024 and 05/05/2024, revealed Resident #32 had an order for apixaban and the Consultant Pharmacist recommended the facility add shift monitoring to detect any bleeding. Resident #32's Medication Administration Record for 06/2024, revealed evidence to indicate staff monitored Resident #32 for bleeding prior to 06/20/2024. In an interview on 06/20/2024 at 8:29 AM, the Director of Nursing (DON) stated he started the position of DON on 05/01/2024. The DON stated he had not gotten the Consultant Pharmacist's MRR for May 2024. According to the DON, the Consultant Pharmacist recommendations for Resident #2 and Resident #32 had not been acted upon. In an interview on 06/20/2024 at 10:06 AM, the Consultant Pharmacist stated the recommendation should have been addressed by now. In an interview on 06/20/2024 at 10:46 AM, the Administrator stated staff should update a resident's physician order with recommendations from the Consultant Pharmacist.

Based on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. The facility had 4 medication errors out of 26 opportunities, which yielded a medication error rate of 15.38% for 1 (Resident #40) of 4 residents observed for medication administration. Findings included: A facility policy titled, Medication Administration Oral Inhalations, dated 05/2016, indicated, 14. If another puff of the same or different medication is required, follow the manufacturer's product information for administration instructions including the acceptable wait time between inhalations. The undated Dulera Patient Information, revealed, 10. Wait at least 30 seconds to take your second puff of Dulera. A facility policy titled, Medication Administration General Guidelines, dated 09/2018, indicated, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Per the policy, 1. Medications are administered in accordance with written orders of the prescriber. An admission Record indicated the facility admitted Resident #40 on 12/13/2022. According to the admission Record, the resident had medical history that included a diagnosis of amyotrophic lateral sclerosis (ALS). Resident #40's Order Summary Report, with active orders as of 06/19/2024, revealed an order dated 08/09/2023, for Dulera (a medication used to treat asthma) Aerosol 200-5 micrograms per action, inhale two puffs two times daily to decrease inflammation in the lungs. The Order Summary Report revealed an order dated 12/13/2022, for omega-3 fatty acid capsule (a medication used to lower triglyceride levels in adults) 500 milligrams by mouth daily for cholesterol control; Peridex Solution (an antiseptic mouthwash used to treat gingivitis) 0.12%, give 15 milliliters every 12 hours for oral care; and riluzole (a prescription medication used for the treatment of ALS) 50 mg one tablet by mouth every 12 hours related to ALS. During a medication administration observation on 06/18/2024 at 9:07 AM, Licensed Vocational Nurse (LVN) #1 administered one puff of the Dulera to Resident #40 followed by a second puff five seconds later. LVN #1 did not administer omega-3 fatty acid capsule, riluzole, or the Peridex Solution to Resident #40 during the medication administration observation. During an interview on 06/18/2024 at 12:11 PM, LVN #1 stated she did not administer the omega-3 fatty acid, riluzole, or the Peridex Solution to Resident #40. LVN #1 confirmed she did not wait at least 30 seconds to administer the second puff of Dulera to Resident #40. During an interview on 06/18/2024 at 12:45 PM, the Director of Nursing stated he expected staff to administer medications according to the physician's orders and per the manufacturer's instructions. During an interview on 06/20/2024 at 10:18 AM, the Administrator stated she expected staff to administer medications according to the physician's orders and per the manufacturer's instructions.

Based on interview, record review, and facility policy review, the facility failed to transcribe a physician's order for wound care for 1 (Resident #2) of 14 sampled residents. Findings included: A facility policy titled, Wound Care, revised in10/2010, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. An admission Record revealed the facility admitted Resident #2 on 11/15/2023. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #2's care plan, initiated on 11/16/2023, revealed the resident had potential/actual skin impairment to skin integrity related to suspected deep tissue injury. Resident #2's Surgical Consult dated 06/12/2024, revealed the physician was asked to see the resident for their opinion on how to manage the resident's wound located on the left inferior knee. The Surgical Consult revealed the wound dressing used was gentamicin (an antibiotic used to treat skin infections), Bactroban (an antibiotic used to treat skin infections), skin prep, and boarded foam. According to the Surgical Consult, the resident's wound was stable and required continued topical wound dressing as noted above. Resident #2's Order Summary Report, with active orders as of 06/19/2024, revealed no order no order for the provision of wound care to the resident's left inferior knee. In an interview on 06/19/2024 at 3:46 PM, the Wound Physician stated Resident #2 had been on topical antibiotics for weeks. The Wound Physician stated that on 06/12/2024 she ordered gentamicin, Bactroban, skin prep, and boarded foam for the resident. The Wound Physician stated she expected the orders to be transcribed into the resident's medical record by the next day shift unless it was a renewal and it was already covered. The Wound Physician stated she did not know what happened or why there were not any wound care orders for the resident. According to the Wound Physician, the treatment nurse should transcribe the orders after rounds. In an interview on 06/20/2024 at 12:58 PM, the Director of Nursing (DON) stated the Wound Physician directed the residents' wound care and the staff were directed to follow their orders. The DON stated the treatment nurse should receive the order and transcribe the order into the resident's electronic medical record (EMR). In an interview on 06/20/2024 at 1:13 PM, Licensed Vocational Nurse (LVN) #3 stated she performed wound care for Resident #2 daily. Per LNV #3, the wound treatment she provided was gentamicin and Bactroban ointment and covered the wound with foam dressing. LVN #3 stated she failed to transcribe the physician's order for wound care to the resident's EMR that was given to her by the Wound Physician. In an interview on 06/20/2024 at 1:41 PM, the Administrator stated staff should process and implement treatment orders.

