**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document and inventory medications brought in by the family, following a hospital discharge. The facility did not identify if the medication label matched the current physician's orders, resulting in a medication error for one of three residents (Resident 1), when reviewed for Pharmacy Services. This failure resulted in Resident 1 receiving a three milligram (mg) dose instead of 1.5 mg dose, as ordered by the physician. Findings:An unannounced visit was made to the facility on 9/3/25, after a complaint was filed regarding a medication error.Resident 1 was admitted to the facility on [DATE], with diagnoses which included kidney transplant, per the facility's Resident Face Sheet.Resident 1's medical record was reviewed on 9/3/25:According to the physician's order, dated 8/3/25,.Give tacrolimus (medication to prevent organ rejection), 0.5 milligrams (mg) amt: 3 capsules to = 1.5 mg oral (by mouth) every 12 hours (8 am and 8 pm) s/p Renal (kidney) Transplant: Nursing Do Not Refill: FM (family) to Supply.According to admission progress notes, dated 8/3/25 at 3:45 P.M., Licensed Nurse 6 (LN 6) documented, Patent was admitted from the hospital. There was no documentation of what medication the family provided, how many bottles, or what the dosage was.According to the social worker note, dated 8/7/25, Resident 1 was moved from the south hall to the west hall, once a private room was available in the facility. According to the nursing progress note dated 8/7/25 at 8:57 P.M., LN 6 documented, LN 4 brought to this writer's attention, patient was given 3 mg of tacrolimus instead of 1.5 mg, MD (doctor) notified with new orders for labs in the A.M., DON (director of nursing), (name) pharmacy, and patient aware of med issue.According to the nursing progress notes dated 8/8/25 at 7:38 A.M., Discussed tacrolimus incident with resident. Bottle of tacrolimus 0.5 mg caps was found and is now on the west cart on her new hallway. Resident would like the wrong dose destroyed.On 9/3/2025, The DON and LN 6 were unavailable for interviews.An interview was conducted with the Assistant Director of Nursing (ADON), on 9/3/25 at 10:55 A.M. The ADON stated he was aware the DON was investigating a medication error involving Resident 1, that the family had brought in. The ADON stated the medication was given to staff when admitted from the hospital. The ADON was unaware if staff inspected the medication labels or inventoried the number of medications before adding to their medication cart. The ADON could not find any documented evidence or inventory of the medications the family supplied to the facility. An interview was conducted with LN 1 on 9/3/25 at 11:31 A.M., regarding Resident 1, who was no longer in the facility. LN 1 stated she was not working on 8/7/25, in the South hall, but was aware of the incident when she returned to work on 8/8/25. LN 1 stated she was very familiar with Resident 1 and had administered Resident 1's medication in the South hallway since her admission. On the morning of 8/8/25, Resident 1 approached LN 1 in the South hallway and asked to see her medication bottle and label on the South hall med cart for tacrolimus. LN 1 stated she removed the medication bottle and showed the resident the label which was listed as, one capsule equals 0.5 mg, give 3 capsules for a total of 1.5 mg. LN 1 stated Resident 1 informed her she was given 3 capsules of 1 mg dose each, equaling a total dose of three milligrams, the previous night in the [NAME] hall. LN 1 stated they must have removed the wrong bottle from the South cart when the medications were moved to the [NAME] hall. LN 1 was unable to say how many bottles of tacrolimus were originally on her cart. LN 1 stated the medication nurses should have reconciled the label on the bottles when first brought in by the family with the current physician's order.An interview was conducted with the facility's contracting pharmacist (CP 1) on 9/3/25 at 11:56 A.M. CP 1 stated Resident 1 provided her own tacrolimus to the facility and the medication was not supplied by the facility's pharmacy. CP 1 stated that sometimes residents supply their own medication, because it is not covered by their medical insurance. CP 1 stated since the pharmacy did not supply the medication, they did not provide oversite, unless the facility asks. CP 1 stated she had no documented evidence the facility asked them to review or provide oversight for the tacrolimus. CP 1 stated a one-time double dose of tacrolimus would not cause any harm or side effects. CP 1 stated the nurses should always verify the medication brought in by someone else, matching the physician's order. CP 1 stated if multiple bottles were brought in, only one bottle should have been on the medication cart and the others removed and stored for when the resident was discharged An interview was conducted with LN 4 on 9/4/25 at 3:58 P.M. LN 4 stated she was working in the west hall on the evening of 8/7/25, and Resident 1 was already settled into her new room. LN 4 stated Resident 1's medications were already on the [NAME] hall med cart, and she proceeded to give the resident her 8 P.M. dose of tacrolimus. LN 4 stated the order read tacrolimus 0.5 mg per capsule, give three capsules for a [NAME] of 1.5 mg. LN 4 stated the medication bottle read 1 mg per capsule, give three capsules for a total of 3 mg. LN 4 stated she was confused, because she knew she could not break a capsule in half to provide the 1.5 mg total dose. LN 4 stated she approached LN 5 in the South hall, who was familiar with Resident 1. LN 4 stated she showed LN 5 the bottle label, and LN 5 grabbed the medication bottle from her saying, This is the right dose. LN 4 stated she watched, as LN 5 walked into Resident 1's room and administered three tablets of the 1 mg capsules. LN 4 stated she was confused and concerned, so after LN 5 returned to the South hall, she approached the nurse in charge (LN 6) to inform her of what had happened.An interview was conducted with the DON on 9/8/25 at 1:35 P.M. The DON stated she had investigated the medication incident involving Resident 1. The DON stated LN 5 and LN 6 worked on the evening shift.An interview was conducted with LN 5 on 9/8/25 at 3:39 P.M., the DON was present. LN 5 stated she was very familiar with Resident 1, since she previously had been on LN 5's hallway (South hall). LN 5 recalled LN 4 coming up to her on the evening of 8/7/25, asking for help. LN 5 stated she did not have any specific memory of the medication or the dose. LN 5 stated she was aware the family brought the medication in, and she recalled giving the resident three capsules. LN 5 stated she could not recall looking at the label, or if the capsules were 0.5 mg or 1 mg. LN 5 stated she could not recall if she spoke with the resident once in the room administering the capsules or if the resident said anything to her. An interview was conducted with LN 6, on 9/8/25 at 3:50 P.M., with the DON being present. LN 6 stated on the evening of 8/7/25, LN 4 approached her, saying she thought there had been a medication error. LN 6 recalled looking at the medication label for tacrolimus, which indicated the capsules were 1 mg each, not 0.5 mg. LN 6 stated she immediately notified the physician, pharmacy, and DON, because she believed there had been a medication error.An interview was conducted with the DON on 9/8/25 at 4 P.M. The DON stated she was unable to prove how many bottles of tacrolimus medications were brought in by the family. The DON stated she had no documented evidence what the medication labels read, the dosage, the expiration date, or the amount of capsules per bottle. The DON stated the medication bottles were never inventoried by staff. The DON stated during her investigation, she was unable to determine who removed Resident 1's medication from the South hall medication cart and put it in the [NAME] hall medication cart.On 9/10/25, Resident 1's hospital medical records were received. Resident 1 was admitted on [DATE] to the hospital. The hospital physician's order, dated 7/31/25, tacrolimus 1.5 mg capsule, twice a day, end 8/2/25. An additional order was written by the physician on 8/3/25 on day of discharge, for tacrolimus 0.5 mg capsules, three capsules twice a day.The facility's policy related to handling medication admitted with residents was reviewed. According to the facility's policy, titled Handling Meds admitted with Residents, dated November 2017, A. MEDS TO BE VERIFIED: Legally, all meds admitted with a resident coming directly from an acute care hospital or skilled facility may be accepted for use without verification from the pharmacist or the residents' attending physician . The med nurse, however, must examine and check for proper packaging and labeling. Attached Assessment for need of medication verification form may be used to determine whether these medication(s) require pharmacist/physician verification. Refer to the labeling section below for further information .The facility's policy related to administering medication was reviewed. According to the facility's policy, titled Administering Medication, dated April 2019, .