Based on observation, interview and record review, the facility failed to follow physician ' s order of supervised feeding for one (Resident 1) of two residents. This failure resulted in Resident 1 potentially choking and aspirating (accidental inhalation of food or liquid into the lungs) when eating. Findings: During a record review of Resident 1 ' s face sheet, undated, Resident 1 was admitted in July 2023 with dysphagia (difficulty swallowing). During an observation on 9/6/24, at 8:32 a.m., Resident 1 had his breakfast tray in front of him. Resident 1 had breakfast on his own with no staff assisting him with feeding. Resident 1 was observed with food particles on his beard. During a record review of Order Summary Report, a physician order with a start date of 8/5/23 indicated, 1:1 feeding assist; aspiration precautions. LUA (left upper arm) flaccid (a type of paralysis in which muscle becomes soft) due to stroke, with meals. During a record review of Resident 1 ' s care plan (how facility will help manage care), the care plan for activities of daily living (ADL-skills required to care for oneself such as eating) for eating indicated need for one-on-one assist. During an interview on 10/24/24, at 10:17 a.m., with Dietary Manager (DM), DM stated Resident 1 required one-on-one feeding assistance with aspiration precautions. During an interview on 10/24/24, at 10:43 a.m., with Registered Dietician (RD), RD stated Resident 1 had a physician order for one-on-one feeding assistance. RD added Resident 1 had dysphagia and was at risk for choking. During an interview on 10/24/24, at 12:20 p.m., with the Director of Nursing (DON), the DON stated Resident one is on one-to-one feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), received treatment and care for a non-pressure ulcer (open area that is not caused by shear or pressure but may be caused by poor circulation) when: 1. Resident 1 developed redness to abdominal folds which became worse. 2. Resident 1's Treatment Administration Record (TAR), had multiple dates without initials/documentation that showed assigned licensed nurses had performed the resident's ordered wound treatments. These failures resulted in Resident 1's avoidable abdominal wound dehiscence which reopened and led to infection. Findings: A review of Resident 1's admission Record, printed on 6/24/24, indicated resident was admitted to the facility on [DATE] with multiple diagnoses that included diabetes mellitus (high blood sugar), morbid obesity, and heart disease with heart failure (a condition in which heart does not pump blood as well as it should). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 4/19/24, indicated Resident 1 had clear speech, was always understood, and was always able to understand. The MDS also indicated Resident 1 required substantial/maximal assist (helper does more than half the effort) to dependent assist (helper does all the effort to complete the activity with the assistance of two or more helpers required for the resident to complete the activity) during her activities of daily living, (ADLs, the basic self-care tasks an individual does on a day-to-day basis). A review of Resident 1's hospital record titled, Interagency Discharge Summary and Orders, dated 4/13/24, prior to Skilled Nursing Facility (SNF) admission on [DATE], did not indicate that resident had unresolved skin issues to her abdominal area. A review of Resident 1's Nursing - Comprehensive Skin Evaluation/Assessment (CSE/A), dated 4/27/24, by Treatment Nurse 1 (TN 1), indicated, 4/22/24 Change of Condition (COC) done for redness with skin tears under abdomen around right iliac crest (the curved part on top of the hip) . Treatment (Tx) initiated: keeping abdominal folds clean and dry. 4/24/24 Nystatin powder was ordered . Review of the Nursing - CSE/A, dated 5/10/24, indicated, Redness with skin tears under abdomen around right iliac crest. - 5/4/24 REDNESS CLEARING UP BUT OPEN AREAS NOTED: RIGHT LATERAL ABDOMINAL (ABD) FOLDS OPEN AREA MEASURES 1.0 CENTIMETER (CM) x 5.5 CM and TWO (2) LEFT LATERAL FOLDS 1.0 CM x 2.0 CM. A review of Resident 1's April 2024 TAR, indicated: Start Date 4/24/24 - Nystatin External Powder 100000 UNIT/GM (Nystatin Topical) Apply to redness to abdominal fold topically two times a day for fungal infection for two weeks. Cleanse with normal saline (NS), pat dry and apply Nystatin powder. Further review of April TAR also indicated: Start date 4/24/24 - Treatment - Right side abdominal fold, reddened, moist, and fragile, every shift. A review of Resident 1's May 2024 TAR, indicated: Start Date: 5/4/24 - Moisture-Associated Skin Damage (MASD) to abdominal folds lateral sides: Cleanse with NS, pat dry, apply Medi honey gel, then cover with foam dressing daily until resolved. Discontinued Date: 5/22/24. Further review of May 2024 TAR also indicated: MASD to abdominal folds left and right sides: Cleanse with NS, pat dry, apply Medi honey gel, cover with Calcium (Ca) Alginate, apply Triad paste to peri wound then cover with dry dressing daily until resolved. During a telephone interview on 6/24/24, at 12:40 p.m., with the TN 1, TN 1 stated Resident 1 developed the abdominal fold open areas over time during resident's stay at the facility. TN 1 stated Resident 1 was referred to the Wound Doctor on 5/22/24. During a concurrent interview and record review on 8/28/24, at 11:42 a.m., Registered Nurse 1 (RN 1) stated Resident 1's May 2024 TAR were not initialed/signed by the scheduled LNs for the following treatment orders and dates: 1. Nystatin External Powder 100000 UNIT/GM (Nystatin Topical) Apply to redness to abdominal fold topically two times a day for fungal infection for two weeks. Cleanse with normal saline (NS), pat dry and apply Nystatin powder - at 0900, on 5/2, 5/3, 5/5, and at 1700, on 5/3, 5/4, and 5/5. 2. Right side abdominal fold, reddened, moist, and fragile every shift - Day Shift, on 5/2, 5/3, 5/5, 5/13, and 5/20; and Evening Shift, on 5/3, 5/4, 5/5, 5/10, 5/11, 5/12, 5/17, 5/18, 5/19, 5/21, and 5/24. 3. MASD to abdominal folds lateral sides - Day Shift, on 5/5, 5/13, and 5/20. RN 1 stated if there were no initials on the boxes, it meant ordered treatments were not performed as scheduled. During a concurrent interview and record review on 8/28/24, at 12:15 p.m., Director of Nursing (DON) stated Resident 1 did not have any skin issues on abdomen upon admission to the facility. A review of Resident 1's Progress Notes, dated 5/25/24, 12 p.m., indicated resident had draining wounds to abdominal folds which were assessed and diagnosed by MD 1, on 5/24/24, as cellulitis (a serious bacterial skin infection) and gave an order for antibiotic for seven days. Further review of the Progress Notes, dated 5/25/24, indicated Resident 1 was sent to the hospital via 911 on this same day. Resident 1 did not return back to facility. A review of Resident 1's hospital records titled Discharge Summary, dated 5/29/24, indicated resident was admitted to the hospital on [DATE] and had a Microbiology Work-up (specimen susceptibility testing) of the abdominal wall, collected on 5/26/24, which indicated culture of, Moderate Enterococcus faecalis (enterococcal species that can cause a variety of infections) (This organism is INTRINSICALLY RESISTANT to cephalosporins, clindamycin, trimethoprim, trimethoprim-sufamethoxazole), Scant Growth Staphylococcus aureus (a bacteria that causes a wide variety of diseases) . A review of Resident 1's hospital clinical records titled, History and Physical (H&P) Notes, dated 5/25/24, by Hospital Medical Doctor (MD), based on Resident Representatives (RR) report indicated, .Patient has developed dehiscence and open wounds over very old lower abdominal surgical sites bilaterally from a very remote tummy tuck surgery (unknown duration), and was started on cephalexin (an antibiotic) one (1) day prior to this admission at SNF for concerns of cellulitis . A review of the facility's policy and procedure (P&P) titled, Wound Care, revision date October 2010, indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Documentation - The following information should be recorded in the resident's medical record .the date and time the wound care was given .the name and the title of the individual performing the care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 2) when: 1. Treatment Nurse 2 (TN 2) and Certified Nursing Assistant 1 (CNA 1) did not wear a disposable gown during Resident 2's wound dressing change. Failure to wear the necessary personal protective equipment (PPE such as gloves, gown, face shield, masks, etc.) had the potential to place residents, staff, and visitors at risk for infection. 2. TN 2 did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove change during the wound dressing change. This failure had the potential to result in infection and spread of infection. Findings: A review of Resident 2's admission Record, printed 8/28/24, indicated resident was readmitted to the facility on [DATE] with diagnosis of diabetes mellitus (high blood sugar). A review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct care), dated 6/18/24, indicated resident was at risk for pressure ulcers (injury to skin and underlying tissues resulting from prolonged pressure on the skin). A review of Resident 2's Physician Order, with a start date of 7/26/24, indicated a treatment order for chronic on/off excoriations to buttocks and sacrococcygeal (bottom of the spine or just above the tailbone) region: Cleanse with soap and water, pat dry, apply Triad paste (zinc-oxide based hydrophilic paste for light to moderate levels of wound exudates) daily. During a concurrent observation and record review on 8/28/24, at 10:30 a.m., outside by Resident 2's room doorway was a posted sign which indicated Enhanced Barrier Precautions (EBP, a set of infection control measures used to reduce spread of multidrug-resistant organisms [MDROs] that involved gown and glove use during high-contact activities). Review of the posted sign indicated, .Wear gloves and gown for the following High-Contact Resident Care Activities .Changing briefs or assisting with toileting .Wound Care: any skin opening requiring a dressing . Further observation showed a PPE supply holder hung by Resident 2's room entrance door, which contained two boxes of gloves and multiple disposable gowns. During an observation and concurrent interviews on 8/28/24, at 10:30 a.m., TN 2 prepared for Resident 2's wound dressing change. Both TN 2 and CNA 1 entered Resident 2's room with gloves and N95 respirator mask, but without gowns on. During wound dressing change, TN 2 did not perform hand hygiene in between glove change before applying the Triad paste to the wound. Upon interview, both TN 2 and CNA 1 stated they should have worn their disposable gowns before Resident 2's wound dressing change took place. TN 2 also stated hand hygiene should be performed when moving from wound cleaning (a dirty procedure) to application of a new dressing (a clean procedure) to prevent infection. During an interview on 8/28/24, at 10:45 a.m., with the Infection Preventionist (IP), IP stated EBP should be observed during resident care with wounds, urinary catheters, tube feedings, or any type of opening or break in the skin, requiring close skin contact. IP stated licensed nurses and CNAs were required to wear gloves and gown when performing close physical contact with residents. IP also stated staff should change gloves and perform hand hygiene in between clean and dirty procedures to prevent spread of infection.

Based on observation, interview, and document review, the facility failed to ensure garbage was stored properly when outside trash bins were leaking, over-filled, and the lids were open, letting waste spill onto the ground. This failure had the potential to attract insects, rodents, and other pests to the facility. Findings: During an observation and concurrent interview on 5/16/24, at 10:04 a.m., with the housekeeping supervisor (HS), the facility's outside trash cans and dumpsters were inspected. There were four large green plastic bins designated for organic food waste in the rear facility entrance. Two of these bins were cracked and leaking dark brown liquid, and the lids were not closed. Waste was piled over the tops of the bins, with open and closed plastic bags with food waste spilling over the tops. There was food waste and trash on the ground surrounding the bins, and dark brown liquid was running down the driveway away from the area. The HS confirmed that the area was unclean, and could result in infection due to insects, vermin and pests. During and observation and concurrent interview on 5/16/24, at 10:10 a.m., with the dietary services manager (DSM), the DSM confirmed that the outside trash area was unclean with the bins leaking and lids open. The DSM stated kitchen staff were responsible for keeping the area clean, and the food waste contaminating the area could result in pests and insects both outside the facility, and through the nearby back entrances to the inner facility. The facility ' s policy and procedure titled, Waste Disposal Policy, revised 1/2012, indicated, All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner .1. All infectious and regulated waste destined for disposal shall be placed in closable leak-proof containers or bags .These containers shall be replaced routinely and not allowed to overfill. The United States Food and Drug Administration's 2022 Food Code indicated, Refuse [waste], recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on observation, interview, and record review, for one of 30 sampled residents (Resident 32), the facility failed to provide the resident with an appropriate facility gown to wear according to her size and preference. This failure resulted in Resident 32 wearing tight clothing, feeling uncomfortable, and restricted to both her upper arms and chest area. Findings: Review of Resident 32's admission Record, printed 1/10/24, indicated resident was admitted to the facility in 2019 with diagnoses of multiple sclerosis (a disabling disease that impacts the central nervous system which controls everything a person does) and morbid obesity (excessive body fat). A review of Resident 32's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 12/9/23, indicated Resident 32 was able to understand others and be understood. The MDS indicated Resident 32 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene including dressing. During a concurrent observation and interview on 1/8/24, at 10:42 a.m., in Resident 32's room, Resident 32 wore a green-colored facility gown, with snaps on both sleeves. Resident 32 stated it was very important for her to choose what clothes she wore. Resident 32 stated the green gown was constricted on the chest area, tight on the upper arm with sleeves snapped together, and made her feel restricted and uncomfortable. Resident 32 stated Certified Nursing Assistants (CNAs) had told her the yellow-colored gowns, which were bigger-sized gowns had not been available for a week. During a concurrent observation and interview on 1/9/24, at 1:47 p.m., with the Housekeeping/Central Supply staff(HSKG/CS), Clean Laundry Supply Storage and Linen Storage Closets were viewed. The shared Linen Supply Storage for Station 2 & 3 Closet and Clean Laundry Room Storage did not have any available beige-leaf (bigger-sized, yellow-colored) gowns. Station 1 Closet had five remaining beige-leaf gowns. HSKG/CS stated Clean Linen Storages were replenished regularly for each shift's (day, evening, and night work schedule) use. HSKG/CS also stated the facility used Outside Laundry Services to wash soiled linens and provide clean linen supplies. HSKG/CS stated each order was delivered every two days and since HSKG/CS placed orders daily, deliveries also came in daily. During an interview on 1/09/24, at 2:11 p.m., with CNA 1, CNA 1 stated Resident 32 liked to wear a facility gown and preferred the yellow-colored gown (a bigger size) over the green-colored gown (a smaller size). Resident 32 currently used a green gown because yellow gowns were not available. CNA 1 stated Resident 32 would usually let CNA know which gown she preferred to use. During a concurrent interview and facility record review on 1/10/24, at 3:00 p.m., with HSKG/CS, Laundry Delivery Invoice Forms were reviewed. HSKG/CS stated Delivery Invoice Form, dated 12/19/23, indicated facility's last ordered and received yellow gowns were 20 pieces of Gown .10x, Beige Leaf, Plastic Snaps. HSKG/CS stated soiled yellow gowns were sent to laundry for washing with no more replacements ordered until yesterday, 1/9/24. Laundry Delivery Invoice Form dated 1/10/24, indicated 30 pieces Gown .10x, Beige Leaf, Plastic Snaps were delivered. A review of the facility's policy and procedure (P&P) titled, Dignity, revised date February 2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction in life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Individual needs and preferences of the resident are identified through the assessment process .When assisting with care, residents are supported in exercising their rights. For example, residents are a. groomed as they wish to be groomed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to contact a physician for a significant change of condition for eight hours and 40 minutes for one of two (Resident 400) sampled residents after Licensed Vocational Nurse 8 (LVN 8) administered multiple doses of unprescribed medications, including opioid medications (a group of medications which are federally regulated substances used for pain control with a potential for physical or psychological dependence) to Resident 400. This failure resulted in Resident 400's hospitalization for excessive sedation and respiratory failure (inadequate breathing efforts) requiring mechanical ventilation (machine used to provide artificial breathing) from the opioid medications overdose. Findings: During a review of Resident 400's admission Record dated 12/22/23, the admission Record indicated Resident 400 was admitted to the facility in 2008 for stroke (brain tissue death resulting in brain function impairment), hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), dysphagia (difficulty swallowing), heart failure and muscle weakness. During a review of Resident 400's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 11/10/23, the MDS indicated Resident 400 had a score of 13 on the Brief Interview for Mental Status. (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 400 was able to be understood and could understand others. The MDS indicated Resident 400 required supervision for oral and personal hygiene such as combing hair, washing hands and face. During a review of Resident 400's, Order Summary Report, Active Orders as of 12/18/23, dated 12/18/23, the Report indicated an order for a regular texture diet. The Report indicated Resident 400 had orders to take medications and food by mouth. The Report indicated Resident 400 had no active orders for baclofen (muscle relaxant medication which can cause drowsiness and shallow breathing), hydrocodone-acetaminophen (an opioid medication), methadone (an opioid medication) or Eliquis (medication to prevent blood clots which can cause stroke or heart attack). During a review of Resident 1's admission Record dated 12/28/23, the admission Record indicated Resident 1 was admitted to the facility in 2013 for atrial fibrillation (irregular heart rhythm which can lead to stroke) and chronic pain. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had a BIMS score of 14. The MDS indicated Resident 400 had adequate vision and was able to be understood and could understand others. During a review of Resident 1's Order Summary Report, Active Orders as of 12/28/23, dated 12/28/23, the Report indicated Resident 1 had medication orders for: baclofen 20 mg (milligram, a unit of measurement) oral tablet, three times a day; hydrocodone-acetaminophen 10-325 mg oral tablet, five times a day; Eliquis 5 mg oral tablet, twice a day; and methadone 10 mg oral tablet, four times a day. During a phone interview on 1/2/24, at 4:40 p.m., with LVN 8, LVN 8 stated on 12/16/23, at 9:00 a.m., she was performing a medication pass for Resident 400 and Resident 1, who shared a room. LVN 8 stated she checked the identity of both residents and prepared both of their medications in separate medication cups. LVN 8 stated she took a medication cup to Resident 400's bedside and watched Resident 400 take the medications, and then left the room. LVN 8 stated 30-40 minutes later, Resident 1 told LVN 8 the medications LVN 8 had left on Resident 1's overbed table did not belong to Resident 1. LVN 8 stated she realized she had accidentally switched the medications and had administered Resident 1's medications to Resident 400. LVN 8 stated Resident 400 had not received her morning medications of metformin (a medication to decrease blood sugar) and amlodipine (used to decrease blood pressure), and aspirin (to prevent blood clots), but had received Resident 1's medications which included methadone, hydrocodone-acetaminophen, Eliquis, and baclofen. LVN 8 stated she called the nurse practitioner (NP) and informed the NP that Resident 400 had received Resident 1's medications; the NP told LVN 8 to monitor Resident 400. During a concurrent phone interview and record review on 1/5/24, at 10:40 a.m., with LVN 8, Resident 1's Controlled Substance Accountability Sheet for methadone 10 mg tab and hydrocodone-acetaminophen 10-325 mg tablet, dated December 2023, was reviewed. LVN 8 stated on 12/16/23, Resident 400 had received two doses of methadone 10 mg at 9:00 a.m., and she recorded the two doses on 12/16/23, at 1:00 p.m. under Qty [quantity] destroyed/wasted of the sheet. LVN 8 stated Resident 400 had received two doses of hydrocodone-acetaminophen 10-325 mg at 9:00 a.m., and she recorded the two doses on 12/16/23, at 1:00 p.m. under Qty destroyed/wasted of the sheet. LVN 8 stated Resident 400 had also received the 9:00 a.m. and 1:00 p.m. dose of baclofen during the 9:00 a.m. medication pass. LVN 8 stated the doses were documented under destroyed/wasted because the doses had not been given to Resident 1. LVN 8 stated, at Resident 1's request, LVN 8 left both the 9 a.m. and 1 p.m. doses of hydrocodone-acetaminophen, methadone, and baclofen at Resident 1's bedside for the 1 p.m. doses to be self-administered later in the day. During a concurrent observation and interview on 12/28/23, at 12:06 p.m., with Resident 1, Resident 1 lay in bed with an overbed table across her lap. A palm-sized box with a hinged lid was on the overbed table. Resident 1 stated she had been Resident 400's roommate on the morning of 12/16/23, when LVN 8 came into the room with both Resident 400's and Resident 1's morning medications and placed the medications on the residents' overbed tables. Resident 1 stated LVN 8 left the room before either resident had taken the medications. Resident 1 stated she noticed while sorting the medications left at her bedside, that the medications were not the correct prescribed medications so Resident 1 called for the nurse. Resident 1 stated she told LVN 8 the medications left at her bedside were not her medications when LVN 8 answered the call bell about 30 minutes later. Resident 1 stated her morning medications included baclofen, hydrocodone-acetaminophen, methadone and Eliquis. Resident 1 stated LVN 8 would leave both the 9 a.m. and the 1 p.m. doses of methadone, hydrocodone-acetaminophen, and baclofen during the 9:00 a.m. medication pass at Resident 1's bedside, so Resident 1 would place the 1 p.m. doses in the hinged box on the overbed table for later self-administration. Resident 1 stated LVN 8 had not verified either Resident 400 or Resident 1's identities before leaving the medications at their bedsides or told either resident the names of their medications. During a concurrent interview and record review on 12/28/23, at 12:39 p.m., with Administrator (Admin) and Operations Manager (OM), Resident 400's, Situation, Background, Assessment, Recommendation, Summary, (SBAR, a communication tool to summarize relevant medical information for changes in condition or unusual incidents) by LVN 8, dated 12/16/23, at 10:30 a.m., was reviewed. The SBAR indicated Resident 400 had a change in condition related to a medication error. OM stated the SBAR note indicated at 9:00 a.m., LVN 8 prepared Resident 400 and Resident 1's medications on the medication cart and took Resident 1's medications to Resident 400 and Resident 400 took Resident 1's medications. The SBAR indicated LVN 8 gave Resident 400's medications to Resident 1 but left the room before Resident 1 took the medications. The SBAR indicated after 30 minutes, Resident 1 informed LVN 8 the medications left with Resident 1 were not the correct prescribed medications. OM stated the SBAR indicated the NP was notified of the medication error and LVN 8 was given instructions to monitor Resident 400. During a phone interview on 12/28/23, at 12:23 p.m., with the NP, the NP stated in the morning of 12/16/23, NP received a text message from a facility staff member about Resident 400 receiving the wrong medications. NP stated she instructed the staff member to call the director of nursing (DON) and to monitor Resident 400. NP stated that was the extent of NP's involvement; NP had not done any follow-up or contacted anyone else after giving those instructions. During a concurrent interview and record review on 12/28/23, at 12:31 p.m., with Admin, the Admin presented a phone screenshot of LVN 8's text messages with NP. The text message indicated LVN 8 informed NP that Resident 400 had received baclofen, methadone, acetaminophen and Eliquis; NP responded with instructions to call the DON and monitor Resident 400. During a phone interview on 12/28/23, at 11:49 a.m., with Licensed Vocational Nurse 9 (LVN 9), LVN 9 stated she had worked the 3 p.m. to 11 p.m. shift on 12/16/23. LVN 9 stated that during the change of shift report on 12/16/23, at 3:00 p.m., LVN 8 reported Resident 400 had taken Resident 1's medications in the morning and needed to be monitored. LVN 9 stated Resident 400 was verbally responsive and had stable vital signs from the beginning of the shift until dinner time. LVN 9 stated at dinner time, a certified nursing assistant (CNA) came to LVN 9 and said Resident 400 was unresponsive, so they went to Resident 400's room. LVN 9 stated attempts to awaken Resident 400 were unsuccessful, and upon checking Resident 400's vital signs, Resident 400's oxygen saturation was 78-80%. (Oxygen saturation is a measurement of oxygen in the blood, expressed as a percentage, with 100 percent the maximum amount of oxygen possible, and normal values greater than 90%.) LVN 9 stated Resident 400 was given supplemental oxygen through a non-rebreather mask (an external mask worn over the nose and mouth to provide 100% oxygen), while 9-1-1 was called for emergency transport to the hospital. During a concurrent interview and record review on 12/28/23, at 12:39 p.m., with Admin and OM, Resident 400's nursing progress notes, for 12/16/23 to 12/17/23, were reviewed. A nursing SBAR progress note by LVN 9, dated 12/16/23, at 6:00 p.m., indicated at 5:28 p.m., Resident 400 had a situation of unresponsiveness different than usual with an oxygen saturation of 78-80% and a respiratory rate of seven (number of breaths per minute, normal respiratory rate is 12 to 18 breaths per minute). The SBAR indicated LVN 9 assessed Resident 400's breathing as labored or rapid breathing, with general weakness and altered level of consciousness. A nursing progress note by LVN 9, dated 12/17/23, at 12:45 a.m., indicated, at 5:28 p.m., Resident 400 was unresponsive to multiple attempts to rouse Resident 400. The note indicated Resident 400 had an oxygen saturation of 88% while using the non-rebreather mask. The progress note indicated at 5:46 p.m., the resident was taken to the emergency room. OM stated she notified Resident 400's physician (MD-1) at 6:40 p.m. as indicated on the progress note. During a phone interview on 12/28/23, at 1:25 p.m., with MD-1, MD-1 stated he was Resident 400's primary physician. MD-1 stated he first learned the medication error at around 5-6 p.m. when he was at home and after Resident 400 was transported to the hospital. MD-1 recalled it was getting dark when he received the phone call from the facility. MD-1 stated he did not receive any communications from NP earlier in the day about Resident 400's medication error. MD-1 stated for medication errors, the staff would contact him to give further information about the medication error. MD-1 stated staff were required to follow facility protocol after a medication error. During a record review of Resident 400's hospitalization record, an emergency physician's Provider Note dated 12/16/23, at 7:29 p.m., indicated Resident 400 was transported by ambulance to the emergency room, at 6:02 p.m., and was diagnosed with altered mental status (term used to refer to a change in consciousness), opioid overdose and apnea (cessation of regular breathing). The Provider note indicated a decision was made to admit Resident 400 to the intensive care unit for further evaluation and management. During a review of facility policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, The individual administering medications verifies the resident's identity before giving the resident his/her medications Medications ordered for a particular resident may not be administered to another resident. During a review of facility's P&P titled, Administering Oral Medications, dated 10/2010, the P&P indicated nursing staff were expected to, confirm identity of resident .remain with the resident until all medications have been taken. During a review of facility's policy and procedure (P&P) titled Adverse Consequences and Medication Errors, dated 2/2023, the P&P indicated a medication error as administration of drugs or biologicals which is not in accordance with physician's orders promptly notify the provider of any significant error or adverse consequence . and adverse drug reactions are reported to the attending physician.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide fingernail care to one of 30 sampled residents (Resident 13) when Resident 13's fingernails on both hands were long. This failure resulted in Resident 13 feeling bothered by the long fingernails and placed him at risk for scratching himself. Findings: A review of Resident 13's admission Record, printed on 01/10/24, indicated Resident 13 was originally admitted to the facility on [DATE]. During a review of Resident 13's Minimum Data Set (MDS, an assessment tool used to guide care) dated 8/25/2023, indicated Resident 13 required limited assistance with personal hygiene. The MDS assessment also indicated Resident 13 was able to understand others and was able to make himself understood. During a concurrent observation and interview on 01/08/24, at 1:39 p.m., Resident 13's fingernails on both hands were long. Resident 13 stated the length of his nails bothered him. During a concurrent interview and record review on 1/10/24, at 1:12 p.m., with the Director of Staff Development (DSD), Resident 13's Electronic Health Record for Nail Care, dated from 12/28/23 to 01/10/24, was reviewed. The record indicated Resident 13 received nail care on 01/08/24, 01/09/24 and 01/10/24. The DSD stated that nail care includes shortening/trimming and cleaning of nails and the Certified Nursing Assistants (CNAs) were responsible for this task. During a concurrent observation and interview on 01/10/24, at 1:30 p.m., Resident 13's fingernails were still long and not trimmed. Resident 13 stated that he preferred his nails shorter. During a concurrent observation and interview on 1/10/24, at 1:33 p.m., with the DSD, DSD stated that Resident 13's fingernails were about 1/8 of an inch long. During an interview on 1/10/24, at 2:33 p.m., with CNA 3, CNA 3 stated she was the assigned CNA for Resident 13 that day and she trimmed Resident 13's fingernails that morning. CNA3 stated she did not know why Resident 13's nails appeared to be the same length as they were on 1/8/24. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated February 2018, the P&P indicated, trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. During a review of the facility's P&P titled, Dignity, dated February 2021, the policy indicated, when assisting with care, residents are supported in exercising their rights. For example, residents are: groomed as they wish to be groomed (hair style, nails, facial hair, etc).

