**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan for hard of hearing (HOH - Hard of hearing) was developed for one out of one sampled resident (Resident 131). This failure had the potential for Resident 131 not to receive the appropriate care. Findings: Resident 131 was admitted to the facility on [DATE] with diagnoses which included fall, back pain, hypertension (high blood pressure) per the facility's admission Record. During an interview with Resident 131's daughter on 12/3/24 at 9:12 A.M. The daughter stated, Resident 131 was HOH and was concerned of Resident 131's safety. During a concurrent interview and record review with licensed nurse (LN) 1 on 12/4/24 at 2:45 P.M. LN 1 stated, Resident 131 did not have a care plan for HOH. LN 1 further stated a care plan for HOH should have been initiated upon admission by the nursing staff to properly address Resident 131's communication needs. During an interview with the Director of Nursing (DON) on 12/5/24 at 10:30 A.M. The DON stated, residents assessed with HOH should have a care plan for staff to address the communication needs. The DON further stated, Resident 131's HOH care plan should have been initiated upon admission for nursing staff to provide Resident 131 safety and care. Review of the facility's policy titled, Care Planning, revised 2/2021, indicated, PROCEDURE .2c Care plan problems include existing difficulties as well as potential problems as identified - sensory impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide staff supervision during an Activity of daily Living (ADL - everyday task) for one of three sampled residents (Resident 7) when Resident 7 was observed using a disposable razor. This failure had the potential to affect Resident 7's well- being. Findings: Resident 7 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (A fib - irregular heart rate), congestive heart failure (CHF - heart failure) per admission Record. During a concurrent observation and interview with Resident 7 on 12/3/24 at 11:45 A.M. Resident 7 was observed shaving her chin unsupervised by facility staff with a disposable razor. Resident 7 stated, she shaves her chin everyday by herself. During a concurrent interview and record review with licensed nurse (LN) 1 on 12/4/24 at 11:30 A.M. Resident 7's nursing care plan (NCP - document with the appropriate nursing care) dated 11/14/24 indicated, Resident 7 was at risk for excessive bleeding related to the use of a blood thinner (medication to treat A- fib). LN 1 stated per NCP, Resident 7 should have been provided with an electric razor and not a disposable razor. LN 1 further stated, Resident 7 should have been supervised while Resident 7 was shaving herself to prevent Resident 7 from an accidental cut and bleeding. During an interview with the Director of Nursing (DON) on 12/5/24 at 8:25 A.M., the DON stated nursing staff should follow the NCP. The DON further stated Resident 7 should have been provided with an electric razor and should have been supervised by a nursing staff while Resident 7 was shaving to prevent an accidental cut and bleeding. Review of the facility's policy titled ADL CARE dated 12/2019, indicated, POLICY. Nursing staff will provide ADL care to each resident daily to meet their individual needs. PROCEDURE: 4. Assist resident as needed with activities of daily living according to resident's plan of care.

Based on observation, interview and record review, the facility failed to ensure all medications were locked for one of two medication carts (Medication Cart #1). This failure had the potential for Medication Cart #1 to be accessed by unauthorized personnel. Findings: An observation was conducted on 12/4/24 at 7:58 A.M. in the hallway by the nursing station. Medication Cart #1 was noted unlocked and unattended by a Licensed Nurse (LN). A concurrent observation and interview was conducted on 12/4/24 at 8:03 A.M. with Licensed Nurse (LN) 1. LN 1 was observed inside the medication room. LN 1 later exited the medication room and went to Medication Cart # 1. LN 1 stated medication cart #1 was left unlocked and unattended when she went to the medication room. LN 1 opened the drawers of Medication Cart # 1 that contained medications without unlocking it with a key. LN 1 stated the key lock button should have been pushed to lock the medication cart. LN 1 stated she should have locked the Medication Cart # 1, when she went inside the medication room to prevent unauthorized people to gain access to the medications. An interview was conducted on 12/5/24 at 8:29 A.M. with the Director of Nursing (DON). The DON stated medication carts should be locked when unattended. The DON further stated it was important to ensure that medication carts were locked to prevent unauthorized access to the medication, for patient safety and for prevention of drug diversion. Review of the facility's policy titled Medication Storage dated 1/2023, indicated, PROCEDURES .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.