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 13 residents (Resident 151) had a physician ordered medication available to be administered. As a result, Resident 151 was not administered one of his medications for six days. Findings: A review of Resident 151's admission Record indicated the resident was admitted to the facility on [DATE]. On 7/11/24 at 8:20 A.M., a medication administration observation was conducted with licensed nurse (LN) 3. LN 3 was observed preparing medications for Resident 151. LN 3 stated Resident 151's calcium carbonate with vitamin D 1250 milligrams-5 micrograms was not available for her to administer to the resident. A review of Resident 151's physician orders dated 7/5/24, indicated the resident was to receive calcium carbonated-vitamin D 500 mg tablet; 1250 milligram-5 micrograms once a day at 8 A.M. for the diagnosis of vitamin D deficiency. A review of Resident 151's medication administration record (MAR) indicated the resident's calcium carbonated-vitamin D 500 mg tablet; 1250 milligram-5 micrograms was Not administered: Drug/item unavailable on 7/6/24 through 7/11/24. On 7/11/24 at 1 P.M., an interview was conducted with LN 3. LN 3 stated she was unsure when to call the physician and notify them that a resident's medication was unavailable. On 7/11/24 at 1:02 P.M., an interview was conducted with LN 4. LN 4 stated by the third day, the resident's physician should be made aware that a medication had been unavailable to give to a resident. LN 4 stated the nurses should not have been continually documenting for six days that Resident 151's medication was unavailable without following up on it. On 7/11/24 at 2:10 P.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 151's calcium carbonated-vitamin D 500 mg tablet; 1250 milligram-5 micrograms was ordered upon the resident's admission [DATE]) and should have been available from the facility's central supply. The DON stated the central supply had waited to order Resident 151's medication on 7/12/24 when ordering other supplies which was not an acceptable practice. The DON stated her expectation was for the admitting nurse to be familiar with the medications available in central supply and clarify with the physician any medications not readily available in the facility's supply. The DON stated the physician could then order something the facility carried or they could request the order be filled by the facility's pharmacy if the medication was not carried in facility stock. The DON stated Resident 151's medication should not have been unavailable to administer to the resident for six days. The DON further stated there was no documentation Resident 151's physician was notified about this unavailable medication. The DON stated the issue should have been followed up on and resolved. On 7/12/24 at 12:07 P.M., an interview was conducted with the DON. The DON stated the facility did not have a policy to guide the ordering and availability of medications available through central supply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the prn (as needed) guidelines for psychotropic medications (medications which alters the mind) for one of five residents (Resident 33) selected for Medication Review, when: 1. A specific behavior was not documented, indicating the necessity of a prn psychotropic medication; and 2. The physician did not document a rationale for the continued use of a prn psychotropic medication beyond the 14-day limit. This failure had the potential for Resident 33 to have increased risk of side effects and a prolonged duration of use. Findings: 1 Resident 33 was admitted to the facility on [DATE], with diagnoses which included non-traumatic intracerebral hemorrhage (bleeding in the brain), per the facility's Resident Face Sheet. On 7/10/24 Resident 33's clinical record was viewed: According to the physician's order, dated 3/17/24, Lorazepam (a drug used to treat anxiety, which act on the brain and nerves), 0.5 milligrams (mg) give twice a day, by mouth, under the tongue as needed for anxiety and/or shortness of breath. Open Ended. The Medication Administration Record (MAR) was reviewed from June 1, 2024, through July 12, 2024. On the June 2024 MAR, nursing documented Lorazepam was administered four times. The documented reasons for administration were listed as: crying inconsolable, yelling out, anxiety with agitation as exhibited by screaming and anxiety manifested by screaming. On the July 2024 MAR nursing documented Lorazepam was administered once. The documented reasons was listed as: yelling out and restlessness. On 7/11/24 at 7:59 A.M., an interview was conducted with Licensed Nurse 10 (LN 10). LN 10 stated Resident 33 was removed from hospice (end of life care) on 3/8/24, and her medication regimen was continued. LN 10 stated psychotropic prn medications required a specific behavior to be exhibited before the medication could be administered. LN 10 stated Resident 33 exhibits the behavior of yelling out constantly, either calling out her son's name or yelling for help. On 7/12/24 at 8:28 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 33's physician listed a behavior of anxiety for the administration of prn Lorazepam, which was not a specific behavior. On 7/12/24 at 9:22 A.M., an interview was conducted with LN 11. LN 11 stated a behavior listed as anxiety was subjected and open to interpretation. LN 11 stated anxiety was a generalized behavior and not specific, such as attempting to get out of bed, excessive crying, or striking out at staff. LN 11 stated the documented behavior must be exhibited before administrating a prn psychotropic medication. LN 11 stated it was the physician's responsibility to list the specific behavior and it was the nurse's responsibility to ensure a specific behavior was listed. On 7/12/24 at 10:15 A.M., an interview and record review was conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated she sat on the psychotropic review committee, which met every quarter. The MDSN reviewed Resident 33's order for Lorazepam prn and stated anxiety was not a specific behavior and was open to interpretation. The MDSN stated a specific behavior should be listed, so staff knew under what circumstances they should administer the medication. The MDSN stated psychotropic medications had the potential to cause serious side effects. According to the facility's policy, titled Antipsychotropic Medication Use, dated December 2016, .13. Residents will not receive a PRN dose of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record . 