Based on observation, record review, interview, and document review, the facility failed to ensure enhanced barrier precautions were implemented for 1 (Resident #26) of 14 sampled residents. Findings included: The Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), 2019 published by the California Department of Public Health (CDPH), revealed, CDPH recommends the use of Enhanced Standard precautions, primarily the use of gowns and gloves for specific care activities, based on the resident's characteristics that are associated with a high risk of MDRO [multidrug-resistant organism] colonization and transmission: Table 1. Characteristics of Residents at High Risk for MDRO Colonization and Transmission Functional Disability: Totally dependent on others for assistance with activities of daily living Incontinence: Habitual soiling with stool or wetting with urine Presence of indwelling devices: urinary catheter, feeding tube, tracheostomy tube, vascular catheters Ventilator-dependence Wounds or presence of pressure ulcer (unhealed) Implement Enhanced Standard Precautions for high risk residents: * Place the high-risk resident in a single bed room. When a single bed room is not available, cohort the resident with a compatible roommate, such as a resident with the same MDRO or resistance mechanism when known. * Wear gowns and gloves while performing the following tasks associated with the greatest risk for MRDO contamination of HCP [health care personnel] hands, clothes and the environment: * Morning and evening care * Device care, for example, urinary catheter, feeding tube, tracheostomy, vascular catheter * Any care activity where close contact with the residents is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, respiratory care An admission Record indicated the facility admitted Resident #26 on 09/08/2020. According to the admission Record, the resident had a medical history that included diagnoses of cutaneous abscess of buttock, cellulitis of buttock, functional quadriplegia, chronic osteomyelitis, and neuromuscular dysfunction of bladder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 06/08/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident had intact cognition. The MDS indicated the resident was dependent upon staff for most activities of daily living, had an indwelling catheter, and one unstageable pressure ulcer. Resident #26's care plan initiated on 06/07/2021, indicated the resident had a reopened stage 4 pressure ulcer on their coccyx related to a history of ulcers and immobility. The resident also had another care plan, initiated on 03/11/2022, that indicated the resident had an indwelling catheter related to a diagnosis of neurogenic bladder. During an observation on 06/18/2024 at 1:42 PM, Certified Nurse Aide (CNA) #1 emptied Resident #26's indwelling catheter bag. CNA #1 wore gloves and did not put on a gown. During an observation on 06/18/2024 at 1:45 PM, CNA #2 provided incontinence care for Resident #26. can #2 wore gloves and a mask, but did not put on a gown. During an observation on 06/18/2024 at 1:50 PM, Licensed Vocational Nurse (LVN) #3 performed wound care for Resident #26. LVN #3 wore gloves during the wound care, but did not put on a gown. During an interview on 06/18/2024 at 2:14 PM, CNA #2 stated she was not required to use enhanced barrier precautions when she provided incontinence care for Resident #26. During an interview on 06/18/2024 at 2:16 PM, LVN #3 stated she was not required to use enhanced barrier precautions for the wound treatment. LVN #3stated she believed enhanced barrier precautions would be required for emptying a catheter bag and for the provision of care for a resident who had a feeding tube. During an interview on 06/18/2024 at 2:18 PM, CNA #1 stated she was not required to use enhanced barrier precautions when she provided incontinence care or emptied a catheter bag unless the resident was in isolation and had signs on their door. During an interview on 06/19/2024 at 8:59 AM, the Infection Preventionist (IP) stated all three of the staff should have worn gloves and a gown for enhanced barrier precautions when they provided care for Resident #26. The IP stated the facility followed the Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), 2019 developed by the California Department of Public Health. During an interview on 06/20/2024 at 10:09 AM, the Administrator stated she knew staff wore personal protective equipment as required and would expect them to wear a gown for enhanced barrier precautions when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the medication Tramadol 50 mg (medication used to help relieve moderate to moderately severe pain) as per physician ' s order for one (Resident 1) of three sampled residents. This failure resulted in Resident 1 receiving a double dose of medication within 12 hours and placed Resident 1 ' s health and safety at risk. Findings: During a review of Resident 1 ' s admission record, printed on 11/1/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a review of Resident 1 ' s physicians orders dated 8/15/23, the physician orders indicated to administer Tramadol HCL oral tablet 50 mg, 1 tablet every 12 hours as needed for pain. During a review of Resident 1 ' s Antibiotic and Controlled Drug Record, dated 8/30/23, the controlled drug record indicated on 9/20/23, Tramadol was taken out of the medication cart at 10:15 p.m. and signed by licensed nurse. The controlled drug record also indicated Tramadol was taken out of the medication cart at 2:21 am on 9/21/23 and signed by licensed nurse. During a concurrent interview and record review on 11/1/23, at 1:08 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Medication administration record (MAR), for [DATE] was reviewed. LVN 1 stated that the MAR indicated Tramadol was administered on 9/21/23 at 2.16 a.m. LVN 1 stated there was no record of Tramadol administered at 10:15 pm on 9/20/23 in the electronic health record. During an interview on 11/1/23, at 2:22 p.m. with Registered Nurse (RN) 1, RN 1 stated on 9/20/23 she administered the medication Tramadol 50 mg orally to Resident 1 at 10:15 pm. RN 1 stated after administering the medication she forgot to click the save in electronic health record and the medication administration was not registered in the system accurately. RN 1 stated this allowed the night shift nurse to administer medication again before it was due. RN 1 stated it is very important to document medication administration correctly to prevent residents getting double doses and can be dangerous. During an interview on 11/1/23 at 2:35 p.m. with Director of Nursing (DON), DON stated it is critical to accurately document medication administration as it is the proof that the medication was given and a way of communication to the other nurses. DON stated when medication administration is not documented correctly there is a high risk for medication error with possibility to cause adverse effects and permanent complications. During a review of the facility ' s undated policy and procedure (P&P) titled, Medication administration, the P&P indicated, To administer oral medication in an organized, accurate and safe manner .Chart medication administration on Medication Administration Record immediately following each resident ' s medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards for care for one of three residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application. This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen. Findings: During a review of Resident 1's admission Record dated [DATE], the admission Records showed Resident 1 was admitted in [DATE]. During a review of Resident 1's Minimum Data Set (MDS - an assessment used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 15 out of 15, indicating intact mental status. Resident 1 was wheelchair bound and Section G of the MDS showed her functional status included needing extensive assistance transferring and independent when moving about the unit once in her wheelchair. Section M of the MDS showed Resident 1 had intact skin but was at risk for developing pressure ulcers/injuries and had moisture-associated skin damage. During an interview on [DATE] at 12:30 p.m. with Resident 1, Resident 1 stated she asked Certified Nurse Assistant (CNA) 1 for hot packs because she had menstrual cramps. Resident 1 stated CNA 1 'broke them and handed two hot packs to her. Resident 1 further stated she took the hot packs to her room and placed them on her abdomen for 30 45 minutes. Resident 1 removed the hot packs when she repeatedly felt moisture and stinging. Resident 1 stated she went to the nurses station to ask the nurses what was on her abdomen and they told her she had a burn. Resident 1 stated her pain was 8/10. Resident 1 further stated Licensed Vocational Nurse (LVN) 1 applied medicine and covered the wound after calling the doctor. During a concurrent interview and record review on [DATE] at 1:02 p.m. with Director of Nursing (DON), CNA 1's California Department of Public Health Nurse Assistant Certification, dated [DATE], was reviewed. The certificate indicated CNA 1's Nurse Assistant certification expired [DATE]. DON stated CNA 1 was registry staff and provided an orientation binder specific to registry on her start date. DON also stated registry staff were required to sign an acknowledgement they reviewed the orientation binder. DON provided an email from CNA 1's employer, dated [DATE], and stated CNA 1 started at the facility on [DATE]. DON further stated she expected certified nurse assistants, including registry, to do shift-to-shift handoff (the transfer of resident information and status from one staff to another between shifts) and go to the charge nurse for any questions. Staff inservices (training/information provided at work) completed in 2023 were also reviewed. CNA 1 attended two of five inservices provided for certified nurse assistants, one on [DATE] for razor disposal, and one on [DATE] for heat packs provided after Resident 1's injury. DON stated no prior inservices for hot packs had been provided. During an interview on [DATE] at 2:43 p.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated hot and cold packs required permission from the charge nurse. She stated she had applied hot and cold packs on residents before and used a towel to protect the resident's skin from getting too hot or too cold. During an interview on [DATE] at 2:59 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated hot packs required a physician's order and were only applied by the charge nurse. LVN 3 also stated hot packs were wrapped in a cloth or towel, and the nurse assessed whether the resident held the hot pack. During an interview on [DATE] at 3:10 p.m. with CNA 1, CNA 1 stated Resident 1 asked for two hot packs. CNA 1 stated she asked Licensed Vocational Nurse (LVN) 2 and was instructed to check the closet in Station 2. CNA 1 stated she activated the hot packs, placed them on a medication cart shelf at Station 2, and told Resident 1 to wait while she got towels. CNA 1 stated she was gone approximately 15 minutes and when she returned, Resident 1 was found in her room with nurses caring for a burn on Resident 1's abdomen. CNA 1 stated she didn't know if Resident 1 had an order for hot packs but assumed it was okay since LVN 2 told her to get the hot packs. During a concurrent observation and interview on [DATE] at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's abdominal wound was observed during a dressing change. LVN 1 stated the wound measured 5 cm x 12 cm. The lower abdominal wound was midline and extended to the right. The wound had pink margins and a white wound bed with two grayish-tan areas, one in the middle of the wound and one to the left. In addition, there were two small, approximately 0.5 cm x 0.5 cm dried, dark brown blisters located just inferior and to the left of Resident 1's umbilicus (belly button). During a telephone interview on [DATE] at 4:33 p.m. with Licensed Vocational Nurse (LVN) 2 and Director of Nursing (DON) present, LVN 2 stated she was the charge nurse the evening of Resident 1's injury. LVN 2 stated CNA 1 did not ask her to use hot packs for Resident 1. LVN 2 further stated Resident 1 did not have an order for hot packs, and she previously told Resident 1 to drink warm water to help relieve her cramping. LVN 2 stated hot packs required a physician order and application by licensed nurses only. During an interview on [DATE] at 4:42 p.m. with DON, DON stated Resident 1 did not have a physician order for hot packs. DON also stated hot packs fell under the facility's Hot Compress Policy and a physician order was required. DON further stated facility staff are expected to follow the manufacturer's instructions on the hot pack packaging. During an interview on [DATE] at 5:03 p.m. with DON, DON stated they could not provide CNA 1's signed orientation binder acknowledgement. During a phone interview on [DATE] at 2:50 p.m. with Resident 1's primary physician (MD 1), MD 1 stated he never ordered hot packs for Resident 1, nor was he called for an order. MD 1 also stated he would have ordered ibuprofen (medication that reduces inflammation) rather than hot packs as treatment for menstrual cramps if he had been called. MD 1 stated Resident 1's diabetes caused her decreased sensation and may have contributed to Resident 1's burns. During a review of the facility's Incident Investigation Summary, undated, the Investigation Summary indicated on [DATE], Resident 1 had an open abdominal wound that measured 5 cm x 12 cm x 0.1 cm caused by two hot packs applied directly to her abdomen. The Investigation Summary also indicated CNA 1 said she was unaware she can't apply items like a heat pack on residents and only a nurse can do so. The Investigation Summary further indicated, Supply of heat packs removed from a nursing supplies closet to allow only licensed personnel to access. During a review of the facility's policy and procedure (P&P) titled, Compress or Soak, Applying Warm, dated 2/2018, the P&P indicated, 1. Verify there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. During a review of [NAME] Instant Disposable Hot Compress packaging, undated, the package indicated, Peak temperature may reach 160?. Do not apply directly to skin, wrap in towel or cloth for protection. Do not use for more than 30 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures (P&P) that prevent abuse, neglect, and exploitation of residents when registry Certified Nursing Assistants (CNAs) were not given abuse training/orientation prior to working with residents. This failure had the potential to result in abuse of residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses that included muscle weakness, end stage kidney disease, and high blood pressure. During a review of Resident 1's Progress Notes, dated 9/4/23, the Progress Notes indicated Resident 1 complained of eight of 10 (0 for no pain and 10 as the most painful) pain on the back of her head after being transferred from the chair to the bed by CNA 1 and she hit her head on the headboard. The Progress Notes indicated Resident 1 had a round contusion at the back of the head that measured half an inch, Resident 1's daughter requested for Resident 1 to be transferred to the hospital for further evaluation. During a review of the History & Physical (H&P), printed 9/7/23, the H&P indicated Resident 1 had a closed head trauma from the incident. During an interview on 9/21/23 at 11:10 a.m. with Director of Nursing (DON), DON stated CNA 1 was assigned to Resident 1 on 9/4/23. DON stated CNA 1 was interviewed and gave a version of the incident that was different from Resident 1's account. DON stated CNA 1 was a registry staff and not a regular employee of the facility. During another interview on 9/21/23 at 11:50 a.m. with DON, DON stated the registry does not provide documentation of abuse training for the registry staff that they send to the facility. DON stated registry staff are given orientation on abuse prevention before they start their first shift. DON stated an Orientation Binder for Registry Nurses and CNAs where orientation acknowledgment forms were filed. During a review of the facility's undated Orientation Acknowledgement, the Orientation Acknowledgement indicated I .with staffing agency have reviewed the Registry Orientation Binder with a [facility staff] which include abuse, hoyer lift (mobility tool used to help seniors with mobility challenges get out of bed or the bath) and resident profiles . The Orientation Acknowledgment form would have the registry staff signature and facility staff signature. During a concurrent interview and record review on 9/21/23 at 11:59 a.m. with Staff Scheduler (SS), the Staffing Schedule was reviewed. SS stated CNA 1, CNA 2 and CNA 3 worked the morning shift, all three CNAs were registry staff who worked on 9/4/23. SS stated CNA 4, also a registry staff who was on the schedule for 9/21/23, was at the facility during the investigation. During an interview on 9/21/23 at 12:01 p.m. with CNA 4, CNA 4 stated being told where to find things and equipment during the first time at the facility but was not given abuse training. During an interview on 9/21/23 at 12:33 p.m. with DON, DON stated there was no documentation that indicated CNA 1, CNA 2, CNA 3, and CNA 4 had abuse training/orientation in the Orientation Binder for Registry Nurses and CNAs. During a review of the facility's P&P titled Abuse Prevention Program, last revised, December 2016, the P&P indicated for resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not limited to, facility staff and staff from other agencies. The administration will require training/orientation that include abuse prevention, identification, and stress management.