Based on observation, interview, and record review the facility failed to store food safely when it: 1. Left a vegan meatball, fruit, vegetables, and other food debris under prep table for 2 days. 2. Did not label the facility's dry, frozen, and refrigerated foods with the month, the day, and the year. 3. Did not clean up loose sugar from the bottom of a box of sugar packets in the dry storage room. 4. Did not refrigerate soy sauce and orange sauce after opening per manufacturer's guidelines on sauces' labels. 5. Did not cover precooked shrimp in a sealed container in the middle section of the walk-in refrigerator. These failures had the potential for foodborne illness and pests. Findings: On 12/3/24 at 8:35 A.M., the initial tour of the facility's kitchen was conducted with the Director of Dining Services (DDS). On 12/3/24 at 8:40 A.M., during the initial tour of the kitchen, a brown ball resembling a meatball, broccoli, strawberry stems, a blueberry, and various crumbs were observed under a prep table in the center of the kitchen. On 12/3/24 at 8:49 A.M., an observation of the first walk-in fridge and interview with C1 was conducted. A metal container in the center shelf of refrigerator was observed with cooked shrimp half covered by plastic wrap. Chef (C1) stated that they were serving shrimp salad for lunch and they were prepping it that morning. C1 stated the importance of storing the shrimp in a sealed container was to prevent contamination and prevent foodborne illness. On 12/3/24 at 8:54 A.M., an observation of the first dry storage room and interview with C1 & the DDS was conducted. All boxes of food products were observed to be labeled with only the month and the day of opening. C1 stated that they go through the dry goods fast so they only label with month and day. C1 stated that the importance of labeling with year is to make sure to maintain food quality and prevent serving expired food. An opened Sauce for Orange Chicken dated 10/28 and soy sauce dated 8/11 were observed in dry storage. Both sauces' labels indicated REFRIGERATE AFTER OPENING FOR QUALITY. C1 stated he was not aware these sauces had to be refrigerated after opening. The DDS stated that he was not aware that these sauces had to be refrigerated after opening either and threw both sauces in garbage. On 12/3/24 at 9:01 A.M., an observation of the second dry storage room and interview with C1 was conducted. Sugar packets in cardboard box were observed with loose sugar all around the packets. C1 stated that he didn't know the sugar box had loose sugar at the bottom of it. C1 stated that sugar should be contained in packet or sealed container to prevent attraction of pests. On 12/4/24 at 9 A.M., an observation of walk-in freezer and interview with the DDS was conducted. Boxes labeled with only month and day were observed all throughout the freezer. The DDS stated that he had been changing the dates in dry storage the day before, but he had not been able to get in the freezer. On 12/4/24 at 9:10 A.M., an observation of food prep area and interview with the DDS was conducted. Observed same brown ball resembling a meatball, various food debris, and small cup under prep table from the day before. DDS picked the ball up from the floor and stated that it was a vegan meatball from Monday on 12/3/24. On 12/4/24 at 1 P.M. an interview was conducted with the DDS. The DDS stated that the expectation was the kitchen should be cleaned daily and there should be no debris under the table. The DDS stated the importance of keeping the area under the prep tables clean was pest prevention. The DDS stated that the expectation was all food should be labeled with received date and expiration date, including month, day, and year. The DDS stated the importance of accurate labeling was to preserve the quality of food, and to prevent food born illness from expired food. The DDS stated that the expectation for perishable foods (i.e. shrimp) should be stored in a sealed container when in the refrigerator. The DDS stated that the importance of storing perishable food in sealed container is to prevent contamination of food and the spread of foodborne illness. The DDS stated that the expectation is that sugar packets should be intact, and there should be no loose sugar in storage area. The DDS stated the importance of storing sugar in sealed container or in sealed individual packets was pest prevention. The DDS stated the expectation for storage of sauces was to follow manufacturer's guidelines on the label of individual sauces. The DDS stated the importance of following manufacturer's guidelines is to prevent foodborne illness from improperly stored sauces. On 12/5/24 at 1:45 P.M., a concurrent observation of photos from kitchen task and interview with the Executive Director (ED) was conducted. The ED stated that the expectation for cleaning prep area was that staff should clean under table daily. The ED state the