2. Resident 33 was admitted to the facility on [DATE], with diagnoses which included non-traumatic intracerebral hemorrhage (bleeding in the brain), per the facility's Resident Face Sheet. On 7/10/24 Resident 33's clinical record was viewed: According to the physician's order, dated 3/17/24, Lorazepam (a drug used to treat anxiety, which act on the brain and nerves), 0.5 milligrams (mg) give twice a day, by mouth, under the tongue as needed for anxiety and/or shortness of breath. Open Ended. On 7/11/24 at 7:59 A.M., an interview was conducted with LN 10. LN 10 stated prn psychotropic medications expired every 14-days. Once the medication expired, the physician was required to write a new order and to document in the progress notes why the medication was being renewed with a justification of its necessity. On 7/12/24 at 8:28 A.M., an interview was conducted with the DON. The DON stated she was aware the physician was required to write a justification when renewing a 14-day prn psychotropic medication. The DON stated she has informed all the physician's that this was a Federal requirement. The DON stated she does not believe Resident 33 had experienced any harm from the continued use of prn Lorazepam, but agreed they were not following the Federal regulation set by CMS (Centers for Medicare and Medicaid Service). On 7/12/24 at 10:05 A.M. a review of the facility's monthly Medication Regimen Review (MRR) binder was conducted. The consulting pharmacist (CP) made the following recommendations for Resident 33 in March and April 2024; The patient has orders for PRN Lorazepam. Please clarify a STOP DATE or if needed to continue beyond 14 days then the MD (Medical Doctor) needs to document the reason why in progress notes or on this letter. The March 2024 MRR contained a handwritten note from the physician which read may stop it, however the medication was continued. The April 2024 MRR contained no documentation from the MD. There were no recommendations made for May and June of 2024 from the CP, even though the prn Lorazepam was renewed every 14-days. On 7/12/24, Resident 33's physician progress notes were reviewed from May 2024 through July 2024. There was no documented evidence by the physician for the continued use or justification of prn Lorazepam. On 7/12/24 at 10:15 A.M., an interview and record review was conducted with the MDSN of Resident 33's MRR for March through June 2024. The MDSN stated she sat on the psychotropic review committee, which met every quarter. The MDSN stated the physician was required to document a justification each time a 14-day prn psychotropic medication was renewed. The MDSN reviewed Resident 33's MRR and stated the consulting pharmacist made the recommendation to discontinue the Lorazepam or else write the reason why it was renewed and required. The MDSN could not find any documentation in the MRR from Resident 33's physician indicating the prn psychotropic medication was justified for continued use. On 7/12/24 at 11:04 A.M., a voice message was left for Resident 33's physician asking for a return call. The physician did not return the call. On 7/12/24 at 1:51 P.M., an interview was conducted with the Consulting Pharmacist (CP). The CP stated Resident 33's prn psychotropic recommendations was based on the Federal requirement, which required the physician to provide a written justification for renewing the 14-day prn. The CP stated she noticed there was no written justification, so the recommendation was made to the physician. According to the facility' policy, titled Antipsychotropic Medication Use, dated December 2016, .14. The need to continue PRN orders for psychotropic medication beyond the 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotropic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure information in one of 13 resident's (Resident 3) medical/clinical record was readily accessible. As a result, it could not be determined if Resident 3 had been administered a controlled medication (medication with high potential for abuse). Findings: A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE]. On 7/11/24 at 4 P.M., copies of Resident 3's physician's orders, medication administration record (MAR), and controlled drug record (CDR, a written record that tracked when a controlled medication was removed from supply) for the resident's lorazepam (a controlled medication) 0.5 milligram tablets was requested from the medical records director (MRD). The MRD confirmed the requested documents would be available by 8 A.M. the following day. On 7/12/24, Resident 3's lorazepam 0.5 mg order, MAR, and CDR were reviewed. Resident 3's CDR indicated the resident's lorazepam had been removed from supply on: 6/26/24 at 6 A.M. 6/27/24 at 6 A.M. 6/28/24 at 6 A.M. 6/29/24 at 6 A.M. 6/30/24 at 6 A.M. Resident 3's MAR did not reflect the resident had been administered the lorazepam 0.5 mg on 6/26/24 through 6/30/24 at 6 A.M. A review of Resident 3's physician orders indicated the resident's 6 A.M. dose of lorazepam 0.5 mg had been discontinued on 6/25/24. On 7/12/24 at 1 P.M., an interview was conducted with licensed nurse (LN) 11. LN 11 stated when administering a controlled medication to a resident, the LN had to sign the CDR and then sign off on the MAR to show that the resident received the medication. On 7/12/24 at 1:08 P.M., an interview was conducted with the director of nursing (DON). The DON was notified that Resident 3's MAR did not reflect the administration of lorazepam 0.5 mg on 6/26/24 through 6/30/24 at 6 A.M. The DON stated she would review the resident's medical record for that documentation. On 7/12/24 at 2:10 P.M., an interview was conducted with the DON. The MRD was also present. The DON stated they were unable to retrieve the requested documentation from Resident 3's medical record. The DON stated this was not a medication diversion (when a controlled medication was unaccounted for and used for illegal purposes), but a matter of the resident's complete MAR being unavailable. The DON stated all of Resident 3's medical/clinical record should have been readily accessible and it was not. The DON acknowledged that because Resident 3's complete MAR was not accessible, it could not be determined if the resident had received her lorazepam. A review of the facility's policy titled Electronic Medical Records revised March 2014, did not provide guidance related to residents' medical records being readily accessible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure meal assistance provided to one sampled resident (Resident 3) was conducted in a sanitary manner when certified nursing assistant (CNA) 1 did not perform hand hygiene (washing hands or using an alcohol-based hand rub) after assisting another resident and did not wear gloves while feeding Resident 3 a sandwich using her bare hands. This deficient practice had the potential to spread microorganisms and to cause foodborne illness among residents. Findings: A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses to include right sided weakness and paralysis following a stroke, difficulty swallowing, and was receiving palliative care (end of life). On 7/9/24 at 12:35 P.M., a lunchtime observation was conducted in the dining room designated for residents that required staff assistance to eat. CNA 1 was observed feeding Resident A, touching the resident's wheelchair, and adjusting the resident's clothing protector. CNA 1 then went to another table to help Resident 3. CNA 1 did not perform hand hygiene. Resident 3 was seated in her gerichair (specialized chair) with her eyes closed. CNA 1 held Resident 3's sandwich in her bare hand and fed it to the resident. Resident 3 consumed a couple bites of the sandwich. CNA 1 then went back to assisting Resident A, again without performing hand hygiene. On 7/11/24 at 1:15 P.M., an interview was conducted with CNA 2. CNA 2 stated it was unacceptable to touch a resident's food with bare hands. CNA 2 stated hand hygiene should have been performed and gloves donned. CNA 2 stated she would not have wanted to eat the sandwich that had been touched by a staff's bare hands. On 7/11/24 at 1:30 P.M., an interview was conducted with the facility's registered dietitian (RD). The RD stated Resident 3's health had declined, and the resident could no longer see. The RD stated Resident 3 was, Totally dependent on staff to feed her. The RD stated staff should not touch ready-to-eat food with bare hands. The RD stated her expectation was for CNA 1 to perform hand hygiene and don gloves before feeding the sandwich to Resident 3. On 7/12/24 at 8 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation for staff to perform hand hygiene and don gloves when assisting a resident to eat handheld food. On 7/12/24 at 9:30 A.M., an interview was conducted with the DON. The DON stated the facility did not have a policy to guide hand hygiene when providing feeding assistance to residents. On 7/12/24 at 9:46 A.M., an interview was conducted with CNA 1. CNA 1 stated she did not know that hand hygiene should be done and gloves worn when feeding a resident a ready-to-eat food. CNA 1 stated she did not receive that training. On 7/12/24 at 12:10 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated he provided hand hygiene training to staff but did not specifically train related to hand hygiene when providing feeding assistance to residents. The DSD stated staff should be performing hand hygiene between residents and that gloves should be worn, after performing hand hygiene, if touching a resident's ready-to-eat food. The DSD stated bare hands should not be used to touch residents' food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its own policy for investigating an abuse allegation, when a certified nurse assistant (CNA), was not suspended, pending an investigation of an alleged verbal abuse allegation for one of two resident (Resident 1), reviewed for resident abuse. As a result, other residents were potentially at risk to be abused by the same CNA. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease, (a progressive disease that affects the nervous system), per the facility ' s Resident Face Sheet. On 4/3/23, Resident 1 ' s clinical record was reviewed: According to the Minimum Data Set, (a clinical assessment tool), dated 3/20/23, listed a cognitive score of 12, indicated moderately impaired cognition. The functional status of activities of daily living, indicated one person staff-assist with bed mobility, transfers, and toiletry. According to the plan of care, titled Behavioral symptoms, dated 3/18/23, interventions listed included: Emphasize rights, security and safety of all, approach calmly and unhurried, attempt to identify underlying cause, attempt to listen to resident vent anger, if they become abusive, explain to resident why you are leaving (ensuring their safety), reassure resident that needs will be met. On 4/3/23 at 10:05 A.M., an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON, regarding the facility ' s self-reported incident of an alleged staff to resident verbal abuse that occurred on 3/26/23 P.M. shift (3 P.M. to 11:30 P.M.) The DON stated she received a call from the evening Resource Nurse (RN), of an allegation of CNA 1 telling Resident 1 to F--K yourself. The DON stated the decision was made to move CNA 1 to a different hallway, to finish out her shift. The DON continued, stated the RN for that shift, started to conduct an investigation and the decision was made to keep CNA 1 working. The DON stated they determined the verbal abuse had occurred and was a temporary lapse of CNA 1 ' s judgment and frustration. On 4/3/23 at 11:12 A.M., an interview was conducted with the RN. The RN stated she was informed by a licensed nurse 1 (LN 1) of something being overheard between Resident 1 and CNA 1. The RC stated she assessed Resident 1, who could not recall anything. The RN notified the DON, and the DON made the decision to move CNA 1 to a different area. On 4/3/23 at 11:41 A.M., an interview was conducted with CNA 1. CNA 1 stated she works all different shifts at the facility and had cared for Resident 1 many times, who is confused and difficult at times. CNA 1 stated Resident 1 told her to F--K off, and as she was walking out of the room, she said F--k yourself. CNA 1 stated she realized she should have just left the room sooner and told the charge nurse she was having difficulty dealing with the resident. CNA 1 stated she was able to finish her shift and she worked the next two days. On 4/3/23 at 11:46 A.M., an interview was conducted with CNA 2. CNA 2 stated if he overheard something inappropriate between staff and a resident, he would immediately intervene and ask the staff member to leave. CNA 2 stated he would inform the charge nurse and document what he saw or heard. CNA 2 stated the facility was responsible for investigating the alleged incident and the staff should be removed from resident care, until it was determined what happened and what should be done. On 4/3/23 at 11:54 P.M., an interview was conducted with LN 2. LN 2 stated if an allegation of abuse occurred between staff and a resident, the staff member should be sent home immediately and removed from resident care. LN 2 stated the facility was required to investigate including the ADM, DON, Human Resource Officer, along with informing the physician and family. On 4/3/23 at 12:12 P.M., an observation and interview was conducted of Resident 1 as he sat in the dining room with another male resident, waiting for lunch. Resident 1 was dressed and well groomed. Resident 1 did not answer the questions asked but smiled instead. According to the facility ' s policy, titled Abuse Investigation and Reporting, dated July 2017, .4. The Administrator will suspend immediately any employee who had been accused of resident abuse, pending the outcome of the investigation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently document a POLST (Physician Orders for Life-Sustaining Treatment) form signed by the family, physician's order, and the computer indicator for code status (Full resuscitation vs Do Not Resuscitate-DNR), for one of three residents (Resident 33), reviewed for Advanced Directives. As a result, there was the potential for Resident 33's wishes to not be honored based on staff confusion of what the resident's wishes were. Findings: Resident 33 was re-admitted to the facility on [DATE], with diagnoses which included pneumonitis (inflammation of the lungs), due to inhalation of food, per the facility's Resident Face Sheet. On 1/24/23, Resident 33's clinical record was reviewed: According to the POLST form, signed by Resident 33's Responsible Party (RP-a person assigned by the resident to make medical and financial decisions on the resident's behalf), dated 12/1/22. The POLST, section A was checked for .Attempt Resuscitation/CPR. Section A requires selecting Full Treatment in Section B. Section B of the POLST, listed Full Treatment, which was not checked, however Selective Treatment-goal of treating medical condition while avoiding burdensome measures .comfort measures .Do not intubate . was checked by the RP. No handwritten clarification of the Resident/RPs wishes were documented. According to the physician orders, dated 12/1/22, .Full Code . According to the electronic record, in the upper left-hand corner of the resident's record was a highlighted red imprint, which read DNR. On 1/25/23 at 9:12 A.M., an interview was conducted with CNA 18. CNA 18 stated if a resident was recorded as DNR, a red sticker would be on their physical arm band. CNA 18 stated other ways to locate a resident's code status, was to look in the electronic record next to their name, or their POLST form which woukd be in the hard copy chart. On 1/25/23 at 9:15 A.M., an observation was conducted of Resident 33's name band, while he laid in bed. The yellow arm band on his right wrist did not have a colored sticker attached to it. On 1/25/23 at 9:15 A.M., an interview was conducted with LN 18. LN 18 stated if she needed to know a resident's code status, she would look in the electronic record and it would be listed next to the resident's name in the upper right area. LN 18 stated she could also look at the physician orders or the POLST form which was in the hard copy record. LN 18 stated if she noticed a conflict in the code status, she would notify the charge nurse, so clarification could be made. On 1/25/23 at 10:22 A.M., an interview and record review was conducted with the SSD. The SSD stated during the interdisciplinary team conferences (IDT-meeting with resident/RP and all department heads, to discuss plan of care) would confirm the resident's code status by reviewing paperwork and verbally confirmingit with the resident or their RP. The SSD stated Resident 33's last IDT conference was on 12/27/22. The SSD reviewed Resident 33's POLST form, which was checked for, Full Code and, Selective Treatment. The SSD stated the form did not make sense because it was all or nothing. The SSD stated you could not have full code and then a selective treatment. The SSD stated the physician changed the resident from DNR to full code on 12/1/22, however the computer still had him defined as DNR, which was very confusing. The SSD continued, stated with these discrepancies the resident might not have his true wishes met, if the resident were to go into cardiac arrest. On 1/26/23 at 3:14 P.M., an interview was conducted with the DON. The DON stated Resident 33 recently changed his code status and was now considered a full code. The DON stated the POLST, physician orders, and computer label should all indicate the same code status. According to the facility's Administrative Manual, titled Physician Orders for Life Sustaining Treatment (POLST) on page 3, dated 3/22/18, .8. The order to Follow POLST instructions will be added to the resident's admitting orders when there is a completed POLST in the chart .10.the POLST form will be placed in the health record .3. Reviewing/Revising the POLST: a. The POLST will be reviewed by the facility interdisciplinary team .