Based on interview, and record review, the facility failed to ensure Restorative Nurse Aide (RNA) services were provided according to the physician's order, and according to professional standards of practice for one of three sampled residents (Resident 1). This failure had the potential to result in a decline in Resident 1 ' s Range Of Motion (ROM) and mobility. Findings: 1. Review of Resident 1's admission record on 1/26/23, indicated Resident 1 was admitted to the facility in 2022. Review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), Resident 1 had a Brief Interview for Mental Status (BIMS) score of 6, meaning Resident 1 ' s cognition was severely impaired. Continued review of Resident 1's MDS indicated, Resident 1 had multiple diagnoses which included Cerebrovascular Accident (CVA or stroke - blood flow to brain is stopped by blockage or rupture of blood vessel). Review of Resident 1's Physician ' s Order Report, dated 9/5/22, indicated a physician's order for an RNA (Restorative Nurse Aide) to perform exercises to upper extremities and lower extremities to all planes 10x or more as tolerated . ambulate with Front Wheel [NAME] (FWW) 50 feet or more as tolerated with btand by Assist / Supervision (SBA/S) in order to maintain current functional level . Review of Resident 1's RNA Referral Form, dated 11/23/22, indicated treatment plan for ambulation for increasing distance. The RNA Referral Form also indicated, Program Goals for Resident 1 was to maintain current ROM status, increase general health and endurance for functional mobility, and maintain current ambulatory status. During a concurrent interview and record review, on 1/26/23, at 12:35 p.m., with Restorative Nurse Aide (RNA) 2, RNA 2 confirmed, Resident 1 had a referral for RNA services but was not done. RNA 2 further added, she could not find any documentation Resident 1 received RNA services for the referral made on 9/5/22. During a concurrent interview and record review, on 1/26/23, at 1:10 p.m., with the Director of Rehabilitation (DOR), DOR stated, there was no documentation to show RNA services was done. DOR also stated, Resident 1 had the potential for decline. DOR further added, Resident 1 could benefit from RNA services to maintain functional level and prevent decline in functioning. During a telephone interview, on 2/1/23, at 4:00 p.m., with the Director of Nursing (DON), DON acknowledged the RNA order for Resident 1's ROM was active but not done. The DON further stated RNA services was ordered to keep Resident 1 ' s functional level and prevent decline in functioning. Durring a review of the facility's policy and procedure (P&P), Resident Mobility and Range of Motion, dated, 7/2017 showed, Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The P&P also showed, Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.

Based on observation, interview and record review, the facility failed to ensure one (Resident 6) of two sampled residents needs were accommodated when administrator (Adm) told him he was not allowed to smoke. This failure caused Resident 6 psychological distress. Findings: During a concurrent observation and interviews on 6/8/21, at 11:36 a.m., with Resident 44 and Resident 6 were on the back patio, Resident 44 was seen smoking and Resident 6 was not. Resident 44 stated he often assists Resident 6 to smoke, but the Adm told Resident 6 he was not allowed to smoke. Resident 6 stated the Adm told him recently he was not allowed to smoke even though he has been smoking at the facility with assistance. Resident 6 further stated he had not smoked all day and felt stressed out that he was not allowed to smoke any longer. During an interview on 6/8/21, at 11:59 a.m., with Adm, Adm stated Resident 6 does not qualify to smoke. Adm further stated Minimum Data Set (MDS - a screening and assessment tool of health status) coordinator completed a safe smoking assessment on Resident 6 and added to the care plan. During a concurrent interview and record review, on 6/8/21, at 12:45 p.m., with MDS, Resident 6's Smoking - Safety Screen (SSS), dated 4/22/21 was reviewed. MDS read from the SSS which indicated, Resident 6 requires one-on-one assistance from staff to smoke, and, safe to smoke with one-on-one assistance. During a review of Resident 6's Care Plan, dated 6/7/21, the Care Plan indicated, Resident 6 is a smoker and requires one-on-one assistance with smoking. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated 7/2017, the P&P indicated, Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.

Based on the observation, interview and record review the facility failed to provide a homelike environment when three (Resident 36, 51 and Resident 255) of five sample residents were complaining about the noise level at night. This failure had the potential to result in Resident 36 and 255 inability to sleep and feeling tired. Findings: During an observation on 06/07/21, at 9:40 a.m.,. a beeping noise was heard from the call light of Resident 51's room number and was ongoing until 3:30 p.m. same day. During an interview with the Director of Nursing ( DON) on 06/07/21, at 3:20 p.m., DON stated the call light had been broken since 6/6/21 on the night shift. DON stated they had called the company to fix the call light on 6/7/21. During an interview with Resident 35 on 06/07/21, at 10:32 a.m., Resident 35 stated There was so much noise at night. Resident 35 stated she was not able to sleep because of a beeping noise and residents yelling. During an interview with Resident 255 on 06/07/21, at 11:28 a.m., Resident 255 stated She was not able to sleep at nighttime because the place was so noisy. Resident 255 stated she was able to hear other residents yelling and talking load and the beeping noise. During a review of the facility's policy and procedure Quality of Life . revised 5/2017, it indicated . 2. The facility staff and management shall maximize, to the extent possible . i. Comfortable noise level .

Based on observation, interviews and record review, the facility failed to follow its Grievances/Complaint policy and procedure to make prompt efforts to resolve a complaint for one (Resident 40) of 15 sampled residents when the facility did not follow up and resolve Resident 40's concerns regarding cold food. This deficient practice had the potential to cause emotional distress. Findings: During an observation on 6/08/21, at 8:08 a.m., breakfast tray for Resident 40 was on the bedside table containing eggs, waffles and harsh browns. During an interview on 6/8/21, at 8:08 a.m., Resident 40 stated that breakfast was always cold. Resident 40 stated the harsh browns was very hard, dry and cold. Resident 40 stated he had complained to the staff about the cold food ,but it continued to be served cold. During an interview with Dietary Supervisor (DS) on 6/09/21, at 2:38 p.m., DS stated Resident 40 had concerns about cold food. DS stated Resident 40 complained to her about cold food and she warmed his food as needed. DS stated she had no documentation regarding resident concerns and could not provide her follow up documentation. During an interview with the Administrator (Admin) on 6/10/21, at 8:57 a.m., Admin stated she was not aware of Resident 40's concerns regarding cold food. Admin stated a grievance /concerns form must be completed to allow follow up with concerns. The facility's policy and procedures titled, Grievance/Complaint, dated 9/1/2008 indicated; Purpose is to facilitate prompt resolution of complaints or grievances for residents and /or their representative.