importance of daily cleaning was pest prevention. The ED stated that the expectation for food labeling was that all food should be labeled with full date including month, day, year. The ED stated that the importance of accurate labeling was to preserve food quality and prevent foodborne illness from spoiled food. The ED stated the expectation for sugar storage in dry storage room is that there should be no loose sugar, and all sugar packets should be intact. The ED stated the importance of proper sugar storage was pest prevention. The ED stated that all sauces should be stored according to manufacturer's guidelines. The ED stated the importance of proper storage was to prevent foodborne illness. The ED stated that perishable food like shrimp should be in a covered and sealed container in the refrigerator. The ED stated the importance of storing perishable food in a seal container was to prevent contamination and prevent food borne illness. Review of facility policy titled FOOD STORAGE dated 1/1/2020 indicated Food storage areas should be clean at all times . Review of facility policy titled STORAGE & INVENTORY dated 1/1/20 indicated It is the policy of this facility to store all dining services supplies in clean, appropriate containers at the proper temperature and in location and manner prescribed by the law . Procedures .6. Date then store on shelves of appropriate height and in the correct manner, all goods in original container or Department of Health approved containers .10 .Date all cases .12. Check all foods in the refrigerator daily to make sure they are appropriately covered. All foods and foods not in original containers must be COVERED, LABELED and DATED .15. Leftovers shall be tightly covered, stored appropriately, and clearly labeled and dated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a policy for advanced directives (a written document that tells health care providers medical decisions to make when unable to speak for yourself) for four of 27 residents reviewed for advanced directives. (Residents 21, 133, 2 and 134) This failure resulted on staff's confusion regarding verifying residents' directives regarding care. Findings: Resident 21 was re-admitted to the facility on [DATE] with the diagnoses including paroxysmal atrial fibrillation (a type of irregular heartbeat) according to Resident 21's Face Sheet. Resident 133 was admitted to the facility on [DATE] with the diagnoses including unstable burst fracture (an injury to the spine) according to Resident 133's Face Sheet. Resident 2 was admitted to the facility on [DATE] with the diagnoses including atherosclerosis of coronary artery (thickening of heart's blood vessels caused by a sticky substance) according to Resident 2's Face Sheet. Resident 4 was admitted to the facility on [DATE] with the diagnoses including aftercare following joint replacement according to Resident 4's Face Sheet. An interview and joint record review was conducted with the Nursing Supervisor (NS) on [DATE], at 2:29 P.M. During a review of Residents 21, 133, and 2's records, the records included an Acknowledgement of Advanced Directive form. The completed Acknowledgement forms indicated Resident 21, 133 and 2 had advanced directives, but were unable to provide a copy. The NS stated Resident 21, 133 and 2's physician's orders also did not specify a code status (the type of resuscitation procedure when the heart stops beating and/or when a person stops breathing). The NS stated Resident 21, 133 and 2's code status should have been transcribed in the physician's orders according to the hospital records. The NS further stated it was important to know resident's code status to care for the resident during an emergency. During a review of Resident 134's records, the Acknowledgement of Advanced Directive form indicated Resident 134 did not have an advanced directive. An interview was conducted with Licensed Nurse (LN) 2 on [DATE], at 1:35 P.M. LN 2 stated a resident's Physician's Order for Life Sustaining Treatment (POLST) will be checked if a resident's heart stopped. LN 2 further stated if a resident did not have a POLST or advanced directive, the physician or immediate family member will be called prior to performing Cardiopulmonary Resuscitation (CPR). During an interview on [DATE], at 1:40 P.M. with LN 1, LN 1 stated if a resident did not have a POLST or advanced directive, the resident was considered full code (full support, CPR). During an interview on [DATE], at 3:50 P.M. with LN 3, LN 3 stated residents were considered full code unless they had a Do Not Resuscitate (DNR) sticker outside of the resident's chart. An interview was conducted with the ADON on [DATE], at 11:45 A.M. The ADON stated it was important for staff to know resident's code status to provide immediate attention to the resident when needed. The ADON further stated the facility did not have a policy and procedure regarding advanced directives.