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a physician's order for a pain medication was followed for 1 of 13 sampled residents (247) when the order for tramadol PRN at bedtime for pain was given at random times. The facility also failed to ensure pain medications ware ordered for all levels of pain for 1 of 13 sampled residents (247). As a result, there was the potential to not properly medicate the residents for pain Findings: Resident #247 was admitted to the facility on [DATE], with diagnosis that included a fractured right hip and surgical repair per the Record of Admission. A care plan for pain was developed on 1/13/23, That included three ordered pain medications: Tramadol, Percocet, and Tylenol. The first approach listed on Resident 247's care plan was to re-administer medications as ordered and evaluate slash record slash report effectiveness and any adverse side effects. An additional approach was to assess past effectiveness and ineffective pain relief measures. There was a Physicians order dated 1/16/23, for tramadol (pain medication) 50 milligrams by mouth PRN (as needed) at bedtime. A review of the MAR indicated that the medication was given at random times during the day, not just at bedtime as ordered. In the previous week the medication was administered on 1/20 at 4:50 A.M., 1/22 at 11:29 A.M. and 1/25 at 2:23 P.M. Resident 247 had two other orders for pain medications: Tylenol for mild pain level 1 to 4 and Percocet for moderate pain level of 4 to 6. No pain medication was listed for any pain greater than a 6 of 10. The LN 11 was interviewed on 11/27/23 at 11 A.M. LN 11 stated if Resident 247's pain was greater than 6 of 10, she would give him the choice of pain medications. LN 11 stated, a choice was given because there was no order for severe pain, she could only him him what was ordered. LN 11 was unaware that there were no medications available for Resident 247's severe pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was changed according to facility policy for two of two sampled Residents (2, 29) reviewed for oxygen use. In addition, an oxygen humidifier was not changed and replaced for Resident 29. These failures had the potential for residents to be exposed for infection and not receive adequate oxygen humidification. Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included atelectasis (collapsed lung) and respiratory failure with hypoxia (not enough oxygen) per the facility's Face Sheet. 2. Resident 29 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia per the facility's Face Sheet. On 1/24/23 at 8:57 A.M., Resident 29 was observed laying on her bed wearing an oxygen cannula (tube) connected to an oxygen concentrator. Resident 2 stated, My nose felt a little dry. The oxygen concentrator was set to three liters and connected to a humidifier. The bottle of humidifier was empty and had a written date, 1/12/23. The oxygen cannula had a written date of 1/6/23 on a clear tape. Resident 29 stated she did not know when the cannula was changed. Resident 29's room did not have an oxygen sign outside the door. On 1/24/23 at 9:25 A.M., a joint observation and interview with the Infection Control Preventionist (ICP) was conducted of Resident 2's room. Resident 2's room had a sign outside the door which indicated, Oxygen in use. The oxygen cannula in Resident 2's room had a date of 1/6/23 written on a clear tape. The ICP stated, This cannula should have been changed. The ICP stated residents with oxygen should have a sign outside their room to alert the staff that the resident was using some oxygen in case there was a fire. The ICP further stated that oxygen cannulas and humidifiers were changed weekly on Thursdays and as needed. During the same time (1/24/23 at 9:25 A.M.), the ICP went inside Resident 29's room and looked at the oxygen concentrator and cannula. The ICP stated it was important to change the cannula and humidifier because of the moisture and mildew in which bacteria could grow. The ICP stated the date on the cannula had been more than a week and it should have been changed. In addition, the ICP stated that Resident 29 was oxygen dependent. Resident 2's clinical record was reviewed. According to the physician's order dated 11/17/22, Change oxygen tubing and humidifier Q (every) week on Thursday . Resident 29's clinical record was reviewed. According to the physician's order dated 10/7/22, Change oxygen tubing and humidifier Q (every) week on Thursday . On 1/24/23 at 10:40 A.M., an interview was conducted with LN 21. LN 21 stated oxygen cannulas and humidifiers were changed weekly. LN 21 stated it was important to change the cannulas and humidifiers because it could grow bacteria. LN 21 stated when they were changed, the nurse should put the date and their initials on the cannula and the humidifier. On 1/25/23 at 9:21 A.M., an interview was conducted with LN 22. LN 22 stated oxygen cannulas and humidifiers were changed weekly. LN 22 stated it was important to write the date when it was changed on order for staff to know that it was done. LN 22 stated it was important to change the cannulas and humidifiers every week and as needed because bacteria could grow, and the humidifier would run out of liquid. On 1/27/22 at 8:46 A.M., an interview was conducted with the DON. The DON stated that it was expected that staff would change the oxygen cannula and humidifier weekly and put the date. The DON stated, I don't know how it was missed. Per the facility's policy titled Subject: Oxygen dated 2019, .Procedure 1. Oxygen cannulas/masks shall be changed every Thursday on night shift (11 p.m.-7a.m.) and additionally when soiled .2.Replace humidifier when empty .

Based on interview and record review the facility failed to ensure nurses' clinical skills and competencies were maintained on an annual basis. This failure had the potential to affect Resident's quality of care and treatment. Findings: On 1/26/23 a joint interview and record review of nurses' competencies was reviewed with the DSD. The DSD stated when a new Licensed Nurse (LN) was hired, the LN attended an orientation in class and on the nursing unit. The DSD stated LNs went through an annual competency skill and used the form titled, Annual Competency Nurses. The DSD stated that the facility has not been doing the annual competency for about a year. On 1/27/23 at 7:15 A.M., an interview was conducted with LN 23. LN 23 stated she had been working in the facility for a year and was not sure if the facility had been doing an annual competency check. LN 23 stated it was important for the nurses to have an annual competency because it was a good reminder to refresh their skills and to make sure they were doing clinical procedures correct. In addition, LN 23 stated she did not have a skills checklist when she went on orientation in the unit. On 1/27/23 at 7:25 A.M., an interview was conducted with LN 24. LN 24 stated she had been working in the facility for over a year. LN 24 stated she was not sure if her licensed nurse skills were validated when she was orienting on the floor because she had, Not seen an orientation skills checklist pertaining to clinical procedures. On 1/27/23 at 7:32 A.M., an interview was conducted with the ICP. The ICP stated he had been working in the facility for about 15 years. The ICP stated the facility had been doing the annual skills competency in the past but have not seen it done for a year and a half or two. The ICP stated it was important to validate the licensed nurses' skills to ensure the skills they knew were up to date. On 1/27/23 at 8:24 A.M., an interview was conducted with LN 25. LN 25 stated she had been working in the facility for four years. LN 25 stated it was important to have a skills refresher to assess the nurses' skills to make sure they knew what they were doing. On 1/27/23 at 8:43 A.M., an interview was conducted with the DON. The DON stated it was important to conduct an annual skills check for licensed nurses because it was important to be up to date on best practices. The DON stated they have not been doing it for the last few years. The DON further stated, This was on me. Per the facility's Administrative Manual titled Training-All Staff dated 9/12/19, . a. A continuing competency-based education program is conducted for all staff at the facility to promote and measure specific competencies and skill sets necessary to provide related services to meet resident needs, safety of the residents . b. iii. Skills based on job duties . Per the facility's job description form titled Director of Nursing Services revised 8/2006, . h. Developing staff training programs for nursing service personnel . Per the facility's Facility Assessment form dated 7/22, . Staff training and competencies .Topic: Specialized care: Inserting and caring for catheter, suctioning, tube feedings, wound care, etc. Frequency: On hire and annual .