Based on observation, interview, and document review, the facility failed to ensure care provided to a resident (Resident 27) was in accordance with professional standards of practice when a staff who was not a nursing staff provided resident care by helping the resident sit up in bed, and serving her lunch tray. This failure had the potential for one resident to receive food not appropriate for her diet resulting in a negative outcome such as an allergy reaction. Findings: Review of the tray card on Resident 27's tray for lunch on 1/9/24 showed Resident 27 was on a Consistent Carbohydrate (a diet typically prescribed to a person to help regulate blood sugar), No Added Salt therapeutic diet. The tray card also showed she had gluten (a protein found in grains such as wheat, barley, and rye) and iodine (a mineral found in some foods) allergies. In the notes section of the tray card, it showed Resident 27 received small portions of starch foods and she disliked wheat bread. An observation on 1/9/24 at 12:37 p.m., showed a food tray delivery cart holding resident lunch trays parked in the hallway by resident rooms. Maintenance Staff 1 (MS1) removed a resident lunch tray from the cart and carried it into the room where Resident 27 was in her bed. MS1 placed the lunch tray on Resident 27's bedside table and raised her bed to prepare her for her lunch. Nursing staff was not in the resident's room at the time. In an interview on 1/10/24 at 11:45 a.m., MS1 confirmed he served residents their food trays because he thought serving food to residents was a way to get to know them. In an interview on 1/12/24 at 9:56 a.m., the Administrator (Admin) stated MS1 should not enter a resident room to pass a food tray directly to the resident. Admin stated if MS1 wanted to help with passing a tray, MS1 could carry it to the resident's door and hand it to a Certified Nursing Assistant (CNA), who would provide the resident with the tray of food. According to the Board of Registered Nursing document titled Unlicensed Assistive Personnel dated 11/94, showed the term unlicensed assistive personnel refers to those health care workers who are not licensed to perform nursing tasks; it also refers to those health care workers who may be trained and certified, but are not licensed. Examples of unlicensed personnel certified nursing assistants, home health aides, and patient care technicians. Registered Nurses (RNs) may assign assistive personnel activities which unlicensed assistive personnel have traditionally performed in the delivery of patient care. These activities of daily living include basic health and hygiene tasks such as those a certified nursing assistant or home health aid is trained to perform. Unlicensed assistive personnel may not reassign an assigned task. To reiterate, it is the direct care RN who ultimately decides the appropriateness of assignment of tasks. The registered nurse must be knowledgeable regarding the unlicensed assistive personnel's education and training, and must have opportunity to periodically verify the individual's ability to perform the specific tasks. Health and Safety Code Section 1338.5(a)(2)(A) requires any individual who is not licensed or certified and has direct resident care duties must be hired-full-time, enrolled in a nurse aide training program and successfully complete the training and competency testing within 4 months of employment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a timely evaluation of one resident's (Resident 72) severe weight loss. This failure had the potential to result in further unintentional and/or undesirable weight loss for one resident. Findings: Review of the undated Policy and Procedure titled Weight Assessment and Intervention, Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded. Unless notified of a significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant, greater than 5% is sever. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is sever. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. A record review for Resident 72 showed she was 78 years, old initially admitted on [DATE]. Resident 72's documented weight history showed the following: 11/2/23 207.8 pounds (lbs) 11/10/23 195.4 lbs (6% weight loss in 9 days compared to 11/2/23 207.8 lbs) 11/13/23 192.2 lbs 11/30/23 187.2 lbs 12/1/23 187.2 lbs 12/12/23 184.2 lbs 12/27/23 178.8 lbs (8.4% weight loss in 48 days compared to 11/10/23 195.4 lbs) A record review for Resident 72 showed a dietary progress note written on 12/27/23. In the progress note, 72's weight history was listed, and the note read . (11/2) 207.8 # [pound] (Initial weight may be inaccurate). Wt [weight] Change: 8.4# (4.5%) weight loss x 26 days (not significant). In an interview with the Registered Dietitian (RD) on 1/11/24 at 12:50 p.m., RD reviewed resident 72's electronic medical record and confirmed she did not do any assessments or progress notes for Resident 72 between her initial assessment on 11/2/23 and a re-admission assessment on 12/26/23. RD stated she reviewed residents' documented weights monthly as well as weekly if she had time. RD said it was not until Resident 72 was readmitted from the hospital on [DATE] when she noticed Resident 72 had weight loss. When asked if the Resident had a severe weight of loss of 6% between 11/2/23 (207.8 lbs) to 11/10/23 (195.4 lbs), RD stated she suspected Resident 72's initial weight (of 207.8 lbs) was inaccurate, and she documented this in her 12/27/23 progress note initial weight may be inaccurate. RD stated if she suspected there was an inaccurate weight, she sent a note to the person who weighed residents or to the Director of Nursing (DON), to reweigh the resident. She stated she did not have documentation to show she requested the resident to be reweighed in order to verify the accuracy of the resident's initial weight. RD stated reweighs were done almost immediately, within one day. RD confirmed a reweigh of Resident 72's initial weight was not done. She stated she did not ensure reweighs were done after she requested a resident to be reweighed. RD also confirmed she documented Resident 72 did not have a significant weight loss in her 12/27/23 progress note. RD confirmed resident 72 did have an 8.5 percent significant weight loss on 12/27/23 when her weight was documented as 178.8 pounds and compared to her documented weight of 195.3 pounds on 11/10/23. RD stated she did not catch the resident's significant weight loss because she only did one month weight comparisons.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 43) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental process and behaviors). Resident 43 received aripiprazole (an antipsychotic medication, used to manage conditions such as psychosis) and sertraline (medication used to treat depression) without side effects and behavior monitoring. Resident 43's care plan did not have the correct side effect monitoring for the aripiprazole use. These failures resulted in inadequate monitoring for effectiveness and adverse effects of psychotropic medications. Findings: 1. A review of clinical record indicated Resident 43 was admitted to the facility with diagnoses including Schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and Depression. A review of Resident 43's physician's orders included the following: -Aripiprazole 2 mg (milligrams) 1 tablet by mouth at bedtime for Schizoaffective disorder manifested by verbal abuse (threatening, screaming, cursing at others), dated 10/24/23. -Sertraline 25 mg 1 tablet by mouth at bedtime for Depression manifested by episode of crying, dated 7/13/22. -Monitor Episodes of Depression AEB (as expressed by): episodes of crying every shift, dated 7/13/22. -Monitor Episodes of Verbal Abuse AEB: Threatening, Screaming, Cursing at others every shift, dated 7/13/22. -Monitor for side effects of Abilify (aripiprazole): Anticholinergic effects (dry mouth, constipation, blurred vision, drowsiness, dizziness, increased heart rate, urinary retention, delirium), increase in total cholesterol and triglycerides, akathisia (inability to remain still), parkinsonism (brain conditions that cause slowed movements, rigidity/stiffness and tremors), neuroleptic malignant syndrome (characterized by high fever, stiffness of the muscles, altered mental status and autonomic dysfunction that may result in death), blood sugar elevation, orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), falls, weight change, tardive dyskinesia (abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected), lethargy/sedation every shift, dated 7/13/22. -Monitor side effects of Zoloft (sertraline) . every shift, dated 7/13/22. During a concurrent interview and record review on 01/11/24, at 10:01 a.m., the Medical Record/Operations Manager (MR/OM) stated the side effect and behavior monitoring for Resident 43's aripiprazole and sertraline were ordered but somehow did not link with the E-MAR (Electronic Medication Administration Record). The MR/OM acknowledged that without documentation the monitoring was not done. During a concurrent interview and record review on 01/11/24, at 10:07 a.m., the Registered Nurse Supervisor (RNS) stated the side effect and behavioral monitoring are documented in the E-MAR. The RNS looked through Resident 43's December 2023 and January 2024 E-MARs and Psychotropic tab and stated she could not find evidence of staff monitoring for side effects and behaviors related to the use of aripiprazole and sertraline. RNS stated I am not sure why the orders did not go over to the E-MAR. On 1/11/24, a review of Resident 43's E-MARs from August 2022 to January 2024 indicated the entries for side effect and behavior monitoring were all blank. 2. On 1/10/24, a review of Resident 43's Anti-psychotic dx (diagnosis) care plan, revised on 07/27/23, indicated one of the interventions for the use of antipsychotic medication was to observe and report signs of Blurred vision, Dizziness, Muscle spasms of neck/back, Shuffling walk, Sexual dysfunction, Diarrhea, Constipation, Drowsiness, Nasal congestion, Nausea, Vomiting, Dry mouth, Skin rashes, Loss of appetite, Increased confusion, Seizure, Tachycardia (rapid heartbeat), Orthostatic hypotension, Photosensitivity. During a concurrent interview and record review on 01/11/24, at 10:07 a.m., the RNS confirmed the aripiprazole side effects on the care plan did not match the side effect profile written on the physician's order (as stated above). During a review of the facility's policy and procedure titled, Psychotropic Medication Use, dated March 2018, P&P indicated, 8. Psychotropic medication management for resident will involve the facility's interdisciplinary team's consideration of the following . adequate monitoring for efficacy and adverse consequences and 12. Monitoring of a resident receiving Psychotropic medication will include an evaluation of effectiveness of the medication, as well as an assessment for possible adverse consequences. Behavior symptoms are reevaluated periodically to determine the potential for reducing or discontinuing the drug based on therapeutic goals, and any adverse effects or possible functional impairment.