Based on observation, interview, and record review, the facility failed to reconcile discontinued controlled medications (medications that are regulated by the government due to the likelihood for being misused and high risk for abuse) received from licensed nurses. This failure had the potential for drug diversion (the illegal distribution or abuse of prescription drugs). Findings: An observation of the controlled medication storage was conducted on 12/14/23, at 9:40 A.M. with the Assistant Director of Nursing (ADON). According to the ADON, the Nursing Supervisor (NS) had the key to the controlled medication storage when the Director of Nursing (DON) was not in the facility. During an interview with the NS on 12/14/23, at 9:44 A.M., the NS stated he did not have the key for the controlled medication storage. The NS stated the key was kept in the DON's office. The NS stated Licensed Nurses (LN) gave him the discontinued controlled medications and placed them in the controlled medication storage until the DON and the pharmacist disposed the medications. The NS further stated there was no record maintained to account for the number of controlled medications received and the name of the LN who gave the controlled medications. During an interview with the ADON on 12/14/23, at 11:45 A.M., the ADON stated it was important to reconcile controlled medications given to the DON to prevent drug diversion. An interview was conducted with the Consultant Pharmacist (CP) on 12/14/23, at 12:29 P.M. The CP stated the DON accepted discontinued controlled medications. The CP stated the DON, and the LN should both sign the controlled medication count sheet prior to disposal with the CP. The CP stated it was important to verify the accuracy of the number of controlled medications for safety reasons. A review of the facility's Policy and Procedure (P&P) titled, Disposal of Medications, dated 1/2023 was conducted. The P&P indicated, .controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal and state laws and regulations .a controlled medication disposition log, or equivalent form shall be used for documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure discharge Minimum Data Set Assessments (MDS, an assessment tool) for two residents (Resident 18 and 5) were completed and/or transmitted to the Centers for Medicare and Medicaid Services (CMS) within acceptable timeframes. This failure resulted in noncompliance with regulatory requirements. Findings: A review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 18's Face Sheet indicated the resident was admitted to the facility on [DATE]. On 1/27/23 at 8:26 A.M., a joint interview and record review was conducted with the MDS coordinator (MDSC). The MDSC reviewed Resident 18's discharge MDS assessment dated [DATE] and signed by the registered nurse on 10/7/22. The MDSC stated Resident 18's discharge MDS assessment had been completed but had not been transmitted/sent to CMS. The MDSC stated it should have been transmitted within 14 days of completion. The MDSC also reviewed Resident 5's discharge MDS assessment dated [DATE]. The MDSC stated the discharge MDS was incomplete. The MDSC stated it should have been completed within 14 days of the resident's discharge on [DATE] and then transmitted within 14 days of completion. The MDSC stated Resident 5's discharge MDS assessment had to be completed before it could be transmitted. The MDSC stated the resident's discharge MDS assessment had not been completed or submitted to CMS timely. On 1/27/23 at 9:17 A.M., an interview was conducted with the director of nursing (DON). The quality assurance nurse was also present. The DON stated it was her expectation that the guidance in the CMS Resident Instrument Assessment (RAI) manual be followed when completing and submitting resident MDS assessments. The DON stated resident MDS assessments should have been submitted within the required timeframes. A review of the facility provided document titled CMS's RAI Version 3.0 Manual, dated October 2019, indicated, .09. Discharge Assessment-Return Not Anticipated . Must be completed . within 14 days after the discharge date . Must be submitted within 14 days after the MDS completion date

Based on observation, interview and record review, the facility failed to ensure that one licensed nurse (LN): 1. Checked residual (liquid feeding that is not absorbed) of tube feed (liquid feeding given through a tube directly to resident's stomach) prior to administering medication, 2. Flushed feeding tube (tube used for liquid feeding) according to facility policy, 3. Milked the line to unclog feeding tube according to facility policy for one resident (17). This failure to follow the facility's feeding tube policy and procedure, made it more likely for Resident 17 to experience : 1. Less medication absorbed via feeding tube, 2. Unwanted mixing of medications in feeding tube, and 3. A clogged feeding tube. Findings: 1. On 1/26/23 at 8:55 A.M., a concurrent observation of medication administration and interview with LN1 was conducted. During administration of medications to Resident 17, LN1 was observed inserting tube feeding syringe to check placement of feeding tube. LN1 did not pull back on the syringe to check if there was residual tube feeding as per facility policy and procedure. On 1/27/23 at 9:30 A.M., an interview with LN1 was conducted. LN1 stated that she was not familiar with the Enteral Feeding Policy and Procedure which guided checking for residual tube feeding. On 1/27/23 at 10:25 A.M., a concurrent interview and record review was conducted with director of nursing (DON). The facility feeding tube policy and procedure entitled Medical Administration, Enteral Tubes dated January 2020 was reviewed. Policy indicated, .GUIDELINES .9. Check gastric content for residual feeding. Return residual volumes to stomach. Report any residual above 100 ml [milliters] . DON stated that LN1 should have checked residual as per facility policy. DON stated the importance of checking tube feed residual was to make sure patient absorbed and digested the formula. Furthermore DON stated, if resident did not absorb formula, he might aspirate. 