Based on interviews and record review the facility failed to ensure one (Resident 3) of six sampled residents received treatement to prevent further decline of range of motion when restorative nursing exercise was not provided as ordered by the physician. This deficient practice had the potential for Resident 3's range of motion to further decline. Findings: During a review of the Minimal Data Set (MDS-an assessment screening tool used to guide care), dated 5/28/21, indicated: Resident 3 had functional limited range of motion on one side of the upper and lower extremities. Resident 3 required 2-person physical assistance with movement to and from lying positron, turns side-to-side, movement to or from bed, chair and wheelchair. Resident 3's diagnosis included hemiplegia (paralysis of one side of the body). During a review of Resident 3's physician orders dated 11/27/20, it indicated Resident 3 was prescribed restorative nursing exercise three times a week for twelve weeks for upper/lower extremities, range of motion for contractor management. During a review of Resident 3's care plan initiated on 1/22/21, it indicated Resident 3 was ordered restorative nursing services three times a week for 12 weeks. During an interview with Restorative Nursing Assistant (RNA) on 6/08/21, at 11:15 a.m., RNA stated Resident 3 had not received restorative exercises for over a month because he had refused. RNA stated he did not document Resident 3's refusal anywhere. During an interview with DON on 6/08/21, at 12:14 p.m., DON stated physical therapy evaluation (PT) was scheduled but was declined due to payment status. DON could not provide documentation to support Resident 3's refusal and scheduled PT that was declined. The facility's policy and procedures, titled Restorative Nursing Services, revised 7/2017 indicated; Residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation and interview, the facility had seven resident's rooms (Rooms A, B, C, D, E, F, G and H) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 6/7/21, at 10:00 a.m.,. the following rooms and corresponding square footage per bed were identified: Room number A and B has three beds, total SQF is 235.30 and SQF per bed is 78.42. Room number C has five beds and total SQF is 463.33 and SQF per bed is 97.41. Room number D, E, F and G has six beds, total SQF is 465.60 and SQF per bed is 77.59. Room number H has five beds and total SQF is 406.28 and SQF per bed is 86.43. During random observation of care and services from 6/7/21 to 6/10/21 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns the eight rooms. Granting of room size waiver recommended.

Based on interview and record review the facility failed to provide necessary treatment and services to promote healing and prevent infection for one (Resident 51) of six sample residents when the facility staff did not provide the wound treatment on multiple shifts for Resident 51's multiple wounds. This deficient practice could result in worsening of Resident 51's existing pressure ulcers. Findings: Review of the facility admission Record, dated 5/17/21, indicated Resident 51 was admitted to the facility with multiple diagnosis including sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body ' s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). During a review of the Treatment Administration Record from 5/1/21 through 5/31/21 the following treatment were not provided: a. The treatment to the wound on the coccyx area to apply collagen powder and cover with foam dressing was not provided on 5/22/21 during the day shift b. The treatment to the wound on the left knee to apply triad and to cover with foam dressing was not provided on 5/18/21, 5/20, 5/24, 5/26, 5/28 and 5/30/21. c. The treatment to the wound on the left ischium (part of the hip bone) to apply santyl (an ointment to remove dead tissue from the wound) and cover with calcium alginate (a type of dressing) and foam dressing was not provided on 5/22/21 and 5/25/21. d. The treatment to the wound on the left foot to apply wound gel and to cover with foam dressing was not provided on 5/22/21 and 5/25/21. e. The treatment to the bilateral heels to apply A&D ointment was not provided on the evening shift of 5/31/21 and on the night shift on 5/25/21, 5/26, 5/27, 5/28, 5/29, 5/30 and 5/31/21 f. The treatment to the coccyx/buttocks area to apply moisture barrier cream was not provided on the evening shift of 5/31/21 and on the night shift on 5/25/21, 5/26, 5/27, 5/28, 5/29, 5/30 and 5/31/21 During a review of the Treatment Administration Record from 6/1/21 through 6/30/21 the following treatment were not provided: a. The treatment to the bilateral heels to apply A&D ointment was not provided on the evening shift of 6/1/21, 6/6 and 6/7/21 and on the night shift on 6/1/21, 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8/21 b. The treatment to the coccyx/buttocks area to apply moisture barrier cream was not provided on the evening shift of 6/1/21, 6/6 and 6/7/21 and on the night shift on 6/1/21, 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8/21 During an interview with the (Director of Nursing) DON on 06/10/21, at 8:43 a.m., DON stated she talked to the nurses who were assigned to Resident 51's wound care and they confirmed that they did not do the wound treatments on multiple shifts for Resident 51. DON stated if staff do not provide the wound care as ordered, the wounds could get worse or Resident 51 could developed new wounds and other complications. During an interview with Licensed Vocational Nurse (LVN) 2 on 06/10/21, at 11:29 a.m., LVN 2 stated Resident 51 refused to have the treatment on those shifts that she was assigned to did the wound care LVN 2 stated she forgot to documented Resident 51 refused treatments. LVN2 stated she did not report to anyone that Resident 51 had refused treatment. LVN 2 was not able to show any documents that Resident 51 refused the treatments on those shifts. During a review of the facility's policy and procedure Wound Care revised October 2010 indicated . Documentation . The following information should be recorded in the resident's medical record . 9. If the resident refused the treatment and the reasons why . reporting 1. Notify the supervisor if the resident refuses the wound care .