Based on observation, interview and record review, the facility had a 7.41% error rate when two medication errors out of 27 opportunities were observed during the medication pass for two of six sampled residents (Residents 28 and 52 ). Resident 28 did not receive carvedilol (medication used to treat high blood pressure) as ordered and Resident 52 received a wrong calcium product. These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect the resident's health.) Findings: 1. During medication administration observation on 01/08/2024, at 10:01 a.m., in Station 1, LVN (Licensed Vocational Nurse) 3 was observed preparing and administering 7 medications to Resident 28. These medications included 1 tablet of allopurinol (medication used to treat gout) , 1 capsule of docusate sodium (medication used to treat constipation), 1 tablet of duloxetine (medication used to treat depression), 1 tablet of finasteride (medication to treat symptoms of an enlarged prostate), one fluticasone inhaler (medication used to treat asthma), 1 tablet of memantine (medication used to treat dementia in patients with Alzheimer's disease) and 1 tablet of valsartan (medication used to treat high blood pressure). A review on 01/08/2024 of Resident 28's Physician's order, dated 12/22/23, and the January 2024 E-MAR (Electronic Medication Administration Record) indicated that carvedilol 3.125mg was scheduled to be given two times a day at 9:00 a.m. and 5:00 p.m. for Resident 28. During a concurrent observation and interview on 01/08/2024, at 02:29 p.m., LVN 3 checked the medication cart drawer and found the 9:00 a.m. and 5:00 p.m. pouches containing carvedilol 3.125 mg (milligrams) for Resident 28. LVN 3 stated she missed giving the carvedilol to Resident 28 during the morning medication pass and will notify the doctor that the dose was missed. 2. During medication administration observation on 01/09/2024, at 08:40 a.m., in Station 2, LVN 6 was observed preparing and administering 8 medications to Resident 52. One of the administered medications was a tablet of calcium 600 mg plus vitamin D 400 IU (international unit). A review on 01/09/2024, the Physician's order dated 07/17/2022 and the January 2024 E-MAR indicated that calcium 600 mg + vitamin D 800 unit was ordered for Resident 52. During a concurrent observation and interview on 01/09/2024, at 01:41 p.m., LVN 6 checked the bottle of calcium 600 mg plus vitamin D 400 IU and compared with the E-MAR. The E-MAR indicated calcium 600 mg + vitamin D 800 unit was ordered for Resident 52. LVN 6 stated the medication cart did not have calcium 600mg with vitamin D 800 unit supply and will clarify the order with the doctor. LVN 6 confirmed the medication given was not the same with the doctor's order. During a review of facility's policy and procedure titled, Administering Medications, dated April 2019, P&P indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to accurately document entries for one of 30 sampled residents (Resident 24), when resident's current physician orders did not reflect oxygen (O2) and nebulizer (a device to take medication in the form of a mist that is inhaled into the lungs) use. This deficient practice resulted in incomplete and inaccurate records and had the potential for Resident 24 to not receive care, services, and treatments as needed. Findings: A review of Resident 24's admission Record, printed 1/10/24, indicated Resident 24 was admitted in March 2023, with diagnosis of chronic respiratory failure (a condition in which the lungs have a hard time loading the blood with O2 or removing carbon dioxide) with hypoxia (low levels of O2 in the body). A review of Resident 24's Care Plan titled, Difficulty Breathing related to Acute and Chronic Respiratory Failure with Hypoxia, undated, indicated, Administer medication/puffers as ordered. Monitor for effectiveness and side effects .Provide oxygen as ordered . Further review of Resident 24's care plan titled, Respiratory - Shortness of Breath, undated, indicated, Administer medications as ordered. Monitor for side effects/adverse reactions and effectiveness .Administer nebulizer treatments as ordered . A review of Resident 24's clinical record titled, Order Details, order date 11/1/23, indicated, Oxygen - at (@) 1-3Liters/Min Via Nasal Cannula as needed (PRN) to Maintain O2 Saturation (Sats) Greater Than 90 Percent (%). A review of Resident 24's clinical record titled, Medication Administration Record (MAR), dated 1/1/2024 - 1/31/2024, indicated, Start Date - 12/22/2023, Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram/3milliliter (MG/3ML) 3 ML inhale orally every 6 hours for respiratory failure via nebulizer. A review of Resident 24's clinical record titled, Order Summary Report, active orders as of 1/8/24, indicated, 12/26/23 Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram/3milliliter (MG/3ML) 3 ML inhale orally every 6 hours for respiratory failure. Resident 24's Order Summary Report did not indicate an O2 or nebulizer treatment/use. During an observation on 1/8/24, at 10:17 a.m., in Resident 24's room, Resident 24 was noted receiving O2 from a portable O2 concentrator (a medical device that delivers O2) running at 4 liters per minute (LPM) via undated nasal cannula tubing. Resident 24 also had a nebulizer machine on top of his bedside table with connecting undated mask cannula tubing. During a concurrent observation, interview, and record review on 1/8/24, at 2:42 p.m., with Registered Nurse Supervisor (RNS), in Resident 24's room, Resident 24 received continuous O2 at 4LPM via nasal cannula from a portable O2 concentrator. Resident 24's current Order Summary Report with active orders, dated 1/8/24, were reviewed and indicated no order for O2 and nebulizer use. RNS stated Resident 24 ran the risk of not receiving oxygen treatment as needed or risk of medication error for the licensed nurses. A review of the facility policy and procedure (P&P) titled, Oxygen Administration, revised October 2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . A review of facility P&P titled, Administering Medications Through a Small Volume (Handheld) Nebulizer, revised October 2010, indicated, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Obtain a physician's order as needed. Review the resident's care plan, current orders, and diagnoses to determine resident needs . A review of facility P&P titled, Oxygen Therapy, undated, indicated, It is the policy of this facility that oxygen therapy is administered as ordered by the physician or as an emergency measure until a physician's order can be obtained. When implemented in an emergency without a physician's order, the physician will be notified as soon as possible after the resident immediate needs are met

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 34) had access to his call device. This failure resulted in Resident 34 not being able to get staff assistance when needed. Findings: A review of Resident 34's face sheet, undated, indicated Resident 34 was admitted in February 2019, with diagnoses of hemiplegia (paralysis) and hemiparesis (partial weakness) of left side of body following cerebral infarction (stroke - blood supply to the brain is cut off), arthritis (inflammation of joints), and muscle wasting (decrease in size of muscles). During a concurrent observation and interview on 1/8/24, at 10:47 a.m., with Resident 34, there was no call device found for Resident 34. Resident 34 stated he had no call light for the last 3 days. Resident 34 stated he needed the call light to call staff for any needs especially at nighttime but could not. During a concurrent observation and interview on 1/8/24, at 11:00 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 went to Resident 34's room, looked under the bed and surrounding areas and could not locate Resident 34's call device. LVN 2 asked Resident 34 where his call light was, and Resident 34 responded he did not have one. LVN 2 stated Certified Nursing Assistant (CNA) should have checked that Resident 34 had a call device. LVN 2 confirmed Resident 34 did not have a call device. During an interview on 1/9/24, at 8:15 a.m., with Housekeeper (HSKG) 1, HSKG 1 stated LVN 2 notified him on the morning of 1/8/24 that Resident 34 did not have a call device. HSKG 1 stated he went to the room and found a call device's cable unplugged from the wall. HSKG 1 stated when cleaning the room, the cable might have been accidentally hit and unplugged. HSKG 1 stated he did not know whose responsibility it was to enter a missing call device on the maintenance log. During an interview on 1/9/24, at 12:10 p.m., with LVN 2, LVN 2 stated when a call device cable was unplugged from the wall, there would be no light showing on the panel located in front of the nursing station to alert staff. LVN 2 stated not having a call light could compromise patient care. During an interview on 1/9/24, at 3:00 p.m., with Resident 34, Resident 34 stated he was moved to another bed three days ago and did not get a call device. Resident 34 further stated he wanted a call device to use if an item dropped on the floor and he needed staff help. A review of the facility's policy and procedure (P&P) titled, Call Lights, dated 1/20/24, the P&P indicated, Staff shall ensure that call lights are placed within reach of the resident.

Based on interview and record review, the facility failed to ensure the Annual (comprehensive) Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within the required time frames for four of 30 sampled residents (Resident 31, Resident 50, Resident 47, and Resident 53). Resident 31, Resident 50, Resident 47, and Resident 53's annual MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items). These deficient practices had the potential for Resident 31, Resident 50, Resident 47, and Resident 53 to not receive the appropriate care and services needed based on these residents' current health status. Findings: A review of Resident 31's admission Record, printed 1/10/24, indicated Resident 31 was admitted to the facility in 2018 with diagnosis of quadriplegia (a form of paralysis that affects all person's limbs and body from the neck down). A review of Resident 50's admission Record, printed 1/10/24, indicated Resident 50 was admitted to the facility in 2021 with diagnosis of Diabetes Mellitus (high blood sugar). A review of Resident 47's admission Record, printed 1/10/24, indicated Resident 47 was admitted to the facility in 2021 with diagnosis of metabolic encephalopathy (a change in how the brain functions). A review of Resident 53's admission Record, printed 1/10/24, indicated Resident 53 was admitted to the facility in 2020 with diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body). During a concurrent interview and record review on 1/10/24, at 2:35 p.m., with the Minimum Data Set Coordinator 1 (MDSC 1), Resident 31, Resident 50, Resident 47, and Resident 53's MDS Assessments were reviewed. Resident 31's Annual ARD was 11/7/23. Resident 50's Annual ARD was 11/3/23. Resident 47's Annual ARD was 11/11/23. Resident 53's Annual ARD was 11/11/23. MDSC 1 stated Resident 31, Resident 50, Resident 47, and Resident 53's comprehensive MDS's should have been completed and submitted no later than 14 days from the ARD. MDSC 1 further stated resident assessments should be completed and submitted in a timely fashion to effectively provide appropriate resident care. A review of the facility record titled, Final Validation Report, submission date 1/11/24, indicated, Resident 31's Care Plan was completed late and is more than 14 days after ARD, Resident 50's Care Plan was completed late and is more than 14 days after ARD, Resident 47's Care Plan was completed late and is more than 14 days after ARD, and Resident 53's Care Plan was completed late and is more than 14 days after ARD. A review of the MDS Manual, Centers of Medicare and Medicaid Services (CMS) Chapter 2: Assessments for the Resident Assessment Instrument (RAI), dated October 2023, indicated, For Annual Assessment (Comprehensive), the MDS Completion Date may be no later than 14 days from the ARD .

Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within the required timeframes for four of 30 sampled residents (Resident 67, Resident 51, Resident 13, and Resident 30). Resident 67, Resident 51, Resident 13, and Resident 30's quarterly MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items). These deficient practices had the potential for Resident 67, Resident 51, Resident 13, and Resident 30 to not receive the appropriate care and services needed based on their current health status. Findings: A review of Resident 67's admission Record, printed 1/10/24, indicated Resident 67 was admitted to the facility in 2023 with diagnosis of Diabetes Mellitus (high blood sugar). A review of Resident 51's admission Record, printed 1/10/24, indicated Resident 51 was admitted to the facility in 2021 with diagnosis of cerebral infarction (a stroke or lack of blood flow to the brain). A review of Resident 13's admission Record, printed 1/10/24, indicated Resident 13 was admitted to the facility in 2022 with diagnosis of end stage renal disease (kidney failure). A review of Resident 30's admission Record, printed 1/10/24, indicated Resident 30 was admitted to the facility in 2020 with diagnosis of Alzheimer's Disease (memory loss). During a concurrent interview and record review on 1/10/24, at 2:35 p.m., with the Minimum Data Set Coordinator 1 (MDSC 1), Resident 67, Resident 51, Resident 13, and Resident 30's MDS Assessments were reviewed. Resident 67's quarterly MDS Assessment indicated an ARD of 11/23/23 and was 34 days overdue. Resident 51's quarterly MDS Assessment indicated an ARD of 11/28/23 and was 46 days overdue. Resident 13's quarterly MDS Assessment indicated an ARD of 11/24/23 and was 32 days overdue. Resident 30's quarterly MDS Assessment indicated an ARD of 11/17/23 and was 40 days overdue. The MDS Coordinator stated a quarterly MDS should have been completed no later than 14 days from the ARD and submitted no later than 14 days from the completion of the MDS Assessment. MDS Coordinator stated Resident 67, Resident 51, Resident 13, and Resident 30 had delayed completion and submission of quarterly MDS Assessments. MDSC 1 further stated resident assessments should be completed and submitted in a timely fashion to effectively provide appropriate resident care. A review of the MDS Manual, Centers of Medicare and Medicaid Services (CMS) Chapter 2: Assessments for the Resident Assessment Instrument (RAI), dated October 2023, indicated, For Quarterly Assessment (Non-Comprehensive), the MDS Completion Date must be no later than 14 days from the ARD .

Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames determined by the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) when: 1. For four of 30 sampled residents (Resident 31, Resident 50, Resident 47, and Resident 53), Annual MDS' were not completed and transmitted within 14 days of the ARD. 2. For four of 30 sampled residents (Resident 67, Resident 51, Resident 13, and Resident 30), Quarterly MDS' were not completed and transmitted within 14 days of the ARD. These deficient practices had the potential for Resident 31, Resident 50, Resident 47, Resident 53, Resident 67, Resident 51, Resident 13, and Resident 30 to not receive the appropriate care and services needed based on these residents' current health status. Findings: 1. A review of Resident 31's admission Record, printed 1/10/24, indicated Resident 31 was admitted to the facility in 2018 with diagnosis of quadriplegia (a form of paralysis that affects all person's limbs and body from the neck down). A review of Resident 50's admission Record, printed 1/10/24, indicated Resident 50 was admitted to the facility in 2021 with diagnosis of Diabetes Mellitus (high blood sugar). A review of Resident 47's admission Record, printed 1/10/24, indicated Resident 47 was admitted to the facility in 2021 with diagnosis of metabolic encephalopathy (a change in how the brain functions). A review of Resident 53's admission Record, printed 1/10/24, indicated Resident 53 was admitted to the facility in 2020 with diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body). During a concurrent interview and record review on 1/10/24, at 2:35 p.m., with the Minimum Data Set Coordinator 1 (MDSC 1), Resident 31, Resident 50, Resident 47, and Resident 53's MDS Assessments were reviewed. Resident 31's Annual ARD was 11/7/23. Resident 50's Annual ARD was 11/3/23. Resident 47's Annual ARD was 11/11/23. Resident 53's Annual ARD was 11/11/23. MDSC 1 stated Resident 31, Resident 50, Resident 47, and Resident 53 had delayed completion and submission of annual MDS Assessments. MDSC 1 further stated comprehensive MDS' should have been completed no later than 14 days from the ARD and submitted no later than 14 days from the Care Plan Completion Date. 2. A review of Resident 67's admission Record, printed 1/10/24, indicated Resident 67 was admitted to the facility in 2023 with diagnosis of Diabetes Mellitus (high blood sugar). A review of Resident 51's admission Record, printed 1/10/24, indicated Resident 51 was admitted to the facility in 2021 with diagnosis of cerebral infarction (a stroke or lack of blood flow to the brain). A review of Resident 13's admission Record, printed 1/10/24, indicated Resident 13 was admitted to the facility in 2022 with diagnosis of end stage renal disease (kidney failure). A review of Resident 30's admission Record, printed 1/10/24, indicated Resident 30 was admitted to the facility in 2020 with diagnosis of Alzheimer's Disease (memory loss). During a concurrent interview and record review on 1/10/24, at 2:35 p.m., with the Minimum Data Set Coordinator 1 (MDSC 1), Resident 67, Resident 51, Resident 13, and Resident 30's MDS Assessments were reviewed. Resident 67's quarterly MDS Assessment indicated an ARD of 11/23/23 and was 34 days overdue. Resident 51's quarterly MDS Assessment indicated an ARD of 11/28/23 and was 46 days overdue. Resident 13's quarterly MDS Assessment indicated an ARD of 11/24/23 and was 32 days overdue. Resident 30's quarterly MDS Assessment indicated an ARD of 11/17/23 and was 40 days overdue. The MDS Coordinator stated a quarterly MDS should have been completed no later than 14 days from the ARD and submitted no later than 14 days from the completion of the MDS Assessment. MDS Coordinator stated Resident 67, Resident 51, Resident 13, and Resident 30 had delayed completion and submission of quarterly MDS Assessments. MDSC 1 further stated resident assessments should be completed and submitted in a timely fashion to effectively provide appropriate resident care. A review of the facility record titled, Final Validation Report, submission date 1/11/24, indicated, Resident 31's Care Plan was completed late and is more than 14 days after ARD, Resident 50's Care Plan was completed late and is more than 14 days after ARD, Resident 47's Care Plan was completed late and is more than 14 days after ARD, and Resident 53's Care Plan was completed late and is more than 14 days after ARD. Further review of the Final Validation Report indicated, Resident 67's assessment was completed late and was more than 14 days after ARD, Resident 51's assessment was completed late and was more than 14 days after ARD, Resident 13's assessment was completed late and was more than 14 days after ARD, and Resident 30's assessment was completed late and was more than 14 days after ARD. A review of the MDS Manual, Centers of Medicare and Medicaid Services (CMS) Chapter 2: Assessments for the Resident Assessment Instrument (RAI), dated October 2023, indicated, For Annual Assessment (Comprehensive), the MDS Completion Date may be no later than 14 days from the ARD and the Transmission Date (submission of assessment electronically) no later than 14 days from the Care Plan Completion Date .For Quarterly Assessment (Non-Comprehensive), the MDS Completion Date must be no later than 14 days from the ARD and the Transmission Date (submission of assessment electronically) no later than 14 days from the MDS Completion Date .

Based on observation, interview, and record review, the facility failed to ensure its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers (medical equipment used to measure and display the amount of sugar [glucose] in the blood) according to the manufacturer's instructions and accepted professional standards of practice when: 1. Two out of three nurses observed during medication administration did not use appropriate disinfectant to clean and disinfect shared glucometers for two out of three sampled residents (Residents 24 and 52). 2. Record review for two out of two registry nurses (an individual licensed or certified by a regulatory agency who receives compensation from a third party agency to work at a nursing care institution) personnel training files did not have evidence of training or competency related to blood glucometer cleaning and disinfection from the agency or from facility. These failures had the potential for widespread transmission of bloodborne diseases (such as Hepatitis B [a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids], Hepatitis C, HIV [human immunodeficiency virus, is a virus that attacks the body's immune system]) among residents. Findings: 1. During the medication administration observation on 01/08/24, at 12:22 p.m., LVN 1 was observed wiping down the shared glucometer (medical equipment used to measure and display the amount of sugar in the blood) with an alcohol prep pad (an antiseptic wipe saturated with 70% isopropyl alcohol) prior to checking Resident 24's blood sugar. She stated the glucometer is being shared among residents receiving blood sugar checks. Shortly after the medication administration for Resident 24, on 01/08/24 at 12:27 p.m., LVN 1 was observed wiping down the shared glucometer with an alcohol prep pad after checking Resident 24's blood sugar. During an interview on 01/08/24, at 12:33 p.m., LVN 1 stated she has been using alcohol prep pad since morning to disinfect the shared glucometer. LVN 1 acknowledged she should have used the Micro-kill Germicidal (to kill germs) wipes to disinfect the glucometer, and that alcohol does not kill all bacteria or viruses. LVN 1 stated she did not receive orientation or training from the facility of what disinfecting wipes to use and has been using alcohol prep pad based on experience. During a concurrent medication administration observation and interview on 01/09/24, at 09:08 a.m., LVN 6 was observed wiping down the shared glucometer with an alcohol prep pad after checking Resident 52's blood sugar. LVN 6 stated she was not oriented as to what type of disinfectant wipe to use for shared glucometer, and there were no germicidal wipes available in the medication cart. During an interview on 01/09/24, at 09:37 a.m., the Director of Nursing (DON) and the DSD/IP stated the alcohol prep pad was not acceptable for cleaning/disinfecting shared glucometers, and the staff should use the disinfecting wipes based on the manufacturer's guidelines. A review of glucometer manufacturer's guidelines indicated the list of validated products for disinfecting the device, and alcohol prep pad was not included in the list. A review of facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised in September 2022, it indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen (microorganisms such as viruses or bacteria that are carried in blood and can cause disease in people) Standard; 5. Reusable items are cleaned and decontaminated or sterilized between residents. A review of an online publication by the CDC titled Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration, reviewed 3/2/11, indicated, The disinfection solvent should be effective against HIV, Hepatitis C, and Hepatitis B virus . 70% ethanol solutions are not effective against viral bloodborne pathogens . Healthcare personnel should consult the manufacturers of blood glucose meters in use at their facilities to determine what products, meeting the criteria specified by the FDA, are compatible with their meter prior to using any EPA-registered disinfectant for disinfection purposes. (https://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html; accessed 1/18/24) 2. During an interview on 01/09/24, at 09:37 a.m., the DSD/IP stated the orientation provided to registry nurses are location of the med room, supplies, report of each resident, fax machine, physician's contact information and access to EHR (Electronic Health Record). The DSD/IP acknowledged the orientation did not include glucometer disinfection. A review of facility's undated checklist, titled Registry Orientation/Training, did not include training on glucometer disinfection. During a concurrent interview and record review on 01/09/24, at 11:52 a.m., with the DSD/IP, when asked how the facility ensure the registry nurses were trained and competent to provide services at the facility, she stated she checked their training in the agency's portal (website to view staff license, background check or trainings). The DSD/IP reviewed the agency's online portal for LVN 1 and LVN 6 and stated both nurses did not have documented records of training or competency on disinfecting glucometer nor clinical training on infection control practices provided by the agency. During an interview on 01/11/24, at 01:31 p.m., the Admin stated the agency providing registry staff did not have a record of staff trainings. The Admin confirmed the facility should have made sure registry staff had adequate training and competency before providing services in the facility. A review of facility's P&P, titled, Staffing, Sufficient and Competent Nursing, revised on August 2022, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure proper medication storage and labeling of medication for one of one sample medication room and two of two medication carts when: 1. A non-licensed staff had access to the main medication room; and 2. Multiple expired, unlabeled, and undated multi-dose vials, eye drops, and inhalers were identified. These failures had the potential for loss or diversion of medications; and residents to receive medication with unsafe and reduced potency from being used past their discard date. Findings: 1. During a concurrent observation and interview on [DATE], at 11:41 a.m., in Station 2/3 with the presence of the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 2, the Housekeeping/Central Supply (HSKG/CS) staff stated she had the key to the medication room and replenished medication and treatment supplies whenever a nurse is available. The DON and LVN 2 acknowledged HSKG/CS staff should not have access to the medication room. HSKG/CS staff was observed giving the medication room key to LVN 2. During a review of facility's policy and procedure (P&P) titled, Storage of Medications, revised 11/2018, P&P indicated, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, cart, and medication supplies are locked when not attended by persons with authorized access. 2a. During medication administration observation on [DATE], at 10:52 a.m., LVN 1 was observed administering a dose of 0.5 milliliter (ml) of lorazepam (a controlled medication used to treat anxiety) concentrate 2 milligrams (mg)/ml orally to Resident 56. The lorazepam bottle did not have an open date on the medication bottle or the carton box it came in. A review of the manufacturer's label with LVN 1 indicated to discard the medication after 90 days. LVN 1 acknowledged it should have been labeled with an open date. 2b. During a concurrent observation and interview on [DATE], at 11:42 a.m., in the Station 2 and 3 Medication Room with the DON and LVN 2, an inspection of the medication refrigerator identified: -One opened latanoprost (medication to treat glaucoma) eye drop bottle without an open date and with an expiration date of 12/2022 -Thirteen 1-ml injectable vials of lorazepam 2 mg/ml for Resident 30 who was already discharged . -One Victoza (medication that helps control blood sugar levels and used to treat type 2 diabetes) injectable pen 18mg/3ml for Resident 3 with an expiration date [DATE] -Three Trulicity (medication that helps control blood sugar level) injectable pens 0.75 mg/0.5ml for Resident 50 with an expiration date of [DATE]. During this inspection, the DON and LVN 2 acknowledged the medications were expired. The DON stated Resident 30's lorazepam should have been removed from active stock to avoid medication error and loss. 2c. During a concurrent observation and interview on [DATE], at 02:32 p.m., an inspection of Station 1 Medication Cart with LVN 3 identified the following: -Three opened lidocaine (local anesthetic) 1% 200mg/20ml multi-dose vials without open date -One opened Sterile Water (for mixing medications) vial for single use -Two latanoprost eye drops bottles without open date; the manufacturer's label indicated to discard 6 weeks after opening -One Alphagan P (medication to treat open-angle glaucoma or high fluid pressure in the eye) eye drop without the pharmacy label -One latanoprost eye drop bottle for Resident 15 with two labels on it: latanoprost 0.005% solution 1 drop into left eye at bedtime and timolol (medication to treat glaucoma) 0.5% 1 drop into left eye daily -One ear drop mediation was stored with multiple eye drops in one compartment -One 887ml bottle of Pro-Stat sugar free liquid protein opened [DATE] with an expiration date of [DATE] -One Covid 19 reagent was stored with multiple eye drops with an expiration date of [DATE] During this inspection, LVN 3 stated she was not a regular staff in the facility so she could not comment but acknowledged the above findings. 2d. During a concurrent observation and interview on [DATE], at 04:11 p.m., an inspection of Station 2 Medication Cart with LVN 7 identified the following: -One Humulin R insulin (medication to control high blood sugar) vial for Resident 57 with an expiration date of [DATE] -Two opened Breo Ellipta (medication used to treat asthma and chronic obstructive pulmonary disease (COPD-group of diseases that cause airflow blockage and breathing-related problems) inhalers without open date; a review of the manufacturer's label indicated to discard 6 weeks after opening or when dose counter is 0, whichever comes first. During the inspection, LVN 7 acknowledged the insulin had expired, and the two Breo inhalers did not have open date. During a review of facility's P&P titled, Expiration Dating (Beyond-use dating), revised 11/2018, P&P indicated, C. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic (eye medications) .once opened, require shorter than the manufacturer's expiration date to insure medication purity and potency. During a review of facility's P&P titled, Storage of Medications, revised 11/2020, P&P indicated, Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During a review of facility's P&P titled, Medication Labeling and Storage, Revised February 2023, P&P indicated, 5. Multi-dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview and facility document review, the facility failed to ensure kitchen staff were competent regarding job duties when kitchen staff did not know the appropriate procedures for cleaning equipment and utensils using the three-compartment sink. This failure had the potential to result in contamination of kitchen equipment and/or utensils leading to illness caused by pathogens (harmful organisms) for 69 residents who received food from the kitchen. Findings: During a concurrent observation and interview in the kitchen on 1/9/24, at 9:57 a.m., [NAME] 1 stated the three-compartment sink would be used to clean dishes if the dish machine was not working. [NAME] 1 demonstrated the steps for manual dish washing using the three-compartment sink. She stated the first sink was filled with water and used for washing the dishes with soap. When she was asked what the water temperature should be for washing the dishes in the first sink, she stated that temperature of wash water should be warm, and stated she did not know the temperature. During the demonstration for use of the sink, [NAME] 1 stated the third sink was used for sanitizing items. When asked how long items were to be submerged in the sanitizer, [NAME] 1 stated she thought about three to four minutes. During a concurrent observation and interview in the kitchen on 1/10/24, at 11:15 a.m., the Dietary Supervisor (DS) stated that the temperature of wash water, rinse water and sanitizer in the 3-compartment sink should be over 110 degrees F. DS also stated items should be submerged in the sanitizer for 30 seconds. A record review of facility policy and procedure (P&P) titled, Sanitation, revised 11/2022, P&P indicated that manual washing and sanitizing is a three-step process for washing, rinsing, and sanitizing: a. scrape food particles and wash using hot water and detergent, b. rinse with hot water to remove soap residue, and c. sanitize with hot water (at least 171 degrees F for 30 seconds) or chemical sanitizing solution. Chemical sanitizing solution (e.g., chorine, iodine, quaternary ammonium compound) are used according to manufacturer's instructions. A record review of manufacturers instructions titled, Ecolab Oasis 146 Multi Quat Sanitizer indicated all surfaces of equipment, ware and utensils should be immersed in sanitizing solution for no less than one minute. According to the U.S. Department of Food and Drug Administration (USDA) Food Code (2022), the temperature of the wash solution in manual warewashing equipment shall be maintained at not less than 43oC (110oF) or the temperature specified on the cleaning agent manufacturer's label instructions.

Based on observation, interview, and facility document review, the facility failed to provide a food/drink substitute of similar nutritive value and/or provide an alternate means of meeting the residents' nutritional needs when: 1. Milk was indicated on the planned lunch menu and was not provided for 43 residents out of 69 residents who received food from the kitchen; and 2. An alternate of equal nutritional value was not provided during a lunch meal for residents who did not like chicken. These failures had the potential for residents who ate food from the kitchen to receive a diet that did not meet their nutritional needs. Findings: Review of the policy and procedure titled Menus revised 2017, showed menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified non-dairy alternatives). 1. Review of the Daily Cook's Menu dated Standard Winter 2023-24 1/9, and used for lunch on 1/9/24, showed residents on all diets except for renal diets, received milk for lunch. Review of the Winter Menu dated Week 1 and provided as the week menu from 1/8/24 - 1/14/24, showed milk served at each meal typed at the bottom of the menu. An observation of trayline food service and concurrent interviews with the Dietary Supervisor (DS) and the Registered Dietitian (RD) on 1/9/24 at 12 p.m., showed residents who's tray tickets did not indicate milk under the standing orders section, did not receive milk on their tray. The Dietary Supervisor (DS) stated milk was not provided on trays for meals unless milk was indicated standing orders on the tray ticket. She stated, if a resident wanted milk, the resident let her know. The Registered Dietitian (RD) stated she was aware not all residents received milk, but milk should be provided if it was on the menu. The RD confirmed milk was part of the approved menu and milk was included in the nutrient analysis of the menu. She stated sometimes a substitution for milk was provided such as yogurt, but only if it was preferred by the resident. The RD said she did not necessarily make sure residents received a substitute for milk to make up for the nutrients, such as calories, protein, calcium, and vitamin D, milk provided. The RD said she did not recommend supplements such as Vitamin D, unless lab results showed the resident was low in the vitamin. Review of 69 resident tray tickets used for lunch on 1/9/24 showed 43 residents were on a diet that allowed milk according to the Daily Cook's menu dated Winter 2023-24 1/9 (renal diets, and lactose intolerant/allergy were not counted), and the tray tickets did not show milk under the standing order section. 2. Review of the Daily Cook's Menu dated Standard Winter 2023-24 1/9, and used for lunch on 1/9/24, showed two ounces of chicken was served for the regular entrée. An observation of trayline food service on 1/9/24 at 12 p.m., showed chicken was served as the main entrée and cheese tortellini was served as an alternate for the entrée. In an interview on 1/10/24 at 10 a.m., the RD stated she approved tortellini as an alternate for the entrée, which was two ounces of chicken, for lunch on 1/9/23. She stated she told the cook to serve 4 ounces (1/2 cup) of tortellini. She stated 4 ounces of cheese tortellini was probably not the same amount of protein as two ounces of chicken. In an interview on 1/10/24 at 3:45 p.m., the RD stated she reviewed the cheese tortellini nutrition information, and the tortellini was not a good alternate for the chicken entrée. She stated the tortellini had significantly less protein than the meat served for lunch on Tuesday (1/9/24). Review of the undated nutrition facts for the Napoleon - Tricolor Tortellini provided as the nutrition facts for the tortellini served as an alternate entrée for lunch on 1/9/24, showed the tortellini provided 9 grams of protein for ¾ of a cup (which meant a ½ cup portion equaled 6 grams of protein). According to the United States Department of Agriculture (USDA), boneless, skinless cooked chicken contains 32.1 grams of protein for a 100 gram portion. Which means a two ounce portion of chicken equals 18.2 grams of protein.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Two out of three nurses failed to disinfect the blood pressure (BP) cuff before and/or after use for two of three sampled residents (Residents 28 and 52), 2. Two out of three nurses during medication administration were observed not using the appropriate disinfectant to clean and disinfect shared glucometers for two out of three sampled residents (Residents 24 and 52), and 3. Resident 25's foley catheter (tube inserted thru the urethra to drain bladder) equipment was lying on the ground. These failures had the potential for the spread of infections and communicable diseases among residents and placed Resident 25 at risk of urinary tract infection (UTI, infection of the urinary tract). Findings: 1. During a medication administration observation on 01/08/24, at 10:01 a.m., Licensed Vocational Nurse (LVN) 3 was observed taking the shared BP apparatus (BP monitor and BP cuff) from the hallway to Resident 28's room without disinfecting the blood pressure cuff then proceeded to wrap it around Resident 28's left arm to check the blood pressure. During an interview on 01/08/24, at 10:22 a.m., LVN 3 acknowledged she should have disinfected the blood pressure cuff before using it for Resident 28. During a medication administration observation on 01/09/24, at 08:51 a.m., LVN 6 was observed placing the shared BP cuff on top of the medication cart without cleaning or disinfecting it after checking Resident 52's BP. During an interview on 01/09/24, at 9:08 a.m., LVN 6 stated she was not informed by the facility staff that blood pressure cuff should be disinfected after use. During an interview on 01/09/24, at 09:37 a.m., the Director of Staff Development/Infection Preventionist (DSD/IP) stated the BP cuff should be disinfected between resident use. A review of facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised in September 2022, P&P indicated, c(1) Non-critical resident-care items (are those that come in contact with intact skin but not mucous membranes) include bedpans, blood pressure cuffs .; 5. Reusable items are cleaned and decontaminated (the process of removing contaminants on an object or area, including chemicals, micro-organisms, or radioactive substances) or sterilized (any process that removes, kills, or deactivates all forms of life and other biological agents present in or on a specific surface, object, or fluid) between residents. 2. During the medication administration observation on 01/08/24, at 12:22 p.m., LVN 1 was observed wiping down the shared glucometer (medical equipment used to measure and display the amount of sugar (glucose) in the blood) with an alcohol prep pad (an antiseptic wipe saturated with 70% isopropyl alcohol) prior to checking Resident 24's blood sugar. She stated the glucometer is being shared among residents receiving BS checks. Shortly after the medication administration for Resident 24, on 01/08/24, at 12:27 p.m., LVN 1 was observed wiping down the shared glucometer with an alcohol prep pad after checking Resident 24's blood sugar. During an interview on 01/08/24, at 12:33 p.m., LVN 1 stated she has been using alcohol prep pad since morning to disinfect the shared glucometer. LVN 1 acknowledged she should have used the Micro-kill Germicidal (to kill germs) wipes to disinfect the glucometer, and that alcohol does not kill all bacteria or viruses. LVN 1 stated she did not receive orientation or training from the facility of what disinfecting wipes to use and has been using alcohol prep pad based on experience. During a concurrent medication administration observation and interview on 01/09/24, at 09:08 a.m., LVN 6 was observed wiping down the shared glucometer with an alcohol prep pad after checking Resident 52's blood sugar. LVN 6 stated she was not oriented as to what type of disinfectant wipe to use for shared glucometer, and there were no germicidal wipes available in the medication cart. During an interview on 01/09/24, at 09:37 a.m., the Director of Nursing (DON) and the DSD/IP stated the alcohol prep pad was not acceptable for cleaning/disinfecting shared glucometers, and the staff should use the disinfecting wipes based on the manufacturer's guidelines. A review of glucometer manufacturer's guidelines indicated the list of validated products for disinfecting the device, and alcohol prep pad is not included in the list. A review of facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised in September 2022, P&P indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Prevention and Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen (microorganisms such as viruses or bacteria that are carried in blood and can cause disease in people) Standard; 5. Reusable items are cleaned and decontaminated or sterilized between residents. A review of an online publication by the CDC titled Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration, reviewed 3/2/11, indicated, The disinfection solvent should be effective against HIV, Hepatitis C, and Hepatitis B virus . 70% ethanol solutions are not effective against viral bloodborne pathogens . Healthcare personnel should consult the manufacturers of blood glucose meters in use at their facilities to determine what products, meeting the criteria specified by the FDA, are compatible with their meter prior to using any EPA-registered disinfectant for disinfection purposes. (https://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html; accessed 1/18/24). 3. A review of Resident 25's admission record indicated Resident 25 was admitted in 2018 for hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), neuromuscular dysfunction (loss of muscle control due to nerve dysfunction) of the bladder and need for assistance with personal care. A record review of Resident 25's minimum data set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 10/12/23, indicated Resident 25 was dependent on the staff for toileting hygiene. A record review of Resident 25's care plan titled, The resident has a foley catheter (tube inserted thru the urethra to drain bladder) related to neurogenic bladder (loss of control of bladder function), dated 12/22/23, was reviewed. The care plan indicated staff ensure privacy cover is placed on foley bag (bag to contain urine from foley catheter.) During a review of Resident 25's physician order set titled, Order Summary Report, dated 1/10/24, the order set indicated Resident 25 had an order for foley catheter daily care. During an observation on 1/8/24, at 10:00 a.m., Resident 25 was in his room lying in bed with the covers over him. Resident 25 had a foley catheter in place. The foley catheter tubing was lying directly on the ground and the foley bag was hanging on the side of the bed without a privacy cover. During a concurrent observation and interview, on 1/9/24, at 2:30 p.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 25 was in his room lying in bed with the covers over him. Resident 25 had a foley catheter in place. LVN 4 observed the foley catheter tubing lying directly on the ground. The foley bag had a privacy cover, but was lying directly on the ground. LVN 4 picked up the foley bag and hung it on the side of the bed. LVN 4 then picked up the catheter tubing and affixed it to the bed in a way it was no longer lying directly on the floor. LVN 4 stated the foley bag and tubing needed to be off the ground to prevent urinary tract infection (UTI). LVN 4 stated she did not know how the tubing and bag got on the floor. During an interview on 1/11/24, at 2:45 p.m., with Infection Preventionist (IP), IP stated staff were expected to check proper placement of resident foley catheter equipment at least every shift and when providing incontinence care. IP stated the foley bag should have a privacy cover and tubing should be off the ground at all times to prevent UTI. During a review of facility policy and procedure (P&P) titled, Care of Catheters, undated, the P&P indicated staff always keep catheter collection bag in a privacy bag make sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review, the facility failed to ensure essential kitchen equipment was in operational working condition when: 1. The right hand side of double oven unit was not operational. 2. A plate warmer was not operational. Findings: In a concurrent interview and observation on 1/9/24, at 09:20 a.m., [NAME] 1 stated that the right side of the oven was broken for about three months, making it difficult for her to cook all necessary food at times. [NAME] 1 also stated that the Dietary Supervisor (DS) was aware part of the oven was not working. [NAME] 1 stated that the plate warmer was broken for two days. In an interview on 1/10/24, at 10:50 a.m., with the Maintenance Supervisor (MS) in the kitchen, MS stated maintenance issues are communicated to him through a group chat via phone, and also via a maintenance binder located in two nursing stations. In a concurrent interview and observation on 1/10/24, at 11:47 a.m., in the kitchen, [NAME] 2 stated she told someone that the oven was not working about two weeks ago. DS stated an outside company came to the facility to fix the oven more than two weeks ago. MS stated he was not aware the oven or plate warmer was broken and he would be responsible for fixing the equipment if the issues with the equipment were not major. MS looked at the oven and confirmed one side was not working. MS said the pilot was not on. In In interview on 1/10/24, at 3:30 p.m., in Administrator (ADM) office, the ADM stated he was not aware that part of the oven or the plate warmer was not working, and that when equipment broke it should be documented in the maintenance log, and staff should let a manager know. He also stated he was not aware an outside company was in the kitchen at any point to repair the oven. In an interview on 1/11/24, at 9:50 a.m., with the Registered Dietician (RD), the RD stated she was not aware that the plate warmer was broken, and that she was aware the oven was not working, but thought it was fixed weeks ago, according to the DS. In an interview on 1/11/24, at 10:32 a.m., with the DS, the DS stated the oven was broken and fixed a while ago, and she would look for a repair receipt to validate this. DS stated there was no documentation to show that the plate warmer was reported broken, but discussed the problem with the MS and the ADM. DS stated she told the ADM that a new plate warmer should be purchased. DS also stated when equipment is broken, it should be entered into the maintenance log, but that she had never done that. It was noted that DS did not provide a receipt/invoice to show the oven was repaired. In a policy and procedure (P&P) document titled, Work Orders, Maintenance, revised 4/2010, P&P indicated that maintenance orders shall be completed in order to establish a priority of maintenance service, and: 1. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director. 2. It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director. 3. A supply of work orders is maintained at each nurses station. 4. Work order requests should be placed in the appropriate file basket at the nurses station. Work orders are picked up daily. 5. Emergency requests will be given priority in making necessary repairs. In a P & P document titled, Maintenance Service, revised 12/2009, P&P indicated, The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 69 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). Review of the job description titled Dietary Supervisor signed by the Dietary Supervisor (DS) on 10/1/23, showed This position must provide supervision for the Dietary Department, ensuring quality food. The Dietary Supervisor will direct and assist the preparation and service of regular meals and therapeutic diets, order food and supplies, maintain area and equipment in sanitary condition, and assure the smooth operation with other nursing facilities departments. During the Re-certification Survey from 1/8/24-1/12/24, multiple issues were identified regarding Food and Nutrition staff competency (Cross-reference F802); following he planned menu (Cross-reference F803); providing palatable food (Cross-reference F804); serving substitution food and drink of equal nutritive value (Cross-reference F806); ensuring food was stored, prepared, and served in a safe and sanitary manner (Cross-reference F812). In an interview on 1/8/24 at 10:10 a.m., DS stated she was the full-time kitchen supervisor. She stated she was not qualified for the position and said she was working toward becoming a Certified Dietary Manager (CDM). DS stated she was finished with her coursework for the CDM, but still needed to take the exam to become certified. In an interview on 1/10/24 at 10 a.m., the Registered Dietitian (RD) stated she worked at this facility and another facility. She stated she was worked at the facilities from 8:30 a.m., to about 5 p.m., and split time between the facilities so she was at this facility about 20 hours a week. In an interview on 1/11/24 at 9:50 a.m., the RD stated her typical day and/or week included participating in the facility stand-up meeting in the morning where she might learn about things pertinent to her, such as resident Change of Conditions (COC), weight loss, swallowing issues, and dietary preferences. She stated she did nutrition assessments for new admissions, and MDS (Minimum Data Set; a tool for implementing standardized assessment and for facilitating care management) annual and quarterly assessments. The RD stated she also did any consults requested by a doctor. The RD stated most of her daily/weekly work was clinical, not kitchen related. The RD stated DS informed her if there were issues in the kitchen than needed to be addressed. In an interview on 1/11/24 at 11:50 a.m., the Administrator stated he just reviewed DS's qualifications and coursework and found she did not have documentation of coursework toward a CDM certification.