2. On 1/26/23 at 8:57 A.M., a concurrent observation of medication administration and interview with LN1 was conducted. LN1 was observed attempting to administer medication dissolved in water by gravity, but was unable to get medication through tubing. LN1 then stated, .I will give it a gentle flush . then flushed the feeding tube with water in her syringe. LN1 stated she flushed with 10 ml. On 1/27/23 at 10:25 A.M., a concurrent interview and record review was conducted with the DON. The facility feeding tube policy and procedure entitled Medical Administration, Enteral Tubes dated January 2020 was reviewed. Policy indicated, .GUIDELINES .11. Enteral tubes(feeding tubes) are flushed with 15 ml of water before administering any medications and after all medications have been administered . DON stated that LN1 should have flushed feeding tube with 15 ml as per facility policy. DON stated the importance of flushing the feeding tube with 15 ml of water was to make sure medications were not mixed, medications were absorbed, and to prevent clogging the length of feeding tube. DON stated without flushing with appropriate amount of water, Resident 17 might not get the full administration of medication. 3. On 1/26/23 at 8:59 A.M., a concurrent observation of medication administration and interview with LN1 was conducted. LN1 was observed flushing the feeding tube without milking the tube per facility policy. LN1 pinched the feeding tube in one spot, then attempted to flush with water, but was unsuccessful in removing the blockage. On 1/27/23 at 10:25 A.M., a concurrent interview and record review was conducted with the DON. The facility feeding tube policy and procedure entitled Medical Administration, Enteral Tubes dated January 2020 was reviewed. Policy indicated, .GUIDELINES .Managing Complications .3. Clogged tube-clogging can occur from internal blockage. A. If the clog is still present, gently milk the tube from top to bottom to release any clog that may be in this part of the tube . DON stated that LN1 should have milked the feeding tube as per policy. DON stated the importance of milking the line was that the method used less pressure than flushing, and it was gentler on the patient than trying to flush out a clog. DON stated that excess flushing can also give patient more fluid than necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to : 1. Reconcile 2 of 3 sampled residents' (27 & 132) Controlled Drug Record (CDR) with Medical Administration Record (MAR), and PRN Pain Assessment Sheet (PPAS), 2. Administer controlled medication per physician order for 2 of 3 sampled residents' (27 & 132), 3. Administer Advair as per physician order for one sampled resident (13). This failure had the potential for the possibility of drug diversion and inadequate pain control. In addition Resident 13 missed multiple doses of an essential breathing medication. Findings: Resident 27 was admitted on [DATE] with diagnoses which include: Fracture of unspecified part and repeated falls per Face Sheet. Resident 132 was admitted on [DATE] with diagnoses which include: Spinal Stenosis, Fusion of Spine, Post Laminectomy Syndrome per Face Sheet. 1. On 1/26/23 at 2:05 P.M., a concurrent interview and record review of CDR, MAR, and PPAS was conducted with LN1 for Resident 132. LN1 stated that there were missing entries on PPAS and MAR that were on the CDR for following dates and times on 1/21/23 at 3:10 A.M. and 1/22/23 at 3:30 A.M. LN1 stated the nurse should have documented pain medications on CDR, PPAS, and MAR when they are administered to patient, because if not documented, it is possible the patient did not receive controlled medication. On 1/26/23 at 2:10 P.M., a concurrent interview and record review of CDR, MAR, and PPAS was conducted with LN1 for Resident 27. LN1 stated that there were missing entries on PPAS and MAR that were on the CDR for following dates and times on 1/21/23 at 9 P.M. and 1/22/23 at 9 P.M. LN1 stated the nurse should have documented pain medications on CDR, PPAS, and MAR when they are administered to patient, because if not documented, it is possible the patient did not receive pain medication. On 1/27/23 at 10:25 A.M., a concurrent interview and record review of CDR, MAR, and PPAS was conducted with DON for Residents 132 and 27. DON stated pain medications should be documented on CDR, PPAS, and MAR when they are administered to resident. DON stated if not documented, the controlled medication could not be reconciled, and there was a potential for medication diversion. Record review of facility policy and procedure entitled Medical Administration, General Guidelines dated January 2021 indicated, . Documentation: 1. The individual who administers the medication dose, records the administration on resident's MAR immediately following the medication being given. In no case should individual who administered the medications report off-duty without first recording the administration of any meds .5. When PRN meds are administered, the following documentation is provided: a. Date and time of administration, dose, route, b. Complaints or symptoms for which medication was given, c. Results achieved from giving the dose and time noted, d. Signature or initials of person recording administration and signature or initials of person recording effects. 