2. During a concurrent observation and interview on 6/8/21, at 12:20 p.m., with the Director of Nursing (DON), in the Medication Storage Room, an uncapped and undated multi-dose vial (MDV) of Aplisol (used in skin tests to help diagnose tuberculosis) was found in the refrigerator. During an observation, on 6/8/21, at 12:30 p.m., with the DON, the uncapped and undated MDV of Aplisol was compared side-by-side to the capped MDV of Aplisol. The fluid level was lower in the uncapped and unlabeled MDV compared to the capped MDV, which indicated the vial had been opened. During an interview on 6/9/21, at 4 p.m., the DON stated she cannot find a facility policy and procedure for dating opening MDV. During a review of the Centers for Disease Control (CDC) Injection safety, dated 6/2019, it indicated If a multi-dose (vial) has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Based on observations, interviews and record review the facility failed to follow it's policy and procedure for labeling and storing all drugs in a locked compartments when; 1. Multiple medications were kept on Resident 40's bedside window. 2. Multiple dose of medication vials were opened, undated and stored in medications storage room refrigerator. These deficient practices had the potential to cause unauthorized access, medication errors and the administration of outdated medications. Findings: During an observation on 6/08/21, at 8:08 a.m., one tube of hydrophilic (wound dressing cream), one tube of Nystop cream and one bottle of 3 % hydrogen peroxide was stored on Resident 40's bedside window. During an interview on 6/8/21, at 8:08 a.m., Resident 40 stated the medications were kept at his bedside window because when he needed the cream and called for assistance no one showed up. During an observation and concurrent interview on 6/08/21, at 8:20 a.m., Licensed Vocational Nurse (LVN1) stated the medications at Resident 40's bed side are for wound care and should be stored in the treatment carts. During a review of the facility's policy and procedures, titled Storage of Medications, revised 4/2007, it indicated Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer. or cart holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview and facility document review, the facility failed to: 1. Ensure the Registered Dietitian (RD) supported the Dietary Supervisor (DS) in maintaining a clean and safe kitchen environment; 2. Ensure the Dietary Supervisor (DS) maintained a clean kitchen and clean equipment on a day-to-day basis; and 3. Involve the RD in the quality assurance and performance improvement (QAPI; a data driven and proactive approach to quality improvement), when food and nutrition services was involved. This failure had the potential for contamination of food leading to foodborne illness for a highly susceptible population of 56 residents who received food from the kitchen out of a facility census of 57. Findings: 1. During the Federal Recertification Survey from 6/7/21-6/10/21, multiple issues were identified inside the kitchen including cleanliness of the environment such as a significant amount of residue, dirt, and/or dust on windows, window screens, window shade, walls, vents, window air-conditioner unit, on the inside surface of cabinets holding clean cooking utensils, food carts, light switch and light switch covers, and imbedded residue in cracked floor tiles. In addition, it was identified that drywall was damaged throughout the kitchen, caulking along wall seems were crumbling, cabinet doors were worn with exposed particle board, and a drawer front surface was cracked. In an interview on 6/8/21, at 9:25 a.m., the RD stated she conducted a monthly sanitation and food safety check. She said she did not report on her monthly inspection the following: the vent located above a reach-in freezer which she confirmed was covered with black residue and the surrounding wall and ceiling had black residue on the surface fanning out from the vent, the light switch and cover by the back door with imbedded black residue which she stated was dirty and dusty, the large support pole by the back door which she confirmed had dried orange drip marks covering a large portion of the surface, broken floor tiles with imbedded black residue, multiple windows in the food preparation area she confirmed had residue and dust around the perimeters and along the window ledge, the window blind she confirmed was dirty and had black residue on the surface but she stated never looked at the blind before, the window air/conditioner which she stated was dirty and covered with dust, the surface of the cabinet next to the stove which held cooking utensils such as pans, had a black residue on the linoleum that covered the shelf surface. She stated it was just scuffed until the residue scraped off onto a paper towel, then she confirmed the shelf was dirty. She also stated she did not report wood cabinets located under a preparation table with the bottom of the outer wood surface worn and cracked exposing particle board. She stated ideally the cabinets should be replaced. She stated she did not report the tall open tray carts which she confirmed had a build-up of thick black residue at the base above all the wheels, and the utility cart with food stored on top which she confirmed had imbedded black residue and stated it was dirty. Review of the last 3 kitchen audits completed by the RD titled Sanitation and Food Safety Checklist dated 3/24/21, 4/30/21, and 5/28/21 showed areas on the report for the RD to assess for cleanliness and condition included but not limited to: all floors, storage devices for dishware, air-cooling system, ceiling vents, all painted surfaces, all windows and doors. Review of the job description titled Consultant Dietitian with a revised date of 2019, showed the RD was responsible for supporting the Food and Nutrition Services Director in maintaining department standards of food service storage, preparation, safety, and delivery to residents. In addition, conducts food safety and sanitation inspections with recommendations for items not meeting standards. Review of the document titled Sanitation dated 2018, showed all equipment shall be maintained as necessary and kept in working order. Also, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 2. During the Federal Recertification Survey from 6/7/21-6/10/21 multiple issues were identified inside the kitchen including cleanliness of the environment such as a significant amount of residue, dirt, and/or dust on windows, window screens, window shade, walls, vents, window air-conditioner unit, on the inside surface of cabinets holding clean cooking utensils, food carts, light switch and light switch covers, and imbedded residue in cracked floor tiles. In addition, it was identified that drywall was damaged throughout the kitchen, caulking along wall seems were crumbling, cabinet doors were worn with exposed particle board, and a drawer front surface was cracked. In an interview on 6/8/2,1 at 9:25 a.m., the DS stated she did not know who was responsible for cleaning the support structure which was a cylindrical support structure from floor to ceiling of at least 10 inches in diameter. It had a rough, painted surface. The surface had orange drip marks on a large portion of the surface. She said the kitchen staff should be responsible for cleaning it and it needed to be cleaned. The DS also stated maintenance was responsible for cleaning a vent located above a reach-in refrigerator. The vent surface was covered with a thick, black, residue. The residue also fanned out on the surrounding wall and ceiling. The DS confirmed the vent and the surrounding area was very dusty and dirty. She said maintenance did not do rounds in the kitchen on a regular basis to check for things that had to be cleaned or fixed. In order for maintenance to clean or fix anything, she had to write it in her logbook, which maintenance checked daily. In an interview and observation on 6/8/21, at 9:49 a.m., the DS stated a kitchen staff cleaned floor by mopping but the maintenance staff was responsible for deep cleaning things that kitchen staff could not do. An observation of the window air conditioner located in a food preparation area had a fuzzy, gray matter on the surface of accordion plastic that connected the air conditioner to the window. She stated maintenance was responsible for cleaning the air conditioner. She said the air conditioner was used every day and stated it was dusty and dirty but did not have it in her logbook for maintenance to clean. On 6/8/21, at 10:31 a.m., in an interview with DS and Dietary Aide 2, DS confirmed 2 tall, metal resident meal tray carts were dirty. An observation showed the area at the base above the wheels of the cart had a thick layer of a thick black residue. DS wiped the black residue with a towel and a black residue came off onto a towel. She stated DA 2 was responsible for cleaning the carts. DA 2 confirmed he cleaned the carts by wiping them down with sanitizer after trays were delivered, but he did not clean the bases to try to remove the built-up residue. In an interview and observation with the Maintenance Supervisor (MS) on 6/9/21, at 10:29 a.m., he stated he did not clean anything in the kitchen, and he was not responsible for cleaning vents. He stated he did clean the window screens once a month but from standing outside of the kitchen and hosing them off. MS confirmed the cabinets located under a food preparation table had a surface that was coming off and exposing the underneath particle board. He said it was not in good condition, so it had to be repaired. He also stated a drawer under the preparation table was cracked and had to be replaced. He said he was not aware of these things since they were not reported to him in the logbook. MS also stated he was not responsible for cleaning the window air conditioner. In an interview with the Administrator on 6/9/21, at 3:10 p.m., she stated the janitor was to make sure every aspect of the kitchen was clean. She stated the janitor went into the kitchen one time per week, early in the morning, and did a deep cleaning. She stated he did things such as scrub and buff the floors. She stated the janitor was also responsible for keeping the baseboards clean. The Administrator stated MS was in charge of cleaning the air conditioner and changing the air conditioner filters in the kitchen. In an interview on 6/9/21, at 4 p.m., Housekeeper 1 (HK1) stated he worked at the facility for 20 years and there was no deep cleaning done in the kitchen by housekeeping staff. He stated housekeeping staff was not allowed in the kitchen to clean. He said the one housekeeping staff that did deep cleaning in the kitchen left working for the facility about 8 years ago. Review of the undated facility cleaning schedule titled Janitor did not showed public bathrooms were cleaned but did not show other areas within the kitchen were cleaned. Review of the undated facility daily work schedule titled Housekeeping did not show any areas in the kitchen were cleaned. In an interview on 6/10/21, at 8:42 a.m., DS stated she did not always check to see that staff cleaned areas they were responsible for on the cleaning schedule. She stated she was too busy. Review of the document titled Dietary aid/Tuesday 11:00 - 2:00 pm Cleaning Schedule dated 1/5/2021 showed wipe windows on the schedule. Review of the job description titled FNS [Food and Nutrition Supervisor] dated 2018, showed the DS was responsible for maintaining cleanliness of kitchen equipment. Review of the document titled Sanitation dated 2018, showed all equipment shall be maintained as necessary and kept in working order. Also, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 3. An observation during the initial tour of the kitchen on 6/7/21, at 10:20 a.m., showed tile baseboards throughout the kitchen were missing or coming away from the wall. Where there was missing baseboard, the drywall was missing or not intact. (Refer to F-812) In addition, a large mixer with a bowl was observed. The inside surface of the bowl had a dark residue that covered the bottom surface. In an interview on 6/7/21, at 10:30 a.m., the Dietary Supervisor (DS) stated the residue in the bowl was not removeable and she did not know what it was. She said it had to be replaced and it was in this condition for 6 years. In an interview with the RD on 6/8/21, at 9:25 a.m., she stated she reported baseboards in disrepair on a regular basis on her monthly inspection report. She also stated she noticed the mixer bowl was in bad condition a couple of years ago and reported it consistently on the inspection report. In a concurrent interview with the Maintenance Supervisor (MS) on 6/8/21, at 9:25 a.m., he stated he was not aware the baseboards were missing and coming off the wall because he did not see the RD reports. Review of the last 3 kitchen audits completed by the RD titled Sanitation and Food Safety Checklist with a revised date of 2019, showed the RD documented the mixing bowl needed to be replaced on 3/24/21, 4/30/2, and 5/28/21. The report also indicated tiles on baseboard falling off on 4/30/21 and 5/28/21. In an interview on 6/9/2,1 at 10:29 a.m., the RD stated her monthly kitchen inspection reports were given to the Administrator, the DS, and the Director of Nursing (DON). She stated she did not take part in the QAPI program and did not know if any kitchen projects were in QAPI. The DS stated the baseboards and mixer were reported in QAPI. In an interview on 6/9/21, at 3:10 p.m., the Administrator (ADM) stated she kept the RD sanitation reports in a binder and usually took care of issues right away. She stated the mixer and baseboards were addressed in QAPI. ADM did not answer when she was asked why the mixing bowl was still in the kitchen if it was not useable. She stated it did not matter if it was in there because the mixer did not work. She stated in QAPI the first priority was giving the facility a face lift. She said in QAPI patient care items and infection control were next on the priority list. She did not consider the mixing bowl and the damaged baseboards a part of infection control. In an interview on 6/9/2, at 4:15 p.m., the RD and DS stated the mixer was plugged in and did work as far as they knew. In an interview and observation with the Administrator on 6/10/21, at 9:55 a.m., the Administrator reviewed her QAPI notes form April 21 showing sideboards were noted to be repaired by the remodeling team by July 2021. She stated sideboards meant baseboards. There was no additional information or documentation to show a plan for fixing the baseboards. The Administrator was not able to show a QAPI plan that was systematic, comprehensive, and data-driven. She stated the baseboards were not in the May 28 QAPI notes. She confirmed the RD was not a part of QAPI. She said there was no documentation