Based on observation, interview and record review, the facility failed to ensure the menu was followed when: 1. An entrée on the menu was not prepared because an ingredient was not purchased. 2. Diet salad dressing was not purchased and was on the lunch menu for residents on a Heart Healthy diet. This failure had to the potential to result in resident dissatisfaction of meals and/or the residents not receiving the appropriate nutrients as set forth by the planned menu for 69 residents who received food from the kitchen. Findings: A review of the facility policy and procedure (P&P) titled, Substitutions, revised 4/2007, indicated substitutions should only be made when unavoidable. A review of the job description titled, Dietary Supervisor, signed by the Dietary Supervisor (DS) on 10/1/23, indicated the DS will direct and assist the preparation of regular and therapeutic diets. The DS is responsible for meeting the quality and quantity of food to meet each resident's needs in accordance with physician order in compliance with approved menus. In addition, the DS is responsible for transmitting orders for appropriate food and supplies. 1. During a review of kitchen document titled, Winter Menu, the lunch menu for 1/9/24 indicated maple chicken was to be served for all diets. In addition, cornbread dressing and poultry gravy was to be served to all residents except for residents on a Consistent Carbohydrate diet (CCHO, typically prescribed to promote blood sugar control), Heart Healthy diet (typically prescribed when a person has or is at risk for heart disease) and Renal diet (typically prescribed to a person with kidney disease). During a concurrent observation and interview on 1/9/24, at 9:20 a.m., [NAME] 1 prepared lunch and stated the lunch being served was teriyaki chicken, rice, and carrots. [NAME] 1 confirmed the menu indicated maple chicken was the entrée and said teriyaki chicken was substituted because the kitchen was out of chicken thighs and only diced chicken was available. [NAME] 1 stated she used diced chicken to prepare the teriyaki chicken. She also said rice was being served instead of cornbread stuffing to go with the chicken teriyaki. A review of the recipe titled, Maple Chicken, dated Winter 2023-24 Week 1, indicated ingredients included, but were not limited to, chicken thighs with bone and maple syrup. A review of the recipe titled, Chicken Teriyaki, dated Fall 2023 Week 3, indicated ingredients included, but were not limited to, chicken thighs with bone. During an interview on 1/10/24, at 9:49 a.m., with DS, DS stated the lunch menu entrée was changed on 1/9/24 because the kitchen was out of chicken thighs and diced chicken was in stock. When the surveyor pointed out the teriyaki chicken recipe also called for chicken thighs, the DS stated they were also out of maple syrup. The DS stated food deliveries from the food supply vendor were on Tuesdays and Fridays. DS stated when the food order was placed on 1/4/24, maple syrup was not available to order from the food supply vendor for the Friday food delivery. The DS stated she could go to the local grocery store to get needed items if the Administrator (ADM) was on-site so she could get his credit card to use for the purchase. During an interview on 1/11/24, at 9:40 a.m., with the Registered Dietitian (RD), when asked if maple syrup was available, would the entrée have been changed from Maple Chicken to Teriyaki chicken for lunch on 1/9/24. The RD stated the menu still had to be changed because the facility was out of chicken thighs. When the surveyor pointed out chicken thighs were called for in the recipe for Maple Chicken and Teriyaki Chicken, she stated she guessed if maple syrup was available, the Maple Chicken could have been prepared. During an interview on 1/12/24, at 9:56 a.m., with ADM, ADM stated he was on-site at the facility on 1/5/24, 1/8/24, and during 1/9/24 and was not approached regarding the necessity to get items from the grocery store or lunch menu preparation. The ADM stated DS had ample time to purchase maple syrup from the grocery store for preparation of lunch on 1/9/24. The ADM also stated the DS had purchased needed items from the local grocery store in the past using her own funds and had been reimbursed by the facility. 2. During a review of kitchen document titled, Winter Menu, the lunch menu for 1/9/24 indicated residents on a Heart Healthy diet received diet dressing with the salad. During an observation on 1/9/24, at 11:15 a.m., kitchen staff prepared lunch trays for residents. Trays with a tray ticket which indicated residents were on a Heart Healthy diet received the same salad dressing as those with Regular diets (a diet without therapeutic restrictions). During an interview on 1/9/24, at 11:30 a.m., with Dietary Aide 1 (DA 1), all residents received the same Caesar dressing and DA confirmed diet dressing was not available. During an interview on 1/9/24, at 11:37 a.m., with RD and DS, the RD confirmed diet dressing was on the menu for Heart Healthy diets and stated she was not aware residents were not receiving diet dressing when it was on the menu. The DS stated she did not order diet dressings.

Based on observation, interviews, and record review, the facility failed to ensure food was palatable when recipes were not followed and foods were bland, as well as over-seasoned. This deficient practice placed 69 residents who received food from the kitchen at risk for decreased nutrient intake leading to nutrition related medical complications. Findings: During an interview on 1/8/24, at 10:50 a.m., Resident 10 stated the food at the facility was bad. During an interview on 1/8/24, at 10:55 a.m., Resident 41 stated the food sucks. During an interview on 1/8/24, at 3:00 p.m., Resident 48 stated the food is not good. During a record review of recipe titled, Chicken Teriyaki, dated 8/21/23, the ingredients for the sauce included pineapple juice, water, soy sauce (low sodium), garlic powder, ginger ground, brown sugar, cornstarch, and water. During a record review of recipe titled, Carrots with Dill, dated 12/6/23, the ingredients included sliced frozen carrots, dill weed, seasoned salt, and margarine. During a record review of recipe titled, Rice, Steamed, dated 12/6/23, the ingredients included long grain white rice, salt, white pepper, and boiling water. During a concurrent observation and interview on 1/9/24, at 9:20 a.m., [NAME] 1 prepared chicken teriyaki for the lunch meal. [NAME] 1 stated the ingredients she used to prepare the teriyaki chicken were diced chicken and one bottle of ready-made teriyaki glaze. [NAME] 1 stated she was not following the standardized recipe for the teriyaki chicken. [NAME] 1 stated she also prepared white rice, and carrots. [NAME] 1 stated the ingredients she used for the carrots were carrots, dill, and butter. On 1/9/24, at 12:55 p.m., a sample test tray with regular and pureed consistency lunch items were tasted by two surveyors, the Registered Dietitian (RD), and the Dietary Supervisor (DS). The surveyors stated the regular textured carrots had a slight dill and butter taste but were still bland, and the pureed carrots did not have a dill or butter taste and were bland. The surveyors stated both the regular texture and pureed rice were bland. The RD stated the carrots and rice were bland. The DS stated additional salt was not added in food preparation, even if called for in the recipe. Both surveyors agreed that regular and pureed chicken teriyaki was very salty. In an interview on 1/10/24, at 9:49 a.m., DS stated all foods were made without adding salt to try to cater to all residents including residents on regular and no added salt diets. She stated if residents wanted to add salt to their food, they could use the salt packet provided on the meal tray. DS stated recipes should be followed. DS stated if salt was in the recipe, maybe the cook could add some salt, but not enough to taste any salt. In an interview on 1/10/24, at 10:00 a.m., the RD stated recipes should be followed. In an interview on 1/11/24, at 9:50 a.m., the RD stated she was not aware ready-made teriyaki sauce was used in place of following the recipe. She agreed the nutrient content could be different if a ready-made sauce was used in place of following the recipe. The RD stated she did not approve or was asked about using ready-made items. During a recipe review of kitchen document titled, Standardized Recipes, dated 4/2007, the document indicated, Only tested, standardized recipes will be used to prepare foods. A review of the job description titled, Cook Department: Dietary, signed by [NAME] 1 on 11/5/15, indicated the cook position essential functions included, but were not limited to: follow recipes and prepare foods that correspond to the menu cycles and recipes; and prepare palatable, nutritionally adequate meals according to the diet type. A review of the job description titled, Dietary Supervisor, signed by DS on 10/1/23, indicated the DS position was responsible for directing and participating in food preparation and service of food that is safe and appetizing and is of the quality and quantity to meet each resident's needs in accordance with physician's order in compliance with approved menus. A review of the job description titled, Registered Dietitian, signed by RD on 7/5/23, indicated the RD was responsible for assisting the coordination of nutrition care services with the DS; monitoring food services operations to ensure nutritional and quality standards; and monitoring food control systems such as preparation methods to ensure food was prepared in an acceptable manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner when: 1. A resident's (Resident 1) personal refrigerator was not monitored for temperature, food expiration dates, and cleanliness. 2. Unpasteurized (not heated to kill dangerous pathogens which can cause foodborne illness), undercooked eggs were served to a resident. 3. Two of two ice machines were not clean. 4. Prepared, leftover Time/Temperature Control for Safety (TCS) food (food requiring time and temperature controls to limit the growth of illness causing bacteria) was not monitored for cooldown. 5. Refrigerated TCS food was not labeled to show when it was to be used-by or discarded. 6. Frozen raw fish stored in the freezer was not covered and open to air. 7. A kitchen staff member did not follow hand hygiene practices. 8. Surface sanitizer solution was not at the appropriate temperature for testing the sanitizer strength. 9. Kitchen walls, ceilings, cabinets, tray-line preparation table, light fixtures, vents, a portable air conditioner filter, and equipment were not clean. 10. Walls, ceilings, the dry food storeroom floor, and the handwashing sink area were not maintained in good repair. 11. Food preparation and food service equipment stored for use were not clean. 12. An industrial can opener was not maintained clean. 13. The microwave was not maintained clean and in good repair. 14. A scoop was stored inside of a bulk storage bin containing rice. 15. Ready-to-eat food came into contact with equipment that was not cleaned and sanitized. These failures placed 69 residents who received food from the kitchen, at risk for food-borne illnesses. Findings: 1. In an interview on 1/10/24, at 2:30 p.m., Licensed Vocational Nurse (LVN) 5 stated there was one resident, Resident 1, in the facility who had a refrigerator to store food brought in by family and/or visitors. LVN 5 stated the refrigerator was located in Resident 1's room. A record review for Resident 1 indicated Resident 1 was [AGE] years old and initially admitted on [DATE]. Diagnoses included but were not limited to paraplegia, muscle weakness, and need for assistance with personal care. During an observation and concurrent interview on 1/10/24, at 2:40 p.m., with Resident 1, Resident 1 was awake and lying in bed with the lights off, and the room was dark. Resident 1 stated it was okay to look inside the small refrigerator/freezer unit stored on the floor in the middle of the room. When the refrigerator was opened, there was a stale food odor. There was no light in the refrigerator, so a flashlight was used to view the contents. The refrigerator was packed with a variety of foods. There was a large plastic grocery bag stored on the bottom shelf. The bag had brown and yellow residue on the surface and the plastic was fraying. There was tape on the inside surface of the bag with brown residue imbedded in the tape. There were several items in the bag including a reusable container with a clear plastic lid, holding food which appeared to be some type of unidentifiable cooked food. There was no label on the container to show what the food was, when it was made, or when to use-by. Also in the bag, was a store bought container of raw milk cheese and the container lid showed perishable, keep refrigerated. There were a couple unlabeled, undated small reusable containers with unidentifiable contents. Food items stored on the top shelf of the refrigerator included a container cream cheese, a package of cheese, and a container of cottage cheese. In the door shelf, there was an opened container of half and half. The shelving and the inside walls of the refrigerator had a significant amount of black and brown residue on the surfaces. A thermometer was not located in the refrigerator. Resident 1 stated her son brought her food twice a month. Resident 1 stated her son cleaned the refrigerator. She stated she only liked to eat her own food and did not like the facility food. During an interview on 1/10/24, at 3:14 p.m., the Director of Staff Development (DSD) stated food brought in for residents from family and visitors could be stored up to 72 hours. DSD confirmed resident 1 had a refrigerator in her room. When the DSD was asked who was responsible for monitoring the refrigerator and cleaning it, she did not know and said she would get back with that information after she looked into it. On 1/10/24, at 3:30 p.m., Resident 1's refrigerator located in her room was observed with the DSD. The DSD stated she could not locate a thermometer inside the refrigerator. The DSD opened the freezer compartment and there were several fillets of raw, frozen fish wrapped in plastic with no dates to identify how long the fish was stored. Resident 1 confirmed there was raw fish stored in her refrigerator. When the DSD was asked her thoughts about the cleanliness of the refrigerator, she did not answer. During an interview on 1/11/24, at 11:50 a.m., the administrator (ADM) stated all of Resident 1's food stored in her refrigerator/freezer was discarded because it was not labeled and dated to determine how long it was stored in the refrigerator. A review of the facility Policy and Procedure (P&P) titled, Foods Brought by Family/Visitors, revised March 2023, indicated food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Family members are asked to inform nursing staff when foods are brought for a resident. Food brought by family/visitors that is left with the resident to consume later is labeled. Perishable foods are stored in re-sealable containers that are labeled with a use-by date. The nursing staff will discard perishable foods on or before the use-by date. A review of the facility P&P titled, Refrigerators and Freezers, revised 11/2022, indicated the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration dates. Refrigerators keep food at or below 41 degrees Fahrenheit (F). Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. All food is appropriately dated to ensure proper rotation by expiration dates. Use-by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use-by dates are indicated once food is opened. Supervisors are responsible for ensuring food items in refrigerators and freezers are not past use-by or expiration dates. Refrigerators and freezers are kept clean, free of debris, and sanitized on a scheduled basis and more often if necessary. 2. During an observation during the initial tour of the kitchen on 1/8/24, starting at 10: 10 a.m., a large box of raw, shell eggs were stored in a kitchen reach-in refrigerator. The box did not indicate the eggs were pasteurized and there was no marking on the eggs to show they were pasteurized. During an interview and concurrent observation on 1/9/24, at 9:20 a.m., [NAME] 1 confirmed the large box of eggs in the reach-in refrigerator were unpasteurized eggs and she used the unpasteurized eggs for fried eggs for resident breakfasts. During an interview on 1/9/24, at 10:37 a.m., with the Registered Dietitian (RD) and the Dietary Supervisor (DS), DS and RD stated runny eggs were served to residents upon request. DS stated one resident (Resident 17) asked for runny eggs this morning and runny eggs were prepared and served for Resident 17. DS stated the white part of the egg was cooked but the yoke was runny. During a concurrent interview and observation in the dry storeroom on 1/10/24 at 11:35 a.m., with RD and DS, RD stated the raw, shell eggs ordered and used to cook runny eggs should be pasteurized. When the RD looked at the eggs stored in the reach-in refrigerator, she confirmed the eggs were not pasteurized. The DS stated she thought the eggs she ordered were pasteurized. DS also looked at the eggs in the refrigerator and confirmed they were not pasteurized. When the DS was asked if it was okay to serve undercooked, unpasteurized eggs, she stated she needed to look into it. The RD stated unpasteurized, undercooked eggs should not be served to residents because the residents were immunocompromised and could get very sick. A review of the P&P titled, Food Preparation and Service, revised 2022 showed only pasteurized shell eggs are cooked and served when residents request undercooked, soft-served, or sunny side up eggs. 3. An observation during an initial tour of the kitchen and a concurrent interview with DS on 1/8/24, starting at 10:10 a.m., indicated an ice machine located in the kitchen. A flashlight was used to look into the ice chute. Pink residue was visible on the inner surface of the ice chute. A white napkin was used to wipe the inside of the ice chute and pink, slimy, moist residue wiped off onto the napkin. DS confirmed there was pink, slimy residue on the inner surface of the ice chute. During a concurrent observation and interview on 1/10/24, at 10:50 a.m., the Maintenance Staff (MS) stated he began working at the facility this past December, and he had not yet cleaned this ice machine. MS stated he believed ice machines should be cleaned monthly with hot water and food-safe sanitizer, and an outside company would clean inside the unit with chemicals. MS opened the ice machine so the inside could be viewed. There was brown residue on the outer surface of the evaporator plate (a metal grid component where water runs over and ice freezes and is formed) plastic cover. MS removed the evaporator plate cover, and the majority of the inside surface was covered with pink residue. The plastic around the evaporator plate had pink, black, and brown residue on the surface. In addition, the tray below the evaporator plate had brown and pink residue on the underneath surface which faced the bin holding formed ice. Review of manufacturer's manual for the ice machine titled, [Model Name] Ice Machines Installation, Operation and Maintenance Manual, revised 02/9/17, showed the ice machine was to be cleaned and sanitized every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing. An observation and interview with RD on 1/10/24, at 11:40 a.m., showed an ice machine (Ice Machine #2) located in a room used to store single use food service items and was also used as the RD's office. The RD stated she did not think the ice machine was in service, however it was turned on and full of ice. Black and pink residue was visible inside ice chute and bin unit, and the residue came off on a white napkin when the inside of the chute was wiped down. During an interview with Certified Nursing Assistant 3 (CNA 3) on 1/10/24, at 2:26 p.m., CNA 3 stated she usually retrieved ice for residents from the ice machine in the ice machine room and pointed in direction of RD office. During an interview on 1/10/24, at 2:27 p.m., CNA 4 stated she usually received ice for residents from the ice machine located in the room where the RD's office was located. She stated she received ice for residents from that ice machine yesterday (1/9/24) but was told not to use it today. During an interview with CNA 2 on 1/10/24, at 2:28 p.m., CNA 2 stated he usually got ice for residents from the ice machine located in RD's office. Review of manufacturer's manual for the ice machine located in the RD's office titled [Ice Machine Brand] Ice Systems Installation and User Manual dated 2/2014, showed it was the user responsibility to keep the ice machine and ice storage in a sanitary condition. Without human intervention, sanitation would not be maintained. Sanitize the ice storage bin as frequently as local health codes require, and every time the ice machine is cleaned and sanitized. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch. 4. An observation and interview during the initial tour of the kitchen on 1/8/24, at 10:45 a.m., showed inside a reach-in refrigerator was a metal container holding breakfast sausage, a brown ground substance, and bacon. The container was covered with foil and had 1/8/24 handwritten on the foil. [NAME] 1 stated the meat was left over from the breakfast trayline and she saved the items to use as an alternate food for residents. She said the brown, ground substance in the container was ground sausage. Temperatures of the food were measured with the surveyor's calibrated thermometer. The sausage was 49.8 degrees Fahrenheit (F), and the ground sausage was 44.4 degrees F. [NAME] 1 stated she placed the meat in the refrigerator after the breakfast trayline, about 8:30 a.m. She stated she did not monitor or document cooldown temperatures for the leftover meat. In an interview on 1/8/24, at 2:40 p.m., DS stated any leftovers should be monitored for cooldown, such as the breakfast sausage. In an interview on 1/10/24, at 10 a.m., when the surveyor asked to view the cooldown log, DS stated she did not know where the cook kept the log. DS stated she typically reviewed all logs but said the cooks did not cool food. DS stated she was not aware cooks were cooling breakfast meat such as sausage. During an interview and observation in the kitchen with DS, on 1/10/24, at 11:30 a.m., a metal container containing chopped, cooked meat was stored in the reach-in refrigerator. The container was covered with foil and a handwritten label showed, Beef 1/9/24, 1/10/24. DS confirmed the meat was cooked at the facility and left over and could be used as an alternate food. She stated the meat should be on the cooldown log. DS stated she was not aware the leftover cooked meat was stored in the refrigerator. DS stated there was not a cooldown log available to show the meat was cooled safely. A record review of document titled, Food Receiving and Storage, revised 11/2022, showed Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 F to 70 F within two hours, and then to a temperature of 41 F or below within the next four hours. The total cooling time between 135 F and 41 F is not to exceed six hours. According to U.S. Food and Drug Administration Federal Food Code 2022, the person in charge must ensure that employees are using proper methods to rapidly cool TCS foods that are not held hot or are not for consumption within 4 hours, through daily oversight of the employees routine monitoring of food temperatures during cooling. 5. An interview and observation during the initial tour of the kitchen with DS, on 1/8/24, starting at 10:10 a.m., showed an opened, half-full plastic container of tuna salad stored in a reach-in refrigerator with 11/28 handwritten on the lid. The DS stated the tuna salad was safe to eat until the expiration date on the container, which she stated she could not read because it was rubbed off. In an interview and observation on 1/8/24, at 2:40 p.m., DS stated the 11/28 date written on the tuna container lid was the date the tuna was received. She reviewed multiple lists posted in the refrigerator/dry food storage room which showed food storage times. She stated tuna salad was not on the lists. DS could not answer how long tuna salad could be stored once the container was opened. During an observation and interview with DS, in the kitchen, on 1/10/24, at 10:30 a.m., a half-full gallon container of milk was observed in the kitchen refrigerator, and there was no opened-date label. The DS stated that milk was safe to be used until the manufacturer's expiration date printed on the container and did not need an opened-date label on it. In an interview on 1/12/24, at 11:20 a.m., DS stated she looked up tuna salad on the USDA (United States Department of Agriculture) website which showed tuna salad could be stored for three to five days. She stated all websites she saw gave the same information about tuna salad storage time. Review of the policy and procedure titled, Refrigerators and Freezers, revised 11/2022, showed the facility will ensure safe refrigerator and freezer maintenance and will observe food expiration dates. All food is appropriately dated to ensure proper rotation by expiration dates. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. Supervisors are responsible for ensuring food items in refrigerators are not past use by or expiration dates. 6. An observation and interview during the initial tour of the kitchen on 1/8/24, starting at 10:10 a.m., showed a box containing six, raw fish filets stored in a reach-in freezer. The box was not sealed with fish open to air (not securely wrapped in plastic). DS confirmed the fish was not covered and stated the box containing the fish should be closed. Review of P & P titled, Food Receiving and Storage, revised 11/2022, showed all foods stored in the freezer are to be covered. 7. During an observation on 1/9/24, at 9:30 a.m., Dietary Aide 1 (DA 1) entered the kitchen. She washed and dried her hands, then touched the lid of a garbage container, located at the dirty side of the dish machine, to throw away a paper towel. DA 1 then put on gloves and began to handle clean plates and pots/pans from the clean side of the dish machine. In an interview on 1/9/24, at 9:35 a.m., DS stated the garbage container at the dirty side of the dish machine was used by the person at the dirty side of the dish machine without handling the soiled dishes. According to the U.S. Food and Drug Administration Federal Food Code 2022, food employees are to wash their hands and exposed portions of their arms immediately before working with clean equipment and utensils and after handling soiled equipment, before donning gloves, and after engaging in activities that contaminate the hands. 8. During an interview and observation in the kitchen, on 1/9/24, at 9:57 a.m., [NAME] 1 demonstrated how to test the surface sanitizer strength. [NAME] 1 filled a red bucket with a solution dispensed from a hose above the three-compartment sink. [NAME] 1 dipped a quaternary ammonia test strip into the solution then removed the strip and compared to the color chart located in the test strip container. [NAME] 1 stated she never measured the temperature of the solution. The temperature of the solution was measured with a surveyor's calibrated thermometer and was 60.2 degrees F. During an observation in the kitchen and interview with DS on 1/10/24, at 10:00 a.m., DS described how to test the surface sanitizer solution for proper strength using test strips. When asked what temperature the sanitizer should be, DS stated the sanitizer solution should be between 65-75 degrees F when testing the strength of the sanitizer solution according to the instructions in the test strip container. DS filled a red bucket to test the strength of the sanitizer. The temperature of the solution was measured and was 58 degrees F. She stated she had to call the outside vendor to adjust the temperature of the dispensed solution. Review of quaternary ammonia test strip instructions located inside the test strip container, for the test strips used by [NAME] 1 and DS, showed when testing the sanitizer solution, the solution temperature should be between 65 and 75 degrees F. 9. An observation during the initial kitchen tour of the kitchen, on 1/8/24, starting at 10:10 a.m., showed gray, fuzzy buildup on the kitchen ceilings in the food preparation areas, on the surface of a large ceiling vent, on the ceiling sprinklers located in the dry food storeroom, on the portable air conditioner vent tubing, on ceiling light fixtures in the food preparation area and in the dry storeroom, on top of oven back surface, in the vent of the juice machine, and on various conduit for electrical wiring. A consecutive observation during the initial tour of the kitchen, on 1/8/24, starting at 10:10 a.m., showed multiple cabinets holding items such as single use food service utensils, boxes of parchment paper, and clean rags, located along the back wall of the kitchen under food preparation counters, had residue brown and black sticky residue build-up on the inside of cabinet doors as well as loose particles on the surface of the shelving inside the cabinets. The cabinets also had peeling paint on the inside surfaces. In a consecutive observation and interview with DS during the initial tour of the kitchen on 1/8/24, starting at 10:10 a.m., DS stated cabinets should be wiped down daily. She looked at the cleaning schedule which showed drawers should be cleaned twice a week. DS stated cabinets were not on the cleaning schedule. DS stated the sign-off on the cleaning schedule showed [NAME] 1 cleaned the drawers which meant she also cleaned the cabinets. DS stated kitchen staff cleaned the walls and maintenance was responsible for cleaning vents and filters. In an interview and observation on 1/8/24, at 2:40 p.m., DS looked at areas around the kitchen such as the surface of the top, back stove area, cords, and plugs above a reach-in refrigerator in the food preparation kitchen area, and the wall beside reach in refrigerator, and confirmed there was gray, fuzzy residue in these areas. She stated the build-up was dust. DS stated kitchen staff were not really responsible for cleaning these areas. She stated kitchen staff were responsible for cleaning higher traffic areas such as counters. In an interview and observation on 1/9/24, at 9:25 a.m., [NAME] 1 opened the cabinet doors under the preparation table along the wall at the back of the kitchen. [NAME] 1 stated when she cleaned the cabinets, she did not clean the inside, she only wiped down the outside surface of the cabinets. An observation on 1/9/24, at 9:57 a.m., showed a gap between two tray-line tables with what resembled food crumbs, and brown residue imbedded in the gaps. In addition, a light colored block, was used to assemble the trayline shelving and the block created a crevice between the block and a hot water well. There was brown build-up imbedded in the crevice, resembling food residue and crumbs. In an interview and observation with MS on 1/10/24, at 11:05 a.m., MS stated staff were supposed to document maintenance needs in a maintenance binder located in 2 nursing stations. MS stated he was not aware there were vents and filters in the kitchen areas that needed cleaning because he was not in the kitchen much since he just started working for the facility in December. He stated he was not informed the vents and filters were dirty. He said anything that had a filter, he was responsible for cleaning and/or fixing. MS stated vents, ceilings, walls, equipment, without filters should be cleaned by housekeeping staff and/or kitchen staff. He stated he would help with the cleaning if he was asked. MS stated and confirmed there were dusty vents in the kitchen areas. MS stated he removed the filter from the portable air conditioning (AC) unit located in the dry food storeroom yesterday (1/9/24) and the filter was very dusty. MS1 stated filters should be cleaned every three months. He stated there were no logs to show when the AC filter was cleaned prior to his cleaning yesterday. MS confirmed light fixtures throughout the kitchen were dusty. MS also confirmed the ceilings were dusty. In an interview and observation on 1/10/24, at 11:33 a.m., MS looked at the block holding up the stainless steel shelving above the trayline. He confirmed the area around the block was dirty and there were imbedded particles between the two trayline tables. He stated the areas should be flush, so crumbs and residue did not collect. MS stated he did not think the trayline shelving was assembled correctly with the use of the block. He stated all the parts should be stainless steel and he thought the block holding up the shelving was silicone. Review of the policy and procedure titled, Sanitation, revised 11/2022, showed kitchen areas are kept clean, free from garbage and debris, and protected from rodents and insects. All counters, shelves, and equipment are to be kept clean, maintained in good repair and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Review of the policy and procedure titled, Departmental (Maintenance) - Plumbing, HVAC and Related Systems, revised 2011, showed to inspect air-conditioning unit drains and filters weekly. Change filters at least monthly during use. Clean air vents and air handling units at least annually. According to the 2022 Federal Food Code, food is to be protected by storing food where it is not exposed to dust; intake air ducts are to be cleaned so they are not a source of contamination by dust, dirt, and other material; equipment food-contact surfaces are to be clean to sight and touch; and nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, and other debris. 10. An observation during an initial tour of the kitchen on 1/8/24, starting at 10:10 a.m., showed white flecks of peeling paint on the kitchen ceiling in the food preparation area. Also, in the food preparation area above the trayline, a metal pole connected to the trayline counter, extended through a hole in the ceiling. The metal pole was at least one- inch in diameter and the holes in the ceiling was larger than the diameter of the hole, creating a gap. Around the hole, the ceiling was cracked and there was exposed drywall, peeling paint, and peeling tape. At the handwashing sink, caulking was missing where the sink came into contact with the wall creating a groove along the wall/sink area. There was brownish residue in the groove. In the dry food storeroom, there was peeling paint on the wall next to the reach-in freezer. Also, on the wall next to the reach-in freezer, the baseboard/molding was separated from the wall creating a large gap between the baseboard and the wall. There was dark brown residue on the wall in the gap area. In addition, three floor tiles were missing from dry food store-room floor, directly in-front of the refrigerator unit, creating a rough, uneven surface measuring one by three feet. During a concurrent interview with the DS during the initial tour of the kitchen on 1/8/24, starting at 10:10 a.m., DS stated she did not notice the maintenance issues such as peeling paint, baseboard pulling away from the wall, floor tiles missing. She stated she did not report these maintenance issues. She said when things in the kitchen were broken, she reported them to maintenance. In an interview and observation with MS, on 1/10/24, at 11:05 a.m., MS stated staff were supposed to document maintenance needs in a maintenance binder located in 2 nursing stations and/or communicate maintenance needs by phone in a group chat. MS stated he was not informed walls and ceilings in the kitchen had peeling paint, the baseboard was not attached to the wall, or floor tiles were missing. He also confirmed caulking was missing between the handwashing sink and the wall and it needed to be repaired. According to the 2022 Federal Food Code, the material for floors, walls, and ceilings are to be smooth, durable, and easily cleanable where food establishment operations are conducted. Smooth means a floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. Equipment that is fixed because it is not easily moveable is to be installed so the space adjoining equipment, walls, and ceilings is not more than one millimeter. Equipment exposed to spillage/seepage are to be sealed to adjoining equipment or walls. 11. An observation and concurrent interview with [NAME] 1 during an initial tour of the kitchen on 1/8/24, starting at 10:10 a.m., showed a shelf underneath a table where the juice machine was stored. The shelf held two crates with various pieces of equipment and utensils such as various sized, metal mixing bowls, metal lids for pans, and large muffin pans. Six of six muffin pans had brown, greasy to the touch residue on the surface. Five of five mixing bowls had residue and/or particles on the inside surface resembling food particles/residue. Five of five metal lids had brown, sticky residue on the surface. [NAME] 1 stated all the items were used for cooking and she stated they were dirty and needed to be washed again. As the initial tour continued, observation and interview on 1/8/24, starting at 10:10 a.m., showed a tall metal shelving rack between the table holding the juice machine and a reach-in refrigerator. The rack had various pieces of equipment and utensils stored on the shelves such as water/juice pitchers and cutting boards. The rack had plastic liners on the shelves. There were particles on the surface of the plastic liner resembling food crumbs. Two pitchers stored on the rack had a sticky residue on the outside surface and two of four cutting boards had a black sticky residue on the surface as well as scratches and cut grooves with pieces of white, plastic coating flaking off the surface. DS stated the cutting boards were not clean and confirmed they had pieces of coating peeling off. She also confirmed the outside surface of the pitchers were sticky and the pitchers were used for water and juice. As the initial tour continued, observation and interview on 1/8/24 starting at 10:10 a.m. showed a food processor was stored on a table next to the stove. [NAME] 1 stated the food processor was just cleaned in the dish machine. Inside the food processor bowl and on the inside surface of the bowl lid, there was white, wet residue. [NAME] 1 stated the food processor was not clean. As the initial tour continued, observation and interview on 1/8/24, starting at 10:10 a.m., showed a large mixer covered in plastic stored on a table next to the stove. The plastic covering the mixer was removed. Inside the bowl of the mixer was a yellow liquid equal to about a teaspoon in measurement. In addition, the mixing paddle and safety guard had brown residue on the surface resembling food residue. [NAME] 1 stated the mixing machine was used weekly. DS confirmed the mixer was not clean. In an interview and observation on 1/8/24, at 2:40 p.m., DS stated if items cleaned in the dish machine came out of the dish machine with residue still on them, the items should be scrubbed and rewashed. The tall metal rack with the plastic liners used to store clean equipment and utensils was viewed with the DS. She confirmed there was debris on the plastic lining and stated staff should wipe the plastic lining, but it was not on the cleaning schedule. An observation on 1/9/24, at 9:46 a.m., showed utensils and equipment hanging from a rack above the trayline area. A cheese grater hanging from the rack was sticky to the touch and had a layer of light, gray and white residue resembling dust on the outside surface. There was also orange residue resembling dried[TRUNCATED]

Based on interview and document review, the facility failed to have a refrigerator to store perishable food brought into the facility for residents by families and visitors. This failure to store perishable food belonging to residents had the potential for a decreased intake of food preferred by residents for 69 residents who ate food by mouth. Findings: In an interview on 1/10/24 at 2:35 p.m., Licensed Vocational Nurse (LVN) 5 stated when food was brought in by visitors and/or family members for a resident, staff encouraged the resident to eat the food and what was not eaten was trashed because there were no refrigerators to store resident food. She also stated there was not a microwave to heat resident food. In an interview on 1/10/24 at 3:14 p.m., the Director of Staff Development (DSD) stated food brought in for residents by family or visitors could be stored in a refrigerator for 72 hours. When she was asked which refrigerator the food was stored in, she stated the facility did not have a refrigerator to store resident food. The policy and procedure titled Food Brought by Family/Visitors revised 2022 was reviewed with the DSD in a consecutive interview on 1/10/24 at 3:16 p.m. The DSD confirmed the policy and procedure showed that perishable food brought in by family or visitors, to be consume later for the resident, would be stored for the resident in a refrigerator and nursing staff will label any stored perishable foods with a use by date. DSD confirmed the policy and procedure did not provide guidance on time frames for use by dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's representative was allowed to obtain a copy of the medical records within the required time frame. This failure had the potential to result in Resident 1's representative undue concern and anxiety on behalf of Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. During a review of the letter requesting medical records dated 8/23/23, the letter, addressed to the facility's Custodian of Records, indicated a request for Resident 1's medical records be sent through the following methods: -Contacting the requesting office at their phone number when medical records are located to schedule a copy appointment. -Emailing the records to the requesting office's email address. -Furnishing a copy via facsimile to the requesting office's fax number. -Mailing a copy of the records to the requesting office's mailing address. During a concurrent interview and review with Operations Manager & Director of Medical Records (OMDMR) on 9/20/23 at 11:38 a.m., the letter requesting for medical records was reviewed. OMDMR stated receiving the letter with the following documents: -Authorization to Handle Claim dated 8/21/23. -Authorization For The Release Of Patient Information. -Declaration of Resident 1's Representative as successor in interest to Resident 1. -Resident 1's Certificate of Death. OMDMR stated receiving the records request letter on her desk on 8/25/23, which was then sent to the facility's legal team on 8/26/23 for clearance. The request letter included a Notice to Subpoenaed Party that indicated the facility must comply with the request on or before 8/28/23. OMDMR stated receiving clearance from facility's legal team on 8/26/23 but did not begin to process the request until 8/28/23. OMDMR also stated the request was processed and access to Resident 1's medical records was available on 8/29/23 but did not send the medical records until 9/1/23. OMDMR could not show a fax confirmation for the medical records sent to the requesting office on 9/1/23. OMDMR stated Requesting Staff (RS) had called on 9/7/23 about the medical records that were not sent to their office. OMDMR stated Resident 1's medical records were sent again via email on 9/7/23. OMDMR stated, for residents who currently stay at the facility, medical records were provided within 48 hours of request, but for residents that were already discharged /were no longer at the facility, medical records could take some time because requests would have to be reviewed and cleared with the facility's legal team. During a telephone interview with RS on 9/20/23 at 9:47 a.m., RS stated making several follow-up calls to the facility several times after the request and subpoena (legal document compelling one to produce documents or records at a specified time) were sent. RS also stated, after many attempts to reach the facility's Custodian of Records, the requesting office received the medical records on 9/19/23, three weeks after the request and subpoena were sent. During a review of the facility's policy and procedure (P&P), undated, titled Medical Records Request Process Procedure, the P&P indicated to notify the Administrator and Director of Nursing (DON) of the request. The facility's P&P did not indicate a time frame in releasing medical records. During an interview with DON on 9/20/23 at 12:36 p.m., DON stated she was not aware of the medical records request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to arrange for a vision consult upon admission for one of 17 sampled residents (Resident 36). The failure to refer Resident 36 for eye care upon admission resulted in Resident 36 not receiving an eye exam on 3/30/22, during the routine eye care visit, with a subsequent delay in services for eleven additional weeks. This failure had the potential to result in impairment of Resident 36's vision. Findings: A review of Resident 36's face sheet, undated, indicated Resident 36 was admitted on [DATE], with a diagnosis of a fracture of nasal bones and a Le Fort I fracture (a horizontal facial fracture characterized by the separation of the hard palate from the upper jaw). The face sheet also indicated Resident 36 had a family member, RP, to act as a responsible party and emergency contact. A review of Resident 36's, Physician Order Report, dated 2/8/22, indicated, Consult-Vision for eye health with follow-up and treatment as indicated. A review of the facility document, Advanced Eyecare Doctor Summary Sheet, dated 3/30/22, indicated there were 22 residents examined by the optometrist; the examination list did not include Resident 36. During an interview on 6/15/22, at 12:20 p.m., with the Social Worker (SW), SW stated Resident 36 had not been placed on the list to be evaluated by the optometrist and therefore had not received an eye examination at the facility. During an interview on 6/15/22, at 1:38 p.m., with the Director of Nursing (DON), the DON stated Resident 36 should have been evaluated by the optometrist since there was an order from the physician for an optometry consult. The DON stated Resident 36 had not been entered onto the list for vision screening and had not received an eye health evaluation while at the facility. The DON stated it is the responsibility of the SW to enter residents' names onto the list to be screened by the optometrist. During a phone interview on 6/15/22, at 3:42 p.m., with RP, RP stated it was important for Resident 36 to have an eye examination. RP stated Resident 36 had fallen and broken multiple bones in his face, which had the potential to affect Resident 36's vision.