2. On 1/26/23 at 2:05 P.M., a concurrent interview and record review of Resident 27's CDR, MAR, and PPAS was conducted with LN1. LN1 stated that according to the PPAS on 1/22/23 at 11 A.M. Resident 27 received Oxycodone 5 milligrams (mg) for pain 7/10 (self rated pain scale 0 is no pain, 10 highest level of pain). Review of order on CDR indicated, Give 1 Tablet (5 mg) .for mild pain .2 tablets(10 mg) for severe pain . LN1 stated she would consider 7/10 pain severe pain, so she would have given Resident 27, 10 mg of Oxycodone. LN1 stated the importance of giving pain medication as ordered, is to help treat the resident's level of pain accordingly. On 1/26/23 at 2:10 P.M., a concurrent interview and record review of Resident 132's CDR, MAR, and PPAS was conducted with LN1. LN1 stated order read Oxycodone IR [Immediate Release] 5 mg tablet, give 2 tablets by mouth every 3 hours as needed for moderate pain & 3 tablets for severe pain . On the following dates and times: 1/21/23(No time written), 1/25/23 (6 P.M.), 1/25/23(10 P.M.) Resident 132 had pain recorded 7/10 on PPAS. Resident 132 received Oxycodone IR 10 mg by mouth each time. LN1 stated that since pain was 7/10, that would be considered severe and Resident 132 should have received 15 mg Oxycodone IR as ordered. LN1 stated the importance of giving pain medication as ordered is to help treat the resident's level of pain accordingly. On 1/27/23 at 10:27 A.M., a concurrent interview and record review of Resident 27's and 132's CDR, MAR, and PPAS was conducted with DON. DON stated that the LN's had not followed the physician's orders for administering correct dosage of pain medication in relation to residents' pain level for both residents. DON stated Resident not receiving correct amount of medicine for residents' level of pain might affect the residents' self-care activities, healing, and put them in unneeded distress. Record review of facility police entitled Medication Administration, General Guidelines date January 2021, indicated .Medication Administration: 1. Medications are administered in accordance with written orders of the the prescriber . 3. Resident 13 was admitted on [DATE] with diagnoses which include Chronic Obstructive Pulmonary Disease ( a lung disease) per Face Sheet. On 1/26/23 at 2:21 P.M., a concurrent observation, interview and record review was conducted with LN1. The medication cart was inspected with LN1. Resident 13's Advair inhaler (a breathing medication) had 28 of 60 doses used and was labeled, OPENED ON 12/17/22. LN1 stated that based on the unit doses in the inhaler, less than half the doses were given. LN1 stated she had been Resident 13's nurse for past 3 days and resident had not refused the medication on the day shift. Resident 13's Physician Orders read Advair HFA 50/250 mg 1 puff twice a day [9 A.M. & 5 P.M.]. On 1/26/23 at 2:25 P.M., an interview was conducted with Resident 13 inside the resident's room. Resident 13 stated she received her Advair treatment once a day in the morning. On 1/27/23 at 10:25 A.M., an interview was conducted with the DON. DON stated that the Advair inhaler should have less doses remaining if the patient was receiving all ordered doses. DON stated that the LN's need to follow physician's order and administer the medication twice a day. Record review of facility policy entitled Medication Administration, General Guidelines date January 2021, indicated, .Medication Administration: 1. Medications are administered in accordance with written orders of the the prescriber .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident 1) who received hospice services, had a person-centered written plan of care for the coordination of care between the facility and the hospice provider. In addition, Resident 1 did not have a physician's order to receive hospice service/care. This failure had the potential to affect the coordination and continuity of care for Resident 1. Findings: A review of Resident 1's Face Sheet indicated the resident was admitted on [DATE] with diagnoses to include heart failure. On 1/26/23 at 1:43 P.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated Resident 1 had been receiving hospice services for a while now. On 1/26/23 at 1:54 P.M., a joint interview and record review was conducted with the infection prevention nurse (IPN). The IPN reviewed Resident 1 clinical record and stated the resident did not have an order from his attending physician to receive hospice care and services. The IPN stated all residents admitted to hospice care were expected to have a physician's order to receive that type of care. The IPN further stated Resident 1 did not have a written plan of care for hospice. The IPN stated Resident 1 should have had a written plan of care for hospice so that everyone providing care to the resident would know what care was being provided by the facility and the hospice agency. The IPN stated this was to make sure Resident 1's care needs were coordinated between the facility and hospice provider. On 1/26/23 at 3:50 P.M., an interview was conducted with the director of nursing (DON). The DON stated there should always be an order from the attending physician to admit a resident into hospice care. The DON stated residents receiving hospice care/services should have a written plan of care to coordinate care between the hospice provider and the facility. On 1/27/23 at 9:17 A.M., an interview was conducted with the DON. The quality assurance nurse was also present. The DON stated the facility did not have a policy for hospice, and that it was her expectation for residents receiving hospice care to have a physician's order and a written plan of care for hospice.