Based on observation, interview, and facility document review, the facility failed to ensure competency of staff in the functions of the food and nutrition service when: 1. [NAME] 2 did not follow and properly document cooldown procedures for a time temperature control for safety (TCS) food (food that is more likely to grow harmful bacteria if not stored appropriately leading to foodborne illness); 2. [NAME] 1 did not appropriately demonstrate how to check the quaternary ammonia strength to clean food contact and nonfood-contact surfaces; 3. [NAME] 1 did not follow the menu for residents on a renal diet; and 4. Dietary Assistant 2 (DA2) did not appropriately demonstrate how to check the chlorine strength for the dish machine. This lack of competency by kitchen staff had the potential to result in contamination of food leading to foodborne illness as well as residents receiving different nutrients as indicated on the planned menu. Findings: 1. An observation during the initial kitchen tour on 6/7/21, at 10:30 a.m., showed a plastic bag filled with cooked white rice. The plastic bag was dated 6/6/21. During a review of the Cool Down Log binder, it did not show any cool down entries for food for the month of June. There was one entry for cooling of rice on 3/6/21. This entry showed the first temperature was taken at 11 a.m. and was 140 degrees Fahrenheit (F). The next temperature was taken at 2 p.m. and was 48 degrees F. This was 3 hours between taking the first and second temperature. The instructions on the cool down log showed a two-step cool down process. The first step was to take the temperature of a food 2 hours or less after the food dropped to 140 degrees F. to ensure the food was 70 degrees F or less. During an interview on 6/9/21, at 2:25 p.m., the Registered Dietitian (RD) confirmed there was no entry for rice on 6/6/21 but there should be if cooked rice was observed in the refrigerator dated 6/6/21. She stated the entry for rice cool down dated 3/6/21 was not documented appropriately to show safe cool down. She said the second temperature should have been recorded after 2 hours at 1 pm to ensure the food was cooled appropriately. During an interview with [NAME] 2 on 6/10/21, at 9:11 a.m., she stated the entry dated 3/6/21 was the entry for the cool down of the rice cooled on 6/6/21. She stated she made a mistake when she wrote the date. She also stated the process for cooling food involved checking the temperature of the food every 2 hours to make sure it was cooling properly. She stated her first entry showed she checked the rice at 11 am and again at 2 pm. She stated the time between 11 a.m. and 2 p.m. was 2 hours so the rice was cooled appropriately 2. During an observation and interview with [NAME] 1 and the RD on 6/8/21, at 10:35 a.m., [NAME] 1 stated she was responsible for checking the quaternary ammonium solution (quat) strength for the red buckets used to clean food contact and nonfood-contact surface areas. She demonstrated how she tested the strength of the solution by filling a red bucket with quat and dipped a quat test strip in the solution for 4 seconds. When the surveyor asked how long she was supposed to hold the test strip in the solution, she stated 10 seconds. She tested again with a new strip and counted to ten out loud very fast. Again, she held the strip in the solution for 4 seconds. The RD confirmed she did not hold the test strip in the solution for 10 seconds. The strip turned a very dark green and when [NAME] 1 compared the strip to the color chart located on in the test strip container, she stated the color of the strip showed the concentration of the quat solution was 200 parts per million (ppm). The color chart showed 200 ppm was a mustard yellow color. The color of the strip was observed by 2 surveyors and both surveyors concluded in comparison to the color chart, the strip showed the strength of the solution was between 300 to 400 ppm. The RD also agreed the strip compared to the color chart was more than 200 ppm. Review of the quat test strip instructions located inside the container of the quat strips showed to immerse for 10 seconds . 3. During an an observation during trayline food service on 6/8/21, at 12 p.m., showed [NAME] 1 plated white rice on trays for residents whose tray tickets showed they were prescribed a renal diet. Review of the Cook's spreadsheet titled Summer Menus Week 1 Tuesday used for lunch on 6/8/21, showed renal diets received wheat pasta with margarine. During an concurrent interview with [NAME] 1, the RD, and DS on 6/8/2,1 at 12 p.m., [NAME] 1 stated she made a mistake and did not cook pasta to serve to residents on a renal diet. DS stated there was pasta available, so the reason for [NAME] 1 not making pasta was not because they ran out. DS stated residents did not like whole wheat pasta. The RD stated [NAME] 1 did not ask her if she could substitute rice for pasta because the cooks knew that rice could be a substitute for pasta if needed. She stated in this case, the residents on a renal diet should have received wheat pasta since they had it in stock. She stated she knew that residents did not like whole wheat pasta, but they accepted regular wheat pasta. 4. In an observation and interview with the RD and DA2 on 6/8/21 at 10:40 a.m., DA2 stated he was responsible for checking dish machine sanitizer strength. He demonstrated how he checked the strength by running a metal bowl through a cycle. When it was finished, he placed a chlorine test strip on the surface of a metal bowl. The test strip turned a dark purple color. He compared the strip to the color chart located in the test strip container and stated it showed the strength of the chlorine sanitizer was 200 ppm and it should be between 100 to 200 ppm. He stated 50 ppm was not okay. The RD stated the chlorine sanitizer strength for the dish machine should be 50 to 100 ppm. Review of the Dish Machine Temperature Log dated 2020 showed in the instruction the chlorine should be 50 to 100 ppm.

Based on observation, interview and record review the facility failed to provide a safe and sanitary environment for four (Residents 21, 26, 36, and 255) of 57 sampled residents, as evidenced by: 1) Nurse did not disinfect and clean BP cuff between using the BP cuff on residents 26, 36, 255 2) Nurses did not follow manufacturer's directions for SaniWipe use on medication baskets 3) Certified Nursing Assistant did not perform hand hygiene after doffing gloves and assisting a resident 4) The facility did not screen staff members for COVID-19 symptoms on 6/6/21 prior to providing care for the residents. . These failures had the potential to result in cross contamination and infection. Findings: 1. During an observation on 6/8/21, at 8:35 am., Registered Nurse (RN)2 removed wrist blood pressure (BP) cuff from his own wrist and placed it directly on the left wrist of Resident 255. After measuring Resident 255 BP. RN 2 removed the BP cuff from Resident 255's wrist and placed it back on his wrist. The BP cuff was not cleaned or disinfected prior to or after use with Resident 255. During an observation on 6/8/21, at 8:50 a.m., RN 2 removed wrist BP cuff from his own wrist and placed it directly on the left wrist of Resident 36. The BP cuff was not cleaned or disinfected prior to or after use with Resident 36. During an observation on 6/8/21, at 9:10 a.m., RN 2 removed wrist BP cuff from his own wrist and placed it directly on the left wrist of Resident 26. The BP cuff was not cleaned or disinfected prior to or after use with Resident 26. During an interview on 6/10/21, at 7:30 a.m., with RN 2, RN 2 stated the wrist BP cuff is from his personal home, and that he cleaned the wrist BP cuff after his shift and not between residents. RN 2 stated if a resident was on isolation he would clean between residents but not if the residents are not on isolation. RN 2 stated he was unsure if the facility had a policy that stated he needed to clean the BP cuff between resident use. During an interview on 6/10/21, at 8 a.m., with the DON, the DON stated BP cuffs are to be cleaned between resident use to maintain infection control. During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 7/2014, it indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard, and Reusable items are cleaned disinfected or sterilized between residents. 2. During an observation on 6/8/21, at 8:45 a.m. and 9:05 a.m., Registered Nurse (RN) 2 wiped the medication basket on the medication cart using Sani-Cloths, and immediately used the basket During an observation on 6/8/21, at 9:45 a.m. and 10:10 a.m., Licensed Vocational Nurse (LVN) 2 wiped the medication basket on the medication cart using Sani-Cloths, and immediately used the basket. During an concurrent observation and interview on 6/10/21, at 7:30 a.m. RN 2 stated he didn't look at the Sani-Cloth germicidal disposable wipe container regarding the wet time or kill time. RN 2 stated he had not read the Sani-Wipe guidelines. During a review of the Sani-Wipe germicidal disposable wipe container on 6/9/21, at 8:10 a.m., it indicated to Allow surface to remain wet for three (3) minutes. Let air dry and Bactericidal, tuberculosis, virucidal in 3 minutes. During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Environmental Surfaces, dated June 2009, indicated Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions and By law, all applicable label instructions on EPA-registered products must be followed. 3. During an observation on 6/7/21, at 10:45 a.m., in Resident 5's room, Certified Nursing Assistant (CNA)1 touched the bedside commode (BSC), it's lid, seat and handles, that was located at the foot of Resident 5's bed. After CNA1 touched the BSC she doffed her gloves, then placed Resident 21's cup on the bedside table. CNA1 did not perform hand hygiene (HH) after she doffed her gloves. During an interview on 6/7/21, at 10:50 a.m., with CNA 1, CNA 1 stated that she should have sanitized her hands after she doffed her gloves, and before she helped Resident 21. During a review of handwashing in-services, dated 12/14/20 and 10/29/20, CNA 1 was signed-in at both in-services. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated August 2015, indicated This facility considers hand hygiene the primary means to prevent the spread of infections, and Use an alcohol-based hand rub . or alternatively soap . and water for the following situations:. After contact with blood or bodily fluids; l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident;. After removing gloves and Hand Hygiene is the final step after removing and disposing of personal protective equipment. 4. During a review of the employee symptoms screening log in the presence of the Director of Nursing (DON), three staff members CNA 4, 5 and 6 were not screened for COVID-19 symptoms on Sunday 6/6/21 prior to providing care for residents. During an interview on 6/09/21, at 8:54 a.m., the DON stated screening logs are checked by the Medical Record Designee (MRD) who is responsible for collecting the forms. During an interview on 6/09/21, at 8:47 a.m., MRD stated she only collects and keep the screening logs. MRD stated I do not verify for accuracy. During an interview on 6/09/21, at 10:11 a.m., the Administrator (Admin) stated she was responsible for verifying that all staff are screened for COVID-19 symptoms prior to proving residents care. The facility's policy and procedures, titled, COVID-19: Clinical Protocol undated, indicated All staff will be required to answer screening questionnaire and have their temperature checked before the beginning of each shift or start of work.

Based on observation, interview, and facility document review, the facility failed to serve two residents (Resident 51 and 49) of 57 sampled residents diets prescribed by a physician. This failure had the potential for two residents, Resident 51 and 49, to receive inadequate calories and/or nutrients contraindicated for a prescribed diet leading to nutritional related health issues. Findings: 1. An observation of trayline food service on 6/8/21, at 12 p.m., showed resident [NAME] 1 placed a scoop of mashed potatoes on a plate for resident 51's lunch. An observation of the tray ticket for Resident 51 located on his tray showed he was on a Regular, Controlled Carbohydrate (a diet typically prescribed to diabetics), Renal (a diet typically prescribed to a person with kidney disease), Thin Liquids. During a review of the Cook's Spreadsheet titled Summer Menus Week 1 Tuesday and used for lunch on 6/8/21, showed residents on a renal diet received wheat pasta with margarine instead of mashed potatoes which was served to regular diets. In a concurrent interview with [NAME] 1, the Registered Dietitian (RD) and the Dietary Supervisor (DS), on 6/8/21, at 12 p.m., the RD confirmed Resident 51 should have not received mashed potatoes because he was on a renal diet. The RD stated the diet for resident 51 was recently changed to Renal. DS stated [NAME] 1 was familiar with all the resident diets, so she did not read all the meal tickets and she missed the new diet change written on the Resident's meal ticket. Review of the Diet Manual For Long Term Care and Residential Facilities 2020 reviewed and signed by the RD on 1/8/21, gave a description of a Renal diet which indicated, this diet is usually ordered when a patient is in renal failure, receiving dialysis, or has elevated serum potassium. Potassium content of the diet is controlled to prevent hyperkalemia (elevated blood potassium). An example of a menu for a Renal diet was given and indicated to avoid potatoes. In an interview with RD on 6/9/21, at 12:25 p.m., the RD stated the diet order for Resident 51 was changed on Monday 6/7/21. She said the cook should have looked at the entire tray ticket during trayline. She stated the kitchen did not get the communication slip from the Director of Nursing (DON) that alerted the kitchen of a new diet. She stated the original communication slip was placed in the resident's chart and the carbon copy was given to the kitchen. In an interview with DS on 6/10/21, at 8:42 a.m., DS stated cooks should look at the tickets when serving food on trayline. She stated sometimes, but not all the time, there was a kitchen staff to help the cook read the trayline tickets and make sure the food on the tray was correct for the prescribed diet. In an interview with RD on 6/10/21, at 9:11 a.m., the RD stated she recommended Resident 51's diet change to a Renal diet based on his lab results. Review of Resident the Nutrition/Dietary note dated 6/4/21, showed the RD stated Given recent lab results with elevated BUN (Blood urea nitrogen; a test used to measure the amount of nitrogen in the blood), Cr (Creatinine; a waste product removed from the body by the kidneys), and K+ (Potassium), recommend to change diet to Renal, CCHO, regular texture . During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department. Nursing will send a Diet Order Communication slip to the Food and Nutrition Services department. The FNS Director or cook in charge will make or adjust the diet profile and tray card as prescribed Any discrepancy in the diet order slip will be clarified by the FNS Director or cook in charge with nursing. During a concurrent interview and record review on 6/10/19 at 12:54 p.m., with DON, Resident 51's Status Report, dated 6/7/21, signed by DON, was reviewed. The status report showed a change to renal diet for Resident 51. DON stated this report is used to communicate diet change orders between nursing and dietary staff. DON stated she gave a dietary staff member the yellow carbon copy but could not remember which staff member. During a review of the facility's Food and Nutrition Services (FNS) director job description, titled Job Description, Position FNS Director, dated 2018, the document indicated, [FNS] is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. In addition, the document indicated, [FNS is to] check trays to ensure diets are served as ordered. During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department. 2. During a concurrent observation and interview on 6/8/21, at 12:40 p.m., with CK 1, RD and DS, the preparation of Resident 49's lunch tray was observed. CK 1 plated mashed potatoes, gravy, shredded beef and spinach. CK 1 placed the plate on Resident 49's meal tray for delivery to Resident 49. The diet order card dated 6/8/21, on Resident 49's tray indicated , Diet order: Mech Soft (easy to chew and swallow food texture), Controlled Carbohydrate, Fortified Diet (foods with additional nutrients added), Thin liquids. CK 1 stated she fortified the meal with melted butter. Melted butter was not observed on Resident 49's meal. RD and DS confirmed residents with a fortified diet should have a scoop of melted butter added to the meal and the butter on Resident 49's meal was missed. During a review of Resident 49's Diet Type Report, dated 6/10/21, the report indicated Resident 49 was on a fortified diet. During a review of the facility's fortified diet menu, titled, Weekly Guideline for Summer 2021 - Week 1, undated, the document indicated for fortified Tuesday lunch, Potatoes: ½ ounce melted margarine. Vegetables ½ ounce melted margarine. During an interview with RD, on 6/9/121, at 12:25 p.m., RD stated CK 1 should have followed the fortified spreadsheet to know what to provide on trayline. She stated Resident 49 was initially placed on a fortified diet due to being underweight and not eating very well. It was recommended for Resident 49 to stay on a fortified diet to maintain weight. During a review of the facility's Food and Nutrition Services (FNS) director job description, titled Job Description, Position FNS Director, dated 2018, the document indicated, [FNS] is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. In addition, the document indicated, [FNS is to] check trays to ensure diets are served as ordered. During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility record review, the facility failed to store food, brought into the facility by visitors, safely for residents. The facility also failed to have a policy to show food would be stored safely for residents upon request. This failure had the potential for decreased food intake by residents who preferred to eat food brought in from outside sources for 56 residents who were able to eat food by mouth out of a facility census of 57. Findings: Review of the undated facility policy and procedure titled Food For Residents From Outside Sources showed food brought in from outside sources for the resident would first be shown to the charge nurse for approval to ensure the food was within the diet order parameters. The nurse would consult with the Food and Nutrition Supervisor (FNS) or the consultant dietitian as needed. Prepared or perishable food must be consumed within one hour of receiving . Unused food would be disposed of immediately thereafter. An observation on 6/8/21 at 2:30 p.m. showed a carton of individual yogurt containers with room [ROOM NUMBER] E and Resident 22's name written on the carton located in a staff refrigerator. There was also a plastic bag with 25 C written on the bag. Inside the bag was a store-bought fruit salad in a plastic container. The fruit salad consisted of cut watermelon, cut cantaloupe, cut honey dew, cut pineapple, and grapes. There was no thermometer in the refrigerator to determine the internal ambient temperature of the refrigerator. In a concurrent interview on 6/8/21 at 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated staff were not allowed to store food for residents brought in from visitors. She said there was no refrigerator to store this type of food. She confirmed the food labeled with resident names and room numbers were residents at the facility. In an interview on 6/8/21 at 2:30 p.m., the Director of Nursing (DON) stated there was not a refrigerator to store food for residents brought in by visitors. She stated she worked at the facility for 5 months and never went upstairs to look in the staff break room refrigerator. She said food brought in from outside was not allowed but sometimes if a resident did not eat well it was allowed. She stated food was not allowed from outside because of concern with infection control as well as the possible contraindication with physician diet orders. She said she encouraged families to not bring in food for residents. The DON looked in the staff refrigerator and confirmed there was food inside labeled with resident name and room numbers. She stated the refrigerator was supposed to be only for staff food. She said nursing was not trained on storing food safely in refrigerators for residents. She said she did not know the appropriate storage temperature for refrigerated foods. The DON confirmed there was no thermometer in the staff refrigerator. A concurrent observation on 6/8/21 at 2:30 p.m., showed the temperature of the melon in the fruit salad was 44 degrees Fahrenheit when measured with a calibrated digital thermometer. In an interview on 6/8/21 at 2:54 p.m., Certified Nursing Assistant 3 (CNA 3) stated she was caring for resident 255 that day. She stated when she came in for her shift that morning the resident had food brought in by visitors at her bedside. CNA 3 stated there were 2 plastic containers of fruit salad and a vegetable platter. She labeled the bag that contained a fruit salad with the resident's room number and placed it in the staff refrigerator at 7:30 a.m. that morning. She left one fruit salad and the vegetable platter at the resident's bedside. She stated she did not know anything about safe food storage temperatures. An observation and interview with resident 255 at 3 p.m., showed she had a vegetable platter and a plastic container of fruit salad. The fruit salad was half full. The resident stated a family member brought the food in for yesterday evening. She said she wanted to keep the fruit salad at her bedside and eat some more of it. In an interview on 6/9/21 at 12:25 p.m., the RD stated no outside food was allowed for residents as long as she was the RD for the facility which was 5 years. She stated she was not aware of any training for nursing about safe food storage. She said yogurt should not be in the refrigerator if the refrigerator is not being monitored for temperatures. She also stated cut melon is a potentially hazardous (time temperature control for safety food; food that has an increased potential to grow bacteria if it is not stored safely.) According to the 2017 Federal Food Code, Time/Temperature Control for Safety Food is to be held at 41 degrees F or less when time is not used as a control.

Based on observation, interview, and record review, for one of 17 sample residents (Resident 43), the facility failed to ensure Resident 43's dignity was maintained when Resident 43's urinary catheter (small flexible tube inserted through the urethra and into the bladder) drainage bag was not covered by a urinary catheter drainage bag cover. For Resident 43, this failure had the potential to result in loss of dignity. Findings: Review of Resident 43's admission record indicated Resident 43 was admitted to the facility with multiple diagnosis that included altered mental status and history of urine infection. Review of Resident 43's Order Summary Report, dated 11/5/18 indicated Resident 43 had a physician's order to .Protect resident's dignity and privacy by placing cover over urinary drainage bag . During an observation on 3/11/19, at 8:50 a.m., Resident 43 was in his bed and his urine bag was attached to the bed frame, and was visible with no drainage bag cover. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/11/19, at 8:50 a.m., LVN 1 stated Resident 43's urine drainage bag was not covered and was visible. Review of the facility's policy and procedure titled, Quality of Life-Dignity, revised August 2009, indicated .11. Demeaning practices and standard of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by .Helping the resident to keep urinary catheter bags covered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one (Resident 38) of 17 sampled residents the facility failed to develop and implement a comprehensive care plan that addressed: 1. Resident 38's medical diagnosis of Depression (state of feeling sad). 2. Resident 38's use of Trazadone and Remeron (medications used to treat depression). This deficient practice had the potential to result in Resident 38 not receiving appropriate care and treatment. Findings: Review of the Resident Face Sheet, dated 3/15/19, indicated Resident 38 was admitted to the facility on [DATE] with multiple diagnoses that included depression. Review of Resident 38's physician orders, dated 3/15/19, indicated Resident 38 had orders to receive 50 mg of Trazadone at bedtime (ordered 1/30/19) for depression and 15 mg of Remeron (ordered 1/30/19) at bedtime for depression. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 3/13/19, at 8:56 a.m., MDSC could not show Resident 38 had care plans that addressed depression and the use of Trazadone and Remeron. MDSC stated Resident 38 needed care plans to address depression and the use of Trazadone and Remeron.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of 17 sample residents (Resident 206) received treatment as ordered by the physician when Resident 206 received four-liters oxygen per minute and the physician order was five liters per minute. This deficient practice had a potential for Resident 206 to not receive the needed amount of oxygen. Findings: Review of Resident 206's admission Record indicated Resident 206 was admitted to the facility on [DATE] with multiple diagnosis including Acute Respiratory Failure with Hypoxia (low oxygen saturation). Review of Resident 206's physician's order, dated 2/27/19, indicated Resident 206 was to receive five liters per minute of oxygen continuously via nasal cannula every shift. During an observation on 3/12/19, at 11:14 a.m., Resident 206 was in bed and receiving four liters per minute of oxygen continuously via nasal cannula. During an interview with Registered nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 on 3/12/19, at 11:14 a.m., both RN 1 and LVN 1 stated Resident 206 was on four liters per minute of oxygen at the time. Review of the facility's policy and procedure titled, Oxygen Administration, revised October 2010 indicated .Review the physician's orders or facility protocol for oxygen administration

Based on interview and record review for one of 17 sample residents (Resident 43) the facility failed to ensure Resident 43 received an appropriate treatment and services as ordered by the physician when the facility's licensed nursing staff did not transcribe correctly or implement Resident 43's physician's order to change the urinary catheter drainage system every 30 days. For Resident 43, this failure had the potential to result in infection. Findings: Review of Resident 43's admission Record, printed 3/11/19, indicated Resident 43 was admitted to the facility with multiple diagnoses that included kidney stones and hydronephrosis (the swelling of a kidney due to a build-up of urine when urine cannot drain out from the kidney to the bladder from a blockage or obstruction). Review of Resident 43's Order Details, dated 11/5/18, indicated Resident 43 had a physician's order for his urinary catheter (small tube inserted through the urethra and into the bladder to drain urine) drainage system (open and closed system, catheter, and drainage bag) every 30 days and as needed for clogging or dislodgement. During an interview with Licensed Vocational Nurse (LVN) 2 on 3/11/19, at 9:59 a.m., LVN 2 stated the last time Resident 43's urinary catheter drainage system was changed was on 1/23/19 while Resident 43 was the hospital. LVN 2 stated Resident 43's urinary catheter drainage system was never changed at the facility because they entered the physician's order in the PRN (as needed) category only by mistake and none of the nurses realized they had to change the catheter every 30 days routinely.

Based on observation, interview, and record review, for one of 17 (Resident 37) sampled residents, the facility failed to follow their infection control practices to prevent spread of infection during wound dressing change when Licensed Vocational Nurse (LVN) 2 did not perform hand hygiene (wash hands with soap and water or use an alcohol based hand rub) in between glove changes, and did not change gloves or perform hand hygiene between dirty to clean procedures. For Resident 37, these failures had the potential to result in infection. Findings: Review of Resident 37's Order Listing Report, dated 3/13/19, indicated Resident 37 had a physician's order for licensed nurses to cleanse his left hip with normal saline, pat dry, apply collagen powder on the wound bed, cover with calcium alginate with Silver and foam dressing one time per day for 14 days. During an observation on 3/12/19, at 9:50 a.m., LVN 2 performed Resident 37's wound dressing change. LVN 2 used gloved hands to remove the old wound dressing from Resident 37's wound on the left hip. LVN 2 then removed her soiled gloves and, without performing hand hygiene, changed into a new pair of gloves. LVN 2 cleaned Resident 37's wound and used the same pair of soiled gloves to complete the wound treatment (a dirty to clean procedure). In an interview immediately following the observation, LVN 2 confirmed handwashing was not done between glove changes and no glove changes occurred in between dirty to clean procedure. Review of facility's policy and procedure, Handwashing/Hand Hygiene, with revised date of August 2015 indicated, .The facility considers hand hygiene the primary means to prevent the spread of infections .Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .after handling used dressings .after removing gloves; .the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand washing/hand hygiene is recognized as the best practice for preventing healthcare-associated infections

Based on observation, interview, and record review, the facility failed to ensure that food was prepared, stored, and served under sanitary conditions when there were multiple unlabeled and/or dated food items in the refrigerator and freezers; there were two cases of bottled water were stored directly on the kitchen floor; the base of the can opener had white, powdery particles; and there was a clear garbage bag with multiple recycled plastic bottles stored on the countertop next to the mixer. These failures had the potential to result in foodborne illness. Findings: During an observation on 3/11/19, at 8:13 a.m., the following food items were noted: a. In Refrigerator 1 - there was a loaf of banana bread in a brown bag and a pitcher of milk that were unlabeled and had no use-by dates; b. In Refrigerator 2 - there was an opened box of margarine spread slices that were unlabeled and had no opened on date, and; c. In Freezer 2 - there were 10 cups of scooped ice cream in a serving tray that were unlabeled and had no use-by date, and; d. there were four clear, large, plastic bins on top of the food storage shelves with no labels of what food items were inside the bins. During an interview on 3/11/19, at 8:13 a.m., both the Dietary Services Supervisor (DSS) and [NAME] 1 stated the food items were undated. Review of facility's policy and procedure, Labeling and Dating, with revised date 11/2018 indicated, .It is important to label all food items in your kitchen with product name, received date, and open date. These include both purchased items and prepared items such as desserts, beverages and sandwiches .Food items need to have multiple dates indicating different situations to state the type of date labeled - Received, Open, or Use by .All items must be labeled with the food product name. These include all items prepared in the facility or transferred to a new container after opening, even if the food is visible in a clear container . During an observation and concurrent interview on 3/11/19, at 8:35 a.m., there were two cases of bottled water stored directly on the floor in the dry goods storage. The DSS stated that multiple cases of bottled water were delivered on Friday 3/8/19, and some were not stored away properly. Review of facility's policy and procedure, General Receiving of Delivery of Foods and Supplies, dated 2018 indicated, .Deliveries are to be put away as quickly as possible. Begin with refrigerated items, then frozen, and then dry goods During an observation and concurrent interview on 3/11/19, at 8:45 a.m., the DSS acknowledged the base of the can opener was covered with white powdery particles. Review of facility's policy and procedure, Can Opener and Base, dated 2018 indicated, .Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation .Wash the base with a brush and cloth and a detergent solution following manufacturer's instructions. Make sure the shaft cavity is clean During an observation on 3/11/19, at 8:55 a.m., a huge, clear, garbage bag with multiple recycled plastic bottles, was stored on the counter, next to the mixer in the kitchen area. On an interview on 3/11/19, at 9 a.m., DSS confirmed that [NAME] 1 stated employee belongings should not be stored in the kitchen area. Review of facility's policy and procedure, Employee Personal Items, dated 2018 indicated, Personal items brought in by staff from outside will not be kept in the kitchen