Based on observation, interview, and record review, the facility failed to follow the physician's orders to refer two of 17 sampled residents (Resident 2 and Resident 54) for podiatry (foot specialty) services. Resident 2 had no podiatry services for four months after one podiatry visit. Resident 54 had no referral for podiatry services for three weeks and three days following admission. These failures resulted in Resident 2 and Resident 54 developing long toenails which had the potential to result in skin breakdown/injury, infection, and amputation of toes and/or feet. Findings: A review of Resident 2's face sheet, undated, indicated an admission date in December 2021. The face sheet indicated Resident 2 had diagnoses of weakness of the left side following a stroke, general weakness, and impaired walking and mobility. A review of Resident 2's physician order, dated 12/15/21, indicated, Consult- podiatry as needed, for fungal infection, thick nails and/or skin lesions. A review of Resident 2's podiatry services note dated 2/18/22, indicated Resident 2 was a new patient with pain and swelling in both feet, fungal infection of the toenails, and dry skin. The note indicated the toenails on both feet were brittle, discolored, elongated, curved inward, overgrown, painful, and had fungal infections. The note indicated the podiatrist (a doctor specializing in treatment of the foot) trimmed and cleaned Resident 2's toenails. During an interview and concurrent observation on 6/13/22 at 11:46 a.m., in Resident 2's room, Resident 2 lay in bed with his lower body under an untucked sheet. Resident 2 stated he wanted to get stronger because he wanted to go home. Resident 2 stated he had a stroke that affected the left side of his body. Resident 2 stated he was in the bed most of the time and exercised his own left arm and leg while he was in bed. Resident 2's feet began to stick out from under the sheet; Resident 2's toenails, on both feet, were yellow, thick, and protruded beyond the ends of the toes. Resident 2's toenails on toes number one (big toe), three, and four curved around and touched the skin on the bottom of the toe. During an interview and concurrent observation on 6/16/22 at 1:02 p.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 2's room, LVN 3 examined Resident 2's feet. LVN 3 stated Resident 2 needed his toenails trimmed. A review of Resident 54's face sheet, undated, indicated Resident 54 was admitted in May 2022, with diagnoses that included end stage renal disease (kidney failure), and chronic respiratory disease. A review of Resident 54's physician orders indicated an order dated 5/22/22, for, Consult- podiatry as needed, for fungal infection, thick nails, and/or skin lesions. During an interview and concurrent observation on 6/13/22 at 11:35 a.m., in Resident 54's room, Resident 54 lay in bed with his right foot on top of the covers. Resident 54's right big toenail (toe number one) was gray and thick; the tip of the toenail was pointed and protruded beyond the end of the toe. During an interview and concurrent record review on 6/17/22 at 10:25 a.m., with the Social Worker (SW), the physician orders and progress notes for Resident 2 and Resident 54 were reviewed; in addition, Resident 2's podiatry service note was reviewed. SW confirmed Resident 2 was last seen by the podiatrist on 2/18/22. SW confirmed the podiatry referral for Resident 54 had not yet been completed. SW stated the podiatrist came to the facility at least once a month. SW stated she had just started updating her podiatry status logs, as she had been preoccupied with resident COVID cases (a contagious respiratory infection).

Based on interview and record review the facility failed to ensure one of eight sampled residents (Resident 39) received services to improve mobility and achieve maximum practicable independence when Resident 39 did not receive restorative nursing services for walking with a walker (an ambulation device with two to four wheeled legs, connected by handlebars to provide stability when walking). The failure to provide daily services to practice walking with a walker potentially contributed to muscle weakness and decreased mobility for ten weeks. Findings: A review of Resident 39's face sheet indicated he was admitted to the facility with diagnoses of generalized muscle weakness and difficulty walking. A review of Resident 39's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/20/22, indicated Resident 39 was understood and could understand others. The MDS indicated Resident 39 had not walked in his room or the unit but had used a wheelchair for locomotion. The MDS indicated Resident 39 needed extensive physical assistance from one person for transfer between surfaces and limited assistance from one person for locomotion. The MDS indicated Resident 39 had not received physical therapy or restorative nursing services during the assessment period. During an interview on 6/13/22 at 9:45 a.m., with Resident 39, Resident 39 stated he had been discharged by physical therapy a while ago, and since then, no one had been helping him to walk with a walker. Resident 39 stated he still had muscle weakness and had to either stay in bed or use a wheelchair to go out of his room. Resident 39 said he wished someone would help him learn to walk with a walker. During an interview on 6/15/22 at 11:15 a.m., with Director of Rehabilitation (DOR), DOR stated physical therapy (PT) discharged Resident 39 to the Restorative Nursing Assistant (RNA) program in March 2022 and the RNAs should provide services to assist Resident 39 to build strength and be able to walk with a walker. DOR stated Resident 39 should have received daily assistance to practice walking with a walker. A review of Resident 39's, Physical Therapy Discharge Summary, Discharge Recommendations and Status, dated 3/31/22, indicated, .Restorative Ambulation Program .ambulation of short distances to gradually build mobility tolerance with 2WW (Two Wheeled Walker) . A review of Resident 39's, Point of Care History, Activities of Daily Living (ADL)s, dated 4/1/22 to 6/15/22, indicated there had been no documented attempts to assist Resident 39 with using a walker for locomotion. During a concurrent interview and record review on 6/15/22 at 10:00 a.m., with the Director of Nursing (DON), Resident 39's ADL sheets, CNA notes, physical therapy discharge summary, and care plans were reviewed. The DON was unable to provide documentation that showed Resident 39 had received assistance walking, or any care plan for RNA services. The DON stated the facility had dropped the RNA program in March 2022 with a plan for Certified Nurse Assistants (CNA)s to provide the services formerly provided by the RNAs. The DON stated the CNAs should have assisted Resident 39 with practicing walking with a walker. During an interview on 6/16/22 at 9:40 a.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated he was one of the regular CNAs for Resident 39. CNA 2 stated there was no physician order and no care plan that indicated Resident 39 should be assisted to practice using the walker. A review of the facility policy and procedure, Restorative Nursing Services, revised July 2017, indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care .5. Restorative goals may include, but are not limited to supporting and assisting the resident in .developing, maintaining, or strengthening his/her physiological and psychological resources .

Based on observation, interview, and record review the facility failed to provide appropriate pharmaceutical services for two of eight sampled residents (Resident 42 and Resident 10) when: 1. Resident 42's had four medications left unattended on her bedside table; the administration of the medications was delayed for one hour and fifty minutes past the scheduled administration time. This failure resulted in Resident 42 not receiving her medications timely, and Resident 10 receiving a more concentrated dose of medication. For Resident 42, the one hour and fifty minutes delay in administration of hydroxyzine (an anti-anxiety drug) resulted in potential stacking of doses as the next dose of hydroxyzine was due in one hour and ten minutes. Stacking of doses had the potential to result in adverse side effects such as seizures. Resident 42's unsupervised medications also had the potential to result in diversion of the medications to other residents, with subsequent adverse side effects such as low blood pressure, fast heart rate, dizziness, drowsiness, seizures. 2. Resident 10's powdered Miralax (stool softener) was diluted in six ounces of water instead of the eight ounces ordered by the physician. This failure had the potential to result in Resident 10's medication to be less effective due to incorrect medication concentration, with the result of constipation. Findings: 1. A review of Resident 42's Face Sheet indicated Resident 42 admitted to the facility with a diagnosis of bullous pemphigoid (a disease caused by reaction of the body's own immune system causing itching, hives, and blisters on the skin), and hypertension (high blood pressure). During an observation on 6/13/22 at 11:50 a.m., in Resident 42's room, Resident 42 lay in bed sleeping. On top of the bedside table adjacent to Resident 42's bed was a plastic cup with four tablets inside the cup. A review of Resident 42's Medication Administration Record (MAR) dated 6/1/22 to 6/15/22, indicated four medications were due for administration at 9 a.m.: hydroxyzine, prednisone (to reduce inflammation), methotrexate (to reduce the body's immune response), amlodipine (to reduce blood pressure). The MAR indicated the hydroxyzine was due three times per day, with administration times of 9 a.m., 1 p.m., and 5 p.m. During an interview on 6/13/22 at 11:55 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had left four of Resident 42's medications on her bedside table in a plastic cup. LVN 1 stated the four medications were prednisone, hydroxyzine, methotrexate, and Amlodipine. LVN 1 stated she had left the medications on the bedside table and gone to the resident room next door to help provide care to another resident. During an interview on 6/14/22 at 1:04 p.m., with the Director of Nursing (DON), DON stated medications should not be left unattended in resident rooms. The DON stated it was important for a nurse to watch a resident take their medications before the nurse left the resident room, to ensure the resident received their medication and that no other residents had access to medications not prescribed for them. A review of the facility's policy and procedure, Administering Medications, revised April 2019, indicated, .Medications are administered within one (1) hour of their prescribed time .The medications shall not be left unattended at the bedside . 2. A review of Resident 10's face sheet indicated an admission date in 2017, with diagnoses of kidney failure and general weakness. A review of Resident 10's Physician Order Report indicated an order with a start date of 8/31/21, for 17 grams of Miralax powder (a stool softener) to be given orally. The order indicated, Special Instructions: For constipation prevention. Mix with 8 oz (ounces) of water or juice. Twice a day . During an observation on 6/15/22 at 9:45 a.m., Licensed Vocational Nurse 2 (LVN 2) prepared the Miralax powder for administration to Resident 10. LVN 2 measured a capful (17 grams) of Miralax powder into a plastic cup and added water into the cup to a level one-half inch below the rim. LVN 2 went into Resident 10's room and gave the cup to Resident 10, who drank the medication. During an interview on 6/15/22 at 10:12 a.m., LVN 2 stated she thought the plastic cup used to administer Resident 10's Miralax held eight ounces of fluid. LVN 2 used a one-ounce medication cup to measure water into the plastic cup and found the cup could only contain a maximum of six ounces. A review of the facility policy, Administering Medication, revised April 2019, indicated, Medications are administered in accordance with prescriber orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to arrange for a dental consult upon admission for one of 17 sampled residents (Resident 36). The failure to refer Resident 36 for a dental exam upon admission resulted in Resident 36 not receiving a dental exam on 3/30/22 or 3/31/22, during the routine dental care visit, with a subsequent delay in services for eleven additional weeks. This failure had the potential to result in difficulty eating and weight loss. Findings: A review of Resident 36's face sheet, undated, indicated Resident 36 was admitted on [DATE] with multiple diagnoses including a fracture of nasal bones and a Le Fort I fracture (a horizontal facial fracture which is characterized by separation of the hard palate from the upper jaw). The face sheet also indicated Resident 36 had a family member as responsible party and emergency contact, RP. A review of Resident 36's Physician Order Report, dated 2/8/22, indicated, Consult-Dental for oral hygiene with follow-up and treatment as indicated. A review of Resident 36's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/14/22, indicated Resident 36 had, obvious or likely cavity or broken natural teeth. During an observation on 6/13/22, at 11:26 a.m., in Resident 36's room, Resident 36 sat up in bed and smiled. Resident 36 was missing an upper front tooth and had a broken upper tooth. A review of facility document titled, Patients seen for dental exams at last screening .on March 30 and 31, 2022, undated, indicated the dentist had examined 29 residents; the examination list did not include Resident 36. During an interview on 6/15/22, at 12:20 p.m., with the Social Worker (SW), SW stated the dentist examined residents at the facility on 3/30/22 and 3/31/22, but Resident 36 had not been placed on the list to be evaluated by the dentist and therefore did not receive a dental screening. During an interview on 6/15/22, at 1:38 p.m., with the Director of Nursing (DON), the DON stated Resident 36 should have been evaluated by the dentist since there was an order from the physician for a dental consult. The DON stated Resident 36 had not been entered onto the list for dental screening and had not received a dental evaluation while at the facility. The DON stated it is the responsibility of the SW to enter residents' names onto the list to be screened by the dentist. During a phone interview on 6/15/22, at 3:42 p.m., with RP, RP stated it was important for Resident 36 to have a dental examination because Resident 36 had fallen and broken bones in his face. RP was concerned about the condition of Resident 36's teeth and his ability to eat.

Based on observation, interview, and record review, for one of 8 sampled residents (Resident 16), the facility failed to ensure Treatment Nurse 1 (TN 1) performed hand hygiene (wash hands with soap and water or use an alcohol-based hand rub) on two occasions during a wound dressing change. The staff failure to change gloves during a wound treatment when moving from wound care (a dirty procedure) to application of a new dressing (a clean procedure), and to sanitize hands after removing gloves had the potential to result in infection and spread of infection. Findings: A review of Resident 16's Face Sheet, dated 6/16/22, indicated Resident 16 was admitted to the facility in 2021 with diagnoses of dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning), and a stage IV pressure ulcer. (A pressure ulcer develops when one or more layers of skin and tissue are damaged as a result of continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV, with stage I the most superficial, and stage IV the deepest ulcer, including damaged skin and muscle down to the level of bone.) A review of Resident 16's Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 4/4/22, indicated Resident 16 was admitted with one Stage 3 pressure ulcer, and one Stage 4 pressure ulcer. A review of Resident 16's physician order with a start date of 6/11/22, indicated a treatment order for a pressure ulcer on Resident16's sacrococcyx (sacrum and tailbone). The order indicated a daily wound care regimen for the ulcer: clean with normal saline (dilute salt water), pat dry, cover with Triad paste (a substance that helps maintain a moist wound environment ideal for healing) and cover the wound with a foam dressing for protection. During an observation on 6/15/22, at 1:25 p.m., TN 1 performed Resident 16's sacrococcyx wound dressing change. TN 1 used gloved hands to remove the old wound dressing, cleaned the wound with normal saline, patted the area dry with clean gauze. Without changing gloves, TN 1 used a swab stick to apply Triad paste to the wound and covered the area with a foam dressing. TN 1 then removed her gloves, and without performing hand hygiene, immediately went to the treatment cart, unlocked and opened the cart, removed a new foam dressing, closed the cart, and carried the supplies back to Resident 16's bedside. TN 1 sanitized her hands, donned new gloves and started another dressing change for Resident 16. During an interview on 6/16/22, at 11:35 a.m., TN 1 stated it was important to do hand hygiene in between dirty and clean procedures, and different wound sites to avoid contaminating the wound and avoid spreading any contamination to a different wound site. During an interview on 6/17/22, at 10:19 a.m., with the Director of Staff Development (DSD), the DSD stated staff should change gloves after removing an old dressing and before placing a new dressing and perform hand hygiene and/or handwashing in between glove changes to prevent infection and cross contamination. A review of the facility's policy and procedure (P&P )titled, Handwashing/Hand Hygiene, revised August 2019, 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 the menu was followed for seven of seven residents when [NAME] 1 prepared white rice for residents on a pureed diet instead of the Spanish rice listed on the menu. This failure had the potential to result in less appetizing and nutritious food, and less food consumption, nutritional imbalance, and weight loss. Findings: A review of the posted facility menu for Week 1 from June 12 to June 18 for Tuesday (6/14/22), indicated lunch included Spanish rice. A review of the facility's Daily Cook's Menu for Week 1, Tuesday, indicated the facility was supposed to serve Spanish rice for pureed diet. During a concurrent observation and interview on 6/14/22 at 12:10 p.m., in the kitchen, [NAME] 1 pureed white rice for residents on a pureed diet. [NAME] 1 stated he thought white rice was the correct food. During an interview on 06/14/22 at 12:10 p.m., with Dietary Supervisor (DS), DS stated that residents on pureed diet should have the same menu as the regular diet, and to prepare the pureed food, Spanish rice, according to the facility recipe for the pureed diet Spanish rice. A review of the facility's policy and procedure Therapeutic diet revised October 2017, indicated . if a mechanically altered diet is ordered such as mechanically chopped meat and puree, the provider will specify the texture modification and follow the recipe . A review of the facility's pureed recipe for Week 1 Standard VE Spring 2022, dated 3/15/22, indicated, Sauté chopped onions, green peppers and celery in vegetable oil. Add uncooked rice and stir over heat until coated with oil. Stir in salt, chili powder and garlic powder. Place in 12X20X4 counter pan .Pour a mixture of tomato juice and water over rice. Bake .Place portions needed of prepared product in blender/food processor. Add 2 TBSP (tablespoons) milk for each portion. Cover securely. Blend until smooth .Reheat .

Based on observation, interview and record review the facility failed to maintain kitchen cabinets in good repair when an undercounter cabinet had doors with chipped and peeling paint (interior and exterior sides), unpainted wooden interior walls were chipped and peeling, the cabinet floor had chips of paint and wood and irregular white, green, yellow, and black stains. The failure to maintain the cabinets in good repair and sanitary conditions had the potential to result in food contamination and food borne illness for any resident eating food. Findings: During a concurrent observation and interview on 6/13/22 at 11:30 a.m., with Dietary Supervisor (DS) in the kitchen, there was a wooden cabinet under the dishwashing three-compartment sink. DS confirmed the condition of the wooden cabinet was as follows: the cabinet doors had chipped and peeling paint (interior and exterior sides), the unpainted wooden interior walls were chipped and peeling, the cabinet floor had chips of paint and wood and irregular white, green, yellow, and black stains. Inside the cabinet was a wooden shelf with two plastic bins filled with clean scoops for measuring resident portions wood; the shelf also had chips of wood and paint. Below the shelf was the floor of the cabinet which had seven stacked clean muffin tins and a plastic bin which held clean spatulas. A review of the facility's policy and procedure, Sanitization, revised October 2008, indicated, The food service area shall be maintained in a clean and sanitary manner . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning, seals, hinges and fasteners will be kept in good repair .

Based on observation and interview, the facility failed to ensure privacy was provided for one of 19 sampled residents (Resident 54), when Licensed Vocational Nurse (LVN) 2 did gastrostomy tube (GT-tube surgically inserted through the stomach to provide hydration, nutrition and medicine to the body) care without closing the privacy curtain. This deficient practice resulted in Resident 54 being exposed during care. Findings: Review of the admission Minimum Data Set (MDS-assessment tool) dated 4/4/19 indicated Resident 54 Basic Interview for Mental Status (BIMS) score was six (meaning not able to make decision independently). On 7/31/19 at 8:13 a.m. LVN 2 was observed from the hallway with the privacy curtain open, providing GT care to Resident 54. Fluid could be seen splashing from the GT. During an interview with LVN 2 on 7/31/19 at 8:15 a.m., she stated, she but got distracted by the resident and did not close the privacy curtain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent one (Resident 181) of thirteen sampled residents was free from Resident 80's aggressive combative and threatening behavior and This failure placed Resident 181 at risk of physical injuries and emotional distress from Resident 80. Findings: Review of an admission Minimum Data Set (MDS- assessment tool) indicated Resident 181 Basic Interview of Mental Status (BIMS) score was 13(meaning-cognitively intact). A progress note, dated 7/31/19 at 9:28 p.m., indicated Licensed Nurse (LN) was drawn to Resident 181 room by Certified Nursing Assistance who stated there was an altercation between roommate (Resident 80). It was noted Resident 80 became agitated and placed his hands to Resident 181. Staff immediately separated the two and immediately called police. Resident 181 spoke with police and stated he does not want to press charges as no harm occurred. With his roommate sent out he feels safe and is ok at the time. Review of the admission MDS dated [DATE] indicated Resident 80's BIMS score was 11(meaning-cognitively intact). A progress note, dated 7/31/19 at 9:28 p.m., indicated LN was drawn to Resident 80's room by Certified Nursing Assistance who stated there was an altercation between roommate (Resident 181). It was noted Resident 80 became agitated and placed his hands on Resident 181. Staff immediately separated the two and immediately called police. Three officers arrived and deescalated the situation and Resident 80 calmed down. After officer left Resident 80 became agitated again. Staff called the police again. Resident was transferred via 911 to the acute hospital secondary to exhibited behavior of altered mental status. Prior nurses notes on 7/13/19, 7/14/19 and, 7/30/19 indicated Resident 80 was combative, aggressive and threatening to staff. A review Resident 80's care plan showed care plans were not develop with goals and interventions to prevent future occurrences. In an interview with the Administrator (ADM) on 8/1/19 at 10:33 a.m., ADM stated, Resident 80 had an altercation with Resident 181 on 7/31/19. Resident 80 was transferred to the acute hospital on a 5150 (a California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others) and was not returned back to our facility. In an observation and concurrent interview with Resident 181 on 8/1/19 at 11:00 a.m., Resident 181 stated, since his admission on [DATE], his roommate Resident 80 has been aggressive to other residents and staff. Resident 181 demonstrated on the surveyor how Resident 80 grabbed his head and how Resident 80 placed his hand around his neck. Resident 181 added he was startled and frightened. Resident 181 stated, he felt safer after the facility moved him to the hospital. In an interview with the Assistant Director of Nursing (ADON) on 8/1/19 at 11:00 a.m., ADON was not able to show records that staff assessed and intervene in Resident 80's aggressive behavior. ADON added there were no Interdisciplinary Team meeting to discuss Resident 80's aggressive behavior and no care plan was developed. In a telephone interview with the Certified Nursing Assistant (CNA2) on 8/1/19 at 8:09 p.m., stated Resident 181 was sitting in his wheelchair facing the wall talking on his cellophane when Resident 80 put his right hand around Resident 181's neck. In a separate telephone interview with Registered Nurse (RN) 2 on 8/1/19 at 8:23 p.m., RN 2 stated she have cared for Resident 80 since admission. Resident 80 have been aggressive to staff. Review of the facilities policy titled, Abuse Prevention Program, dated, December 2016 indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on observation, interview and record review, the facility failed to develop, revise and implement a comprehensive person-centered care plan (a document that provides direction on the type of nursing care the individual/family/community may need) for three (Residents 56,174,72) of thirteen sampled residents within 48 hours after admission or readmission at the facility when: 1. There was no care plan to address Resident 56's shortness of breath. 2. There was no care plan to address Resident 174's primary diagnosis of Alcohol Dependence with Withdrawal. 3. Resident 72 did not have a care plan to address care and management of a [Peripherally Inserted Central Catheter (PICC)] line. These failures have the potential for residents not to receive individualized care immediately after admission to facility. Findings: 1. Review of the admission Record indicated Resident 56, was admitted to the facility with multiple diagnoses including multiple lung diseases. In an observation and concurrent interview with Resident 56 on 7/29/19 at 9:00 a.m., Resident 56 appeared alert and awake sitting on his bed eating breakfast and using oxygen at 3 L/min by nasal cannula. Resident 56 stated he was constantly on oxygen, because he was short of breath. Review of the Care Plans with the Assistant Director of Nurses (ADON) on 7/31/19 at 1:30 p.m., ADON confirmed there was no care plan to address and monitor Resident 56 for shortness of breath. 2. Review of the admission Records indicated Resident 174, was admitted to the facility with multiple diagnosis including, Alcohol Dependence and Alcohol withdrawal. In an observation and concurrent interview on 7/30/19 at 9:00 a.m., Resident 174 was in sitting in the wheelchair appeared weak, his fingers with noticeable tremors. Resident 174 stated that he was admitted because of his drinking issues. In an interview with the Assistant Director of Nurses (ADON) on 7/30/19 at 10:00 a.m., the ADON confirmed a care plan was not developed to assess and monitor Resident 174's for alcohol withdrawal symptoms. 3. Review of the Face Sheet indicated Resident 72 was admitted to the facility with a Percutaneous Indwelling Central Catheter [(PICC Line) a catheter inserted into the vein used to give intravenous fluids and blood transfusions]. In an interview with Registered Nurse (RN)3 on 7/31/19 at 1:36 p.m., RN 3 stated, the length of the catheter should be inspected and measured daily for signs and symptoms of complications. In an interview with the Director of Nursing (DON) on 8/2/19 at 11:58 a.m., DON stated there was no care plan to address the management and care of Resident 72's PICC line. According to the American Society of Anesthesiology report titled Practice Guidelines for Central Venous Access - A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, dated March 2012, The clinical need for keeping the catheter in place should be assessed daily. The catheter insertion site should be inspected daily for signs of infection. Catheter access ports should be wiped with an appropriate antiseptic before each access when using an existing central venous catheter for injection or aspiration. Central venous catheter stopcocks or access ports should be capped when not in use. Confirm Final Location of Catheter Tip. Review of the facility's policy titled, Care Plans - Comprehensive, dated January 2011 indicated, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's comprehensive care plan is designed to incorporate identified problem areas,

Based on observation, interview and record review, for one of three residents (Resident 29), on dialysis (process when machine filters blood of toxins when kidneys are not healthy enough to do it), the facility failed to ensure a comprehensive care plan was revised to address management of phosphorus (mineral found in food). This failure had the potential to result in increased phosphorus levels without timely management. Findings: 1. Review of Resident 29's Face Sheet indicated Resident 29 was admitted to the facility with multiple diagnoses including kidney disease. During an interview with Licensed Vocational Nurse 4 (LVN 4) on 8/1/19 at 10:03 a.m., LVN 4 stated Resident 29 went to dialysis center with a sack lunch for lunch. During a telephone interview with Registered Nurse (RN) 4 on 8/1/19 at 10:29 a.m., RN 4 stated she had not seen phosphate binders inside Resident 29's sack lunch and had asked other technicians who also told her they have not seen any medication sent with the sack lunch. RN 4 stated she would have administered the phosphate binder if it was inside the sack lunch. During a telephone interview with Registered Dietician (RD) 2 on 8/1/19 at 10:36 a.m., RD 2 stated she communicated with RD 1 on a monthly basis, often discussing laboratory results. RD 2 stated the last communication she had with RD 1 was this month (July 2019) regarding monthly laboratory results. Review of Resident 29's Calcium and Phosphorus Blood Test Results Update Report printed on 7/25/19 indicated on 7/9/19, Resident 29's phosphorus level was 6.6 milligram (mg. per deciliter (mg./dL). The result indicated normal blood phosphorus range 3.0 to 5.5 mg./dL. Review of a document provided by RD 1 regarding monthly Labs (laboratory) dated 7/17/19 read The phos (phosphorus- mineral found in food) was high so pt. (Resident 29) needs to cut back on high phos foods or just make sure pt. is getting both Ca (calcium) acetate/phoslo and Renvela/sevelamer (phosphate binders). Review of Resident 29's Medication Administration Record (MAR) for July 2019 indicated the following: -calcium acetate capsule 667 mg. 2 tablets by mouth was ordered to be given three times daily with meals. The MAR indicated calcium acetate was not given with lunch while Resident 29 was out on dialysis treatment 12 times over a 31-day period. -calcium acetate 667 mg. 1 tablet three times a day with snacks was not administered 12 times over a 31-day period. -Renvela 800 mg. 1 tablet three times daily with snacks was not administered 9 times over a 31-day period. -Renvela 800 mg. 2 tablets with meals was not administered 11 times over 31-day period. Reason for not administering the medications was resident not available, dialysis day. During an interview and concurrent review of Resident 29's MAR and dialysis care plan with Director of Nursing (DON) on 8/1/19 at 11:19 a.m., DON stated phosphate binders should still be administered even when Resident 29 went to dialysis. Resident 29's dialysis care plan indicated a goal for Resident 29 not to have complications at dialysis shunt site. One of the interventions included to hold medications when resident 29 was out on dialysis. DON stated Resident 29's dialysis care plan should be revised because there was no reason to hold phosphate binders if Resident 29 was still eating.

Based on observation, interviews and record review, the facility failed to provide pain management for one (Resident 175) of thirteen sampled residents when: 1. PRN (as needed) pain medication was not available. 2. Staff did not give the prescribed pain medication as ordered to address complaints of severe pain. This deficient practice resulted in Resident 175 having unresolved pain and unmet care needs, affecting Resident 175's overall well-being. Findings: Review of the Face Sheet indicated Resident 175 was admitted to facility with multiple diagnosis including Total Hip Replacement (THR), joint pain and Chronic Pain. According to Physician's (MD) order dated, 7/22/19, staff was to; Monitor for presence of pain every shift for Resident 175 using scale 0-10, 0 = No pain, 1-2 = Least Pain; 3-4 = Mild Pain; 5-6 = Moderate Pain; 7-8 = Severe Pain; 9-10 = Very Severe/Horrible/Worst Pain. During an observation and concurrent interview on 7/30/19 at 9:30 a.m. Resident 175 was awake lying in bed crying stating she was having severe hip pain. She stated she used to get routine pain medications without asking but now it takes staff sometime to give her the pain medication. She said a staff told her they ran out of her pain medicine. Resident 175 added it was so frustrating. Review of the physician's order dated 7/22/19 indicated Resident 175 was to receive, OxyContin (narcotic pain medication to treat moderate to severe pain); 10 mg by mouth, every 12 hours. Review of the Medication Administration Record (MAR) showed that on 7/22/19, the facility did not give Resident 175 pain medication because the pain medication was not available. In an interview with the Licensed Vocational Nurse (LVN1) on 7/30/19 at 9:00 a.m., LVN1 confirmed that the prescription was just reordered awaiting for physician's signature. In a separate observation and concurrent interview on 7/30/19 at 12:53 p.m. Resident 175 was awake sitting on the side of her bed. Resident 175 was complaining of pain of 7-8/10 scale. Resident 175 told the Physical Therapy (PT) at the bedside she was not going to PT unless she get her pain medication. 2. Review of the MD order dated, 7/22/19 showed Resident 175 was to receive the medication Oxycodone two tablet five milligrams for mild pain and 10 mg for moderate pain. On 7/23/19 the MD ordered for Resident 175 to have Oxycodone, 15 mg for severe pain. Review of the Medication Administration Record (MAR) dated, July 2019 showed: On 7/25/19 Resident 175 complained of 7/10 (severe pain). MAR indicated that Resident 175 was given 5 mg for mild pain instead of 15 mg for severe pain; On 7/23/19 Resident 175 received 15 mg of oxycodone instead of 30 mg for severe pain. Review of the Care Plan dated 7/22/19 indicated, Administer medications as ordered. Review of the facility's policy titled, Pain Assessment and Management, dated March 2015 indicated, Pain management interventions shall be consistent with the resident's goals for treatment,,, and Pain management interventions shall reflect the sources, type and severity of pain .

Based on observation, interview, and record review, the facility failed to attempt to use alternatives and assess one of one sampled resident (Resident 46) for risk or entrapment or injuries prior to installing a bed rail (may be used interchangeably with side rail. This failure resulted in Resident 46 sustaining a right middle finger skin tear. Findings: Review of annual Minimum Data Set (MDS-assessment tool) dated 6/3/19 indicated Resident 46 had a basic Interview of Mental Status score of four (meaning not able to make decision, not cognitively intact). During an observation on 7/30/19 at 9:34 a.m., Resident 46's right middle finger was covered in white bandage. There was a quarter bed rail to his right side and the left side of his bed was pushed against the wall. During an observation and concurrent interview with Maintenance Supervisor (MS) on 8/2/19 at 9:41 a.m., MS stated Resident 46's bed rail was loosely attached and wiggly. MS stated bed rails are checked every month and recorded on a log. Review of the Weekly Preventive Maintenance Task Sheet for July 2019 with MS on 8/2/19 at 10:10 a.m., indicated on 7/2/19 when Resident 46's bed was checked, it was marked N/A (not applicable). During an interview and concurrent record review with Director of Nursing (DON) on 8/2/19 at 9:58 a.m., DON stated the Side Rail Evaluation/Consent dated 7/19/18 indicated Resident 46 had a quarter bed rail on the top right side of the bed. DON stated there was no alternatives attempted prior to decision to install bed rail, and there was no reason provided why alternatives were not attempted. Under Evaluation of Resident's Size and Weight, there was no answer provided if the bed rail was appropriate for Resident 46's height and weight. DON stated the Maintenance log would not indicate whether Resident 46's bed rail was still safe for him. DON also stated there was no care plan developed to address Resident 46's bed rail use. Review of Resident 46's Interdisciplinary Team (IDT, a group composed of individuals from different departments of the facility) Progress Notes indicated on 6/9/19, Resident 46 was observed to have skin tear on the right middle finger. The IDT notes indicated Root Cause: resident has a tendency to hold on the side rails and push side rails which may have caused skin tear of the right middle finger. Review of the facility's policy and procedure titled Proper Use of Side Rails last revised December 2016 indicated general guidelines that including the following: -An assessment will be made to determine the resident's risk of entrapment to ensure the bed's dimensions are appropriate for the resident's size and weight. - The use of side rails will be addressed in the resident care plan. - Less restrictive interventions will be incorporated in care planning like providing a trapeze for bed mobility or position changes while in bed. - Documentation will indicate if less restrictive approaches are not successful, prior to decision to using a side rail.

Based on interview and record review, the facility failed to provide an environment free from unnecessary drugs for one (Resident 80) of thirteen sampled residents when: 1. Tegretol [anticonvulsant medication - used to treat seizures, nerve pain, and bipolar disorder (a disorder associated with episodes of mood swings) was ordered without adequate indication for use. 2. Staff did not monitor Resident 80 for the black box warning [the most serious medication warning required by the U.S. Food and Drug Administration (FDA)]. These deficient practices had the potential for serious adverse effects and complications including death. Findings: Review of the Physician's orders dated, 7/12/19 showed Resident 80 was to receive the medication Carbamezapine known as Tegretol two tablets by mouth twice a day. Review of the Medication Administration Record (MAR) and Progress Notes dated, July 2019 indicated staff did not document any monitoring for the black box warning. In an interview with the Assistant Director of Nurses (ADON) on 7/31/19 at 9:00 a.m., ADON confirmed that Tegretol was ordered without indication for use. In an interview with the Assistant Director of Nurses (ADON) on 7/31/19 at 9:00 a.m., ADON was not able to show staff monitored Resident 80 for the FDA's black box warning for serious adverse effects and complications for the medication Tegretol. ADON added that there was no baseline Tegretol blood level. In a telephone interview with the Pharmacist on 8/1/19 at 9:30 a.m., Pharmacist confirmed there was no specific indication for administrating Tegretol to Resident 80. Pharmacist stated Tegretol given to Resident 80 was indicated for seizure. Pharmacist stated at least a baseline level for Tegretol should be done. Review of the facility's policy titled, Medication Regimen Reviews, dated April 2007 indicated, The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility . The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. According to Novartis Pharmaceuticals, makers of Tegretol, The FDA requires Tegretol to carry a black-box warning because this drug may cause a rare but serious skin rash that may lead to death. These rashes are likely to show up within the first four months of taking the medication, but could also occur at any time. Sep 25, 2014. Ref:

Based on observation, interview and record review, the facility failed to remove expired medications from stock when, an expired antibiotic solution was stored in the Medication Room. This practices placed residents at risk for receiving expired medication which is ineffective and non-potent due to improper storage. Findings: During an observation of station one Medication Room on 7/30/19 at 8:09 a.m., a 60 milliliter (ml) bottle of Clindamycin Phosphate (an antibiotic) topical solution with an expiration date of June 2019 was stored on the shelf with current medications. In an interview with the Assistant Director of Nursing (ADON) on 7/30/19 at 8:09 a.m., ADON confirmed the clindamycin topical solution was expired. Review of the facility's policy titled, Medication Storage in the Facility, dated June 2018 indicated, All expired medications will be removed from the active supply and destroyed in the facility regardless of amount remaining.

Based on observation, interview and record review, the facility failed to ensure food was stored and prepared under sanitary condition when: 1. An open expired container of prepared yellow mustard was stored inside the reach in refrigerator. 2. Bins for oatmeal and powdered thickener had lids that were coming off. Two empty boxes placed on top of each bin lid had powdery residue on the bottom. 3. The dish machine log was not completed for two days in a row. These failures had the potential to result in food borne illnesses. Findings: During an observation of the Dietary Department and concurrent interview with the Registered Dietician( RD) on 7/30/19 at 7:30 a.m., there was an open container of prepared yellow mustard with a use by date of 7/16/19 stored inside the reach-in refrigerator. RD stated the mustard should be thrown away. Inside the dry food storage area, the storage bins for powdered thickener and oatmeal lids were coming off. Two empty boxes placed on top of each lid over the bin had powdery residue on the bottom. During an interview and concurrent review of the dishwasher log with the Dish washer Aide (DA)1, on 7/30/19 at 9:36 a.m., DA 1, stated the dishwasher sanitation was not recorded on the dishwasher log for two consecutive days on a weekend. DA 1 stated, she would not know if the dishwasher was checked for sanitizer concentration on those days because they were not written on the log. Review of the dishwasher log indicated on 7/23/19 and 7/24/19,the dishwasher sanitation concentration was not checked during dinner. The log also indicated, on 7/27/19, dishwasher sanitation concentrations were not recorded for breakfast and lunch and on 7/28/19, sanitation concentration was not recorded for none of the meals. Review of the facility's policy and procedure titled Dishwashing Machine Use last revised March 2010 indicated a supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility-approved log.

Based on observations, interviews and record reviews, the facility failed to follow its infection control policy and procedure for three of 19 sampled residents (Resident 12, 26 and 72). When: 1. Licensed Vocational Nurse LVN) 2 did not wash hands before gastrostomy tube care (G-tube- tube surgically inserted into the stomach used to provide nutrition, hydration and medicine to the body) for Resident 26 2. LVN 2 did not wash hands before medication preparation for Resident 12 3. Resident 72's PICC (peripherally inserted central catheter-thin, soft, long tube inserted into a vein for medication or blood draws) line dressing was not changed. These deficient practices placed residents at risk for developing infections. Findings: 1. During a concurrent medication administration, observation and interview on 7/31/19 at 8:28 a.m., LVN 2 took the blood pressure of Resident 12 without gloves, then put on gloves and cleaned the blood pressure apparatus, removed gloves and without washing her hands started preparing medicines. She said, she should have washed her hands before preparing medicines. 2. During a concurrent observation of Resident 26 and interview on 7/31/19 at 10:55 a.m., LVN 2 touched/used the computer in nurse's station two three, went inside Resident 26's bathroom, without washing hands took water from the bathroom faucet then went to Resident 26's bedside and prepared to flush the G-tube. LVN 2 stated, she's supposed to wash her hands before flushing the G-tube. Review of record Handwashing/Hand Hygiene, dated August 2015 indicated, use alcohol-based hand rub or soap and water after contact with resident's intact skin, before preparing or handling medications, after contact with medical equipment and after removing gloves. 3. Review of Resident 72's Face Sheet indicated Resident 72 was admitted to the facility with multiple diagnoses including a bone infection. During an observation and concurrent interview on 7/30/19 at 10:55 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 72 had a Peripherally-Inserted Central Catheter (PICC line, a thin catheter inserted into a vein in the arm, leg or neck with the tip positioned in a large vein that carries blood into the heart, used for long-term intravenous (through a vein) administration of antibiotics) line in her left upper arm. LVN 5 stated the PICC line dressing was dated 7/12/19. During an interview and concurrent review of the physician's orders with LVN 3 on 7/31/19 at 11:04 a.m., LVN 3 stated the physician's order indicated PICC line should be changed once weekly. During an interview with Director of Nursing (DON) on 7/31/19 at 1:22 p.m., DON stated PICC line was started on 7/12/19 and the dressing should have been changed weekly, otherwise, Resident 72's line was prone to infection. Review of Resident 72's plan of care for PICC lines dated 7/12/19 indicated dressing change guidelines as follows: -Perform the first dressing change 7 days after the insertion on 7/19/19 or per the facility protocol. Thereafter change the dressing and Stat lock (stabilization device, to hold the catheter in place) as per the facility protocol or once per week and PRN (as needed) if soiled or compromised in any way. Review of The Nurses' Infusion Manual for Long Term Care Facilities titled Central Venous Catheter (CVC) Dressing Change last revised 7/1/12 indicated The central catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. A transparent dressing is the preferred dressing which should be changed at least weekly.