Based on observation, interview and record review, the facility failed to ensure that one licensed nurse (LN) disinfected a glucometer (machine that measures blood sugar) according to facility policy. This failure had the potential to spread blood borne (from blood) infections among residents being tested with the glucometer. Findings: On 1/26/23 at 11:27 A.M., a concurrent observation, interview, and record review was conducted with LN2. LN2 was observed disinfecting a glucometer after taking a blood sugar reading. LN2 cleaned the glucometer with a disinfectant wipe and put wet glucometer in cup to dry. Within 10 seconds the glucometer was visibly dry. LN2 stated that she was not sure how long the glucometer needed to remain wet with the disinfectant or what wet time meant. LN2 stated the directions of disinfectant wipes indicated .For Use as One-Step Cleaner/Disinfectant Product .All surfaces must remain wet for 1 minute . On 1/27/23 at 9:35 A.M., an interview with infection prevention nurse (IPN) was conducted. IPN stated LN2 did not disinfect the glucometer correctly per the disinfectant wipes directions. IPN stated the glucometer had to stay wet with the disinfectant solution for one minute. IPN stated the importance of disinfecting the glucometer according to policy is to prevent the spread of blood borne infection between residents. On 1/27/23 at 10:30 A.M., a concurrent interview and record review was conducted with director of nursing (DON). Facility policy and procedure entitled DISINFECTION OF RESIDENT CARE ITEMS dated July 2021 indicated, .PROCEDURE .2. Glucometers will be cleaned with wipes designed to destroy both bacteria and viruses after each resident use according to manufactures guideline. DON stated that LN2 should have disinfected the glucometer according to facility policy and disinfectant wipes directions for use. DON stated the importance of disinfecting the glucometer according to policy is to prevent infections from spreading between residents.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were met in the kitchen when: 1) Stored food was not consistently labeled and dated. 2) Stored food was not removed from storage when it was expired or reached its use by date. 3) Food preparation and cooking areas had food debris and trash on the shelving, inside the reach-in refrigerators, and on the floors. The cooking area's backsplash and stove hood was covered in a thin, brown, oily substance. 4) Clean water pitchers for resident use were stored wet. Baking sheets were stored directly on the floor. 5) Dented cans were stored in circulation among non-dented cans. 6) Kitchen cleaning schedules and logs were not maintained. These failures had the potential to place residents who consumed food from the kitchen, at risk for foodborne illness. Findings: On 1/24/23 at 8:35 A.M., a joint observation of the facility's kitchen and interview was conducted with the certified dietary manager (CDM). The head chef (HC) was also present. In the food preparation and cooking area, an unlabeled and undated opened bag of dry mashed potatoes was wrapped in clear plastic and was placed on a cooking shelf. The CDM stated the mashed potatoes should have been labeled and dated as to when it was opened and for how long it could be used. The shelves in the food preparation and cooking area had dried on liquid smears, crumbs and other food debris, empty plastic wrappers, and three empty soft drink cans. The flooring in the food preparation and cooking area was coated with a thin layer that felt tacky and slick underfoot. There was dried food debris, including objects resembling french fries, on the flooring. Two baking sheets were stored directly on the floor next to the stove. The CDM stated baking sheets should not have been kept on the floor. The backsplash behind the stove and wall which extended upward and onto the hood, was covered with a thin brown, oily layer. Dark brown, solid drippings hung from the hood and the tubing connecting to the hood. The CDM stated it looked like grease was on the backsplash and stove hood and that those areas needed to be cleaned. The line refrigerator had food debris and crumbs on the shelving. The walk-in refrigerator had an opened bag of spinach and a white bag which contained English muffins that were unlabeled and undated. The CDM stated the spinach should have been labeled with an opened date and use by date. The CDM stated the English muffins should have been labeled and dated. A tray of lunch prep (sliced vegetables for a salad bar) had a use by date of 1/18/23. The CDM stated the lunch prep should have been removed from the walk-in refrigerator and thrown away on 1/18/23. There was a box of coffee cakes with an expiration date marked 1/23/23. A container of sliced strawberries had a use by date of 1/19/23. A container of beef base was unlabeled and undated. A box of approximately 12 whole potatoes coated with an oily substance had a use by date of 1/20/23. Five containers of cream had an expiration date of 1/23/23. The CDM stated all food items past their use by date and/or expiration date should have been removed from the walk-in refrigerator. In the dry storage area, there were approximately 36 stacked resident water pitchers that were visibly wet. The CDM stated the clean pitchers should have been fully air dried before being stacked and put into storage. A large can of sauerkraut had an approximate one inch dent along the top seam of the can. A large can of bean salad had an approximate three inch dent in the middle of the can. Both cans were in circulation among other non-dented cans. The CDM stated dented cans should have been removed from circulation and placed in the designated return area. On 1/26/23 at 8:33 A.M., an interview was conducted with the facility's registered dietitian (RD). The RD stated there should not have been a greasy layer on the kitchen floors, backsplash, or on the stove hood. The RD stated there should not have been dried food debris on the flooring and shelving in the food preparation and cooking areas. The RD stated food debris that was not promptly cleaned up could potentially attract pests to the kitchen. The RD stated it was her expectation for the food preparation, cooking areas, and the kitchen as a whole, to be wiped down after food was prepared and for the area to be cleaned daily in the evening when the kitchen closed. The RD stated the kitchen should not appear visibly soiled. The RD stated opened food should be labeled and dated. The RD stated the labels and dates should have been followed and expired food should have been removed from the food storage areas. The RD stated this was to have been done in order to ensure food safety, protect against foodborne illness, and to avoid contamination of the other stored food. The RD stated baking sheets should not have been kept on the floor. The RD stated water pitchers should have been fully air dried before being placed in storage. The RD stated all dented cans should have been pulled from circulation. On 1/26/23 at 2:45 P.M., a joint interview and record review was conducted with the CDM. The CDM reviewed the kitchen cleaning logs that included a check for food labeling and dating. The cleaning logs were blank. The CDM stated the cleaning logs had not been completed for some time. The CDM stated there was no staff assigned as being responsible for the various cleaning sections on the cleaning logs. The CDM stated it was his and the HC's responsibility to ensure dietary staff were cleaning the kitchen daily and signing the cleaning logs. The CDM acknowledged it could not be verified when the kitchen was last cleaned since the cleaning logs were blank. On 1/26/23 at 3:50 P.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that the facility's kitchen sanitation was maintained and cleaning was being done regularly to prevent residents from experiencing foodborne illness. According to the U.S. Department of Agriculture Food Safety and Inspection Service's article titled, Shelf-Stable Food Safety, dated 3/24/15, .Discard deeply dented cans. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam A review of the facility's policy titled Dining Services Sanitation, dated 1/1/20, indicated, . (a) All kitchens and kitchen areas shall be kept clean, free from litter and rubbish A review of the facility's policy titled Dining Services Daily Cleaning Schedule, dated 1/1/20, indicated, . Any food, which has spilled in the refrigerator, shall be wiped up at once . Floors shall be mopped after each meal .Clean and straighten all shelves, drawers and cupboards in the kitchen area where food or other supplies are stored. Thoroughly wipe out interior and exterior surfaces to remove any grease and food particles . 4. Wipe out and clean the inside or the oven hoods and outside surfaces A review of the facility provided document titled Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, dated 5/30/19, did not provide guidance related to the facility's process for labeling and dating food items.