Based on observation, interview, and record review, the facility failed to secure (lock) one of three treatment carts (South unit cart), reviewed for medication storage. Findings: On 1/25/23 at 10:33 A.M., an observation was conducted in the South unit. The treatment cart was unlocked, and no staff were nearby. The top two drawers contained multiple prescriptions of residents' creams and ointments. On 1/25/23 10:35 A.M. a observation and interview was conducted with LN 16. LN 16 was observed going to the medication cart, which was next to the treatment cart. LN 16 locked the treatment cart when she observed it was unlocked. LN 16 stated she locked the cart because, Someone could get into the cart, that should not be allowed to. On 1/25/23 at 10:45 A.M., an interview was conducted with the DSD. The DSD stated the treatment cart should be locked, whenever it was not in use. The DSD stated if the treatment cart was left unlocked, anyone could have access to prescription medications. On 1/26/23 at 11:12 A.M., an observation was conducted in the South unit. The treatment cart was left unlocked and no staff were nearby. The top two drawers contained prescriptions of creams and ointments. On 1/26/23 at 11:13 A.M., a male CNA was observed walking past the unlocked treatment cart. On 1/26/23 at 11:14 A.M., LN 17 returned to the medication cart, which was next to the treatment cart. On 1/26/23 at 11:16 A.M., a food service worker walked past the unlocked treatment cart and into the small dining room. On 1/26/23 11:17 A.M., an observation and interview was conducted with LN 17, as she stood next to the medication and treatment cart. LN 17 observed the treatment cart unlocked and stated it should be locked because people could have access to the creams and ointments. LN 17 stated she unlocked the cart about 10 minutes earlier to get something, and she forgot to lock it back up. On 1/26/23 at 3:14 P.M., an interview was conducted with the DON. The DON stated she expected the treatment carts to be locked whenever not in use. The DON stated when the treatment carts were left unlocked, staff and residents had access to unauthorized medication. According to the facility policy titled Storage of Medication, dated April 2007, .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use .shall not be left unattended if open or otherwise potentially available to others .

Based on observation, interview and record review, the facility failed to ensure the pureed diet was prepared and served in a manner that conserved nutritive value, flavor, and appearance. This deficient practice affected the nutrient content and increased the risk of choking for eight residents on a pureed diet, and one sampled resident (R2) on a liquefied (drinkable) pureed diet. Cross reference F800, F802 Findings: During a kitchen observation and interview on 1/24/23 at 9:21 AM, [NAME] (CK) 2 had already prepared the pureed diet meals, prior to surveyor observation. The pureed diet lunch meal items including pureed vegetables, pureed hummus, pureed sausage, pureed pear, and pureed coleslaw were in individual 1x6-inch metal hotel shot pans inside the steamer warming. CK 2 stated there were eight residents on pureed diets and the lunch tray line service would start at 11:30 A.M. According to the facility's therapeutic menu spreadsheet on Monday, 1/24/23 for lunch, the pureed diets were to receive: 4 oz. pureed vegetables and 4 oz. of pureed hummus HOT, 4 oz. pureed sausage, 4 oz. pureed pear, 4 oz. of pureed cooked coleslaw, and 4 oz. of puree peach crisp. During a lunch meal dining observation and interview on 1/24/23 at 11:26 AM in the main dining room, Resident #2 (R2) stated she was unhappy with her pureed diet food and did not like the flavor and texture. R2 further stated, it was awful. A review of Resident 2's lunch meal tray ticket indicated Diet: Regular, Consistency: Drinkable Puree, Moist; Honey Thick Liquids, Portion: Small .Devices: All Food & Beverages in Mugs, Dislikes: Straw; Likes: Puree Soup in Mug . A review of Resident 2's Face Sheet indicated the facility admitted R2 on 11/17/22 with diagnoses including dysphagia (difficulty swallowing) and gastro-esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube (esophagus) connecting your mouth and stomach). A review of the facility's Nutrition Weigh Variance Assessment for R2 dated 1/10/23, completed by the RD indicated, the physician's diet order: Regular diet; Puree, moist texture; honey thick liquids; Ensure supplements twice a day, between meals. A review of Resident 2's Nutrition Progress Note dated 1/10/23 completed by the RD, indicated Resident requests foods/beverages in mug. RD Recommends Drinkable/Liquified Texture Puree (add milk, water, gravy or broth to thin)/Moist Regular Diet with HTL/Aspiration Precautions/ Small portions No Straws: 1:1 Supervision with all meals. During a kitchen observation and interview on 1/25/23 at 8:57 A.M., CK 1 prepared the lunch meal for 8 pureed diet entrees. CK 1 was observed blending weighed amounts of grated cheddar and white cheeses, pinto beans, and water for the main regular diet entrée - tostada bowl. Then he blended 4 cups of water, 1cup liquid eggs, and 2 oz cream of wheat to 8 cooked fish fillets for the second puree entrée- fish. Next, CK 1 added a half cup of water to 4 cups of cooked rice to make pureed rice and stated the texture should be mashed potato level thickness. He repeated the same process for the pureed couscous. After he finished, he poured the food items into 1x6 inch metal hotel shot pans and placed into the steamer at 9:29 A.M. CK 1 stated he followed the directions in the Pureed recipe binder but did not receive any training on how to prepare the pureed diet food. CK 1 used measuring utensils or scoops most times but not consistently throughout the pureed preparation. A review of the facility's therapeutic menu spreadsheet on Thursday, 1/26/23, indicated the lunch meal for the Regular diet included two meal options: 1) 4 ounces (oz.) Caesar Seabass ½ cup salad with cilantro Caesar dressing with a dinner roll, and 2) 4 oz. Grilled chicken sandwich with avocado on a Telera roll, set-up (lettuce, tomato, onion, and pickles), carrot raisin salad, and lemon ice. Residents on the Puree diet were to receive the choice of one two meal options: 1) 4 oz. puree fish, 4 oz. cooked carrots, 2 oz. puree dinner roll; 2) 4 oz. pureed chicken patty, 4 oz. carrot, serve coleslaw, No bread (later changed to 4 oz. bread by RD on 1/26/23 at 11:00 A.M.), and 4 oz. Italian ice or fruit smoothie. The two soups offered to both the regular and pureed diets included vegetable and butternut squash soups. During a concurrent observation and interview in the satellite kitchen on 1/26/2023 at 12:41 P.M., Dietary Aide (DA) 1 prepared Resident 2's lunch meal in four individual coffee mugs. DA 1 scooped 6 oz. of puree vegetable soup and poured into one coffee mug, then added water to fill the rim of the mug and stirred it up. DA 1 then scooped 4 oz. puree fish and 4 oz. cooked carrots, then placed in two separate coffee mugs. DA 1 added hot water to each of them and filled them to the rim with hot water, then stirred them up. DA 1 stated he prepared them to be a drinkable texture. DA 1 did not use any scoops or measuring utensil to determine the amount of water needed to liquify the pureed food poured into the mugs. DA 1 further stated he was not trained on how to prepare a drinkable liquified pureed diet. According to the International Dysphagia Diet Standardisation Initiative (IDDS) 2019, the Liquefied Pureed diet is considered a Level 3 - Liquidised Moderately Thick consistency which the texture can be drunk from a cup, eaten with a spoon but not thin as water. Furthermore, the IDDSI indicated the Level 3 diet is designed for residents who have difficulty eating solid food (including puree texture) from spoon or fork and liquefied adequately to flow freely. During a test tray observation and interview on 1/26/2023 at 12:50 P.M., with Registered Dietitian (RD) and the Food Service Director (FSD). The pureed fish tasted dry and bland, not flavorful. The FSD stated the pureed fish could use more seasoning. The RD stated the pureed soup texture was thin. The RD further stated and acknowledged the pureed diet foods needed to meet the nutrition needs of the residents on pureed diets, so texture and taste was important, as well as, avoiding choking risks. Both the RD and FSD acknowledged the action to warm the food multiple hours before trayline service could lead to dryness, altered taste, and a hardened food texture. During an interview with the RD and FSD on 1/27/2023 at 9:24 A.M., the RD stated the pureed meal diet foods should have a mashed potato consistency and the liquefied puree diet should have a smoothie texture. The RD stated, The regular servings for a liquefied pureed diet are to be served and thinned with appropriate fluids for flavor and to ensure proper nutrients. The RD also stated it is important for the Cooks and Diet Aides be trained in how to correctly prepare the pureed diets. The FSD stated he had not trained staff or provided an in-service on therapeutic diets preparation, including pureed diets because I could use more training. Per the RD, I did not provide the Cooks or Diet Aides with proper training on how to prepare the pureed diet meals. A review of the Culinary Department Inservice Training dated 4/2022 titled Diet Textures and Consistencies did not include information about how to conserve nutritive value and flavor in pureed foods through preparation methods. Additionally, CK 1 and CK 2 were not on attendance sheet for the in-service training. According to authors' Steele et al. in the 2015 Dysphagia journal article .texture-modified foods and thickened liquids has become a cornerstone of clinical practice to address dysphagia (swallowing impairment). In the case of liquids .thin liquids (such as water) pose safety challenges for people with dysphagia because they flow quickly . A review of the facility's 2021 Diet Manual, the Pureed Diet indicated Indications- This diet is a modification of the Regular Diet for those who have severe problems chewing and swallowing .all foods must be the consistency of mashed potatoes. Fluids should be allowed thickness only as allowed by physician's orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe infection control practices were followed when: 1. A kitchen aide did not disinfect hands between delivery of meals to residents in one of two resident dining rooms (main dining room), reviewed for dining observation task; and 2. A urinary catheter drainage bag was in contact with the floor for one of three residents (Resident 33), reviewed for urinary catheter care. As a result, there was the potential for cross contamination of microorganisms (bacteria, virus, fungus). Findings: 1. On 1/24/23 at 12:03 P.M., an observation was conducted in the main dining room during the first dining observation. Food server 16 (FS 16) was passing out coffee to residents sitting at a table. FS 16 was observed putting his gloved right hand on a resident's wheelchair handle as he leaned into the resident and asked her if wanted a bowl of soup. FS 16 returned to the coffee/soup area without changing his gloves or washing his hands and was observed pouring a cup of coffee and delivered it to the same table. FS 16 used the same gloved hands to grab a resident's wheelchair handle at a different table, as he leaned in to ask the female if she wanted soup. FS 16 returned to coffee/soup area without removing his gloves or washing his hands, and grabbed a straw and brought it to back to the table. FS 16 was observed returning to the coffee/soup station without changing his gloves or washing his hands and he removed two soup bowls from a cupboard in a lower cabinet. FS 16 removed the lid from the soup dispenser and used a soup ladle to pour soup into the two bowls. FS 16 picked up the two bowls from the top of the bowl and delivered them to the table. On 1/24/23 at 12:05 P.M. FS 16 was observed leaving the satellite kitchen area, returning to the dining room, while putting on a new pair of gloves. FS 16 went to another table to asked if soup was wanted. On 1/24/23 at 2:06 P.M., FS 16 removed two bowls of soup from the lower cabinet by grabbing the door handle with his gloved hands. FS 16 removed the lid of the soup dispenser and ladled two bowls of soup. FS 16 was observed grabbing the soup bowls from the top and walked them to the table. On 1/24/23 at 12:09 P.M., FS 16 did not change his gloves or washed his hands as he moved around the dining room. FS 16 was observed opening a binder next to the coffee and soup stand, FS 16 flipped through pages of the binder with the same gloves on. FS 16 then removed a soup bowl from the cabinet below, lifted the lid off the soup dispenser and used a ladle to pour soup. FS 16 delivered the soup to a table by holding it on the top of the bowl. Another female resident at the same table said something, and FS 16 was observed picking up her soup bowl from the top of the bowl and walked it into the satellite kitchen without removing his gloves or washing his hands. On 1/24/23 at 12:13 P.M., FS 16 was observed in the satellite kitchen opening a microwave door with the same gloved hands, placing the soup inside, and programing the microwave. Seconds later, FS 17 was observed removing the soup from the microwave by grabbing it from the top with the same gloved hands and returning it to the resident in the dining room. On 1/24/23 at 12:14 P.M., an interview was conducted with FS 16. FS 16 stated he was supposed to remove his gloves and wash his hands whenever he touched any object and before he touched any food products. FS 16 stated he did change his gloves and wash his hands between task in the dining room and he should have. 01/24/23 12:46 P.M., an interview was conducted with the RD. The RD stated FS workers should be removing their gloves and washing their hands in between task to prevent cross contamination. On 1/25/23 at 10:16 A.M., an interview was conducted with the ICN. The ICN stated staff should always clean and disinfect their hands whenever they touch objects and before they serve any food. The ICN stated by not changing gloves and disinfecting the hands, there was a potential for cross contamination. On 01/26/23 at 3:14 P.M., an interview was conducted with the DON. The DON stated staff were expected to clean and disinfect their hands between meal service task, to prevent cross contamination of food. According to the facility's Culinary policy, titled Handwashing, dated July 2022, .1. When to wash hands: .b. After touching bare human body parts . g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks . i. Before donning disposable gloves for working with food and after gloves are removed . j. After engaging in other activities that contaminate the hands . 2. Resident 33 was readmitted to the facility on [DATE] with diagnoses which included benign prostatic hyperplasia (a weak urine stream) with lower urinary tract symptoms (frequency, pain with urination), per the facility's Resident Face Sheet. On 1/25/23 at 8:56 A.M., an observation was conducted inside Resident 33's room, as the resident was sitting up in bed eating breakfast. A urinary catheter drainage bag was hanging from the right side of the bed frame and was visible from the hallway. The urinary drainage bag was leaning sideway, as it rested on the floor. On 1/25/23 at 8:57 A.M., an observation and interview was conducted with CNA 16. CA 16 observed the urinary catheter drainage bag resting on the floor and stated it should not be in contact with the floor, because bacteria from the floor could travel up into the resident. CNA 16 left the room to get the assigned CNA for this resident. On 1/25/23 at 9:06 A.M., an observation and interview was conducted with CNA 17. CNA 17 stated Resident 33's catheter bag was touching the floor and it should not be. CNA 17 stated bacteria was on the floor, which could cause an infection to the resident. On 1/25/23 at 9:37 A.M., Resident 33's clinical record was reviewed: According to the physician orders, dated 11/30/22, Foley catheter 16Fr (size). According to the care plan, titled Infection related to urinary tract infection, dated 12/21/22, listed an intervention of, .Follow principles of infection control . On 1/25/23 at 10:12 A.M., an interview was conducted with the ICN. The ICN stated catheters drainage bags should never be in contact with the floor because cross contamination could occur. On 1/25/23 at 10:33 A.M., an interview was conducted with the DSD. The DSD stated staff were trained to never allow the urinary drainage bags to come in contact with the floor, because of the bacteria on the floor. The DSD stated if a urinary drainage bag became contaminated from the floor, it could have a negative impact on the resident. On 1/26/23 at 3:14 P.M., an interview was conducted with the DON. The DON stated she expected all staff to ensure urinary drainage bags were kept off the floor to avoid cross contamination. According to the facility's policy, titled Catheter Care, Urinary, dated September 2014, .Infection Control: .b. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observations, staff interviews, and record reviews, the facility failed to ensure overall operational systems were established for oversight of the Food and Nutrition Services department. This failure to ensure an effective system for day-to-day dietary operations oversight may have placed 49 residents at risk for foodborne illness or further compromised their nutrition and health status due to unsafe, unsanitary, and improper dietetic service practices. Cross reference F802, F804, and F812 Findings: During the facility's recertification survey from 1/24/23-1/27/23, multiple deficient practices were identified in the Food and Nutrition Services Department's main and satellite kitchens, which included storage of expired, unlabeled, or undated foods; unsanitary kitchen food storage equipment; untrained staff in therapeutic diet food preparation; sanitary equipment cleaning; and no hairnet use with staff entry into the satellite kitchen. Findings: Storage of Expired, Unlabeled, and Undated Foods During the initial tour of the main kitchen on 1/24/2023 at 8:36 A.M. with the Registered Dietitian (RD), observations of the walk-in refrigerator and walk-in freezer were expired, unlabeled and undated food items. The foods included: a clear container labeled Ground Beef, Prep Date: 1/16/2023, Use by: 1/19/2023 in the meat refrigerator. The RD stated the ground meat was expired and should have been thrown away. During the kitchen observation on 1/24/23 at 10:12 A.M, two large plastic bin containers were inside the dry storage, one contained rice and the other had white flour. The large containers were unlabeled and undated. The FSD stated the large bins should have been labeled and dated because they recently arrived in the last food delivery a couple of days ago. During a concurrent observation and interview on 1/25/2023 at 11:25 A.M. in the satellite kitchen, a medium sized clear plastic bin with 24 mighty shakes were found in the reach-in refrigerator. The bin was labeled and dated Prep Date: 1/18/2023, Use By: 2/18/2023. Dietary Aide (DA) 2 stated the mighty shakes used by date should have been 14 days from the time it was thawed from the freezer. During an interview on 1/25/2023 at 11:48 A.M. the RD, the RD stated the mighty shakes should have been dated 14 days after it was transferred from the freezer to the reach-in refrigerator. According the 2022 US FDA Food Code, Section 3-602.11 titled Food Labels, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . A review of the Mighty Shakes label manufacturer's instructions dated 1/18/2013 indicated, .Storage after open: Refrigerated, Shelf life after open: Up to 14 days @ 34 - 40 degrees . A review of the facility's policy and procedure titled Food storage dated 7/2022 indicated, .12. Refrigerated food storage: .f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded . Improper storage of potentially hazardous foods (PHF)/time and temperature control for safety (TCS) foods could lead to the development of pathogens that contaminate the food and may cause foodborne illness if consumed. The facility staff failed to demonstrate an effective system for ordering safe food, storing meats, particularly meat, produce, and frozen beverages; or sufficient knowledge to ensure that unsafe food was stored or served to residents. Unsanitary kitchen equipment (freezer fan and ice machine) and cleaning process During a main kitchen observation on 1/24/2023 at 8:47 A.M., inside the Parve walk-in refrigerator there were seven large hotel metal pans of uncovered vegetables including zucchini squash, parsley, green beans, and raw chicken. The evaporator fan inside the walk-in refrigerator was filled with gray lint, dust, and black scum. The RD acknowledged the dirty evaporator fan and stated it should have been clean to avoid getting dirt on the uncovered food. During a kitchen observation and interview on 1/24/2023 at 9:57 A.M., the DSW 1 stated he cleaned the outside of ice machine every day. Per DSW 1, every month he would turn off the ice machine, empty the ice, clean the ice machine with soap using a scrubber. DSW 1 stated he used a soap cleanser not produced by the ice machine company to clean brown calcified substances, and he did not know how to remove the water trough to clean that part of the machine. The DSW also stated the ice machine was cleaned every six months by an outside company. During a concurrent interview and record review on 1/24/2023 at 10:10 A.M., with the RD, the RD stated the ice machine daily cleaning logs were initialed by the kitchen staff who cleaned it and signed at the end of the month. The RD acknowledged the December 2022 monthly cleaning log was not signed off, and further stated it should have been signed off. During a kitchen observation and interview with Vendor (VD) 1, the RD and Foodservice Director (FSD) on 1/24/2023 at 2:41 P.M., VD 1 described the process he used to clean the ice machine. VD 1 stated he turned the ice machine off, removed the ice from the bin, and pour a mixture of descale lime remover solution to the machine and press the cleaning button. A Surveyor took a white paper towel and wiped the inside area of the ice chute and ice tray attached to the making part. The paper towel had dark brown crusty, semi-grimy substances on it. The FSD and RD acknowledged the dirt and grime substances on the paper towel. Both the FSD and RD stated it should not be there and the machine should be visibly clean. A review of the ice machine's manufacturer's guidelines, the cleaning instructions indicated .water trough can be removed and the manufacturer's ice machine cleaner and sanitizer are the only products approved for use in (manufacturer's name) ice machines. According to the 2022 US FDA Food Code, Section 3-303.11, titled Ice Used as Exterior Coolant, Prohibited as Ingredient, Ice that has been in contact with unsanitized surfaces .may contain pathogens and other contaminants if this ice is then used as a food ingredient, it could be contaminated . According to the 2022 US FDA Food Code, Section 4-204.17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. According to the 2022 US FDA Food Code, Section 4-501.11 Good Repair and Proper Adjustment. (Equipment) Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. A review of the facility's policy and procedure dated 7/24/2020, titled Equipment Sanitation indicated, .Equipment in the Culinary department will be maintained in a sanitary manner . Culinary Director is responsible for maintenance, safety and sanitation of equipment .Develop policies and procedures for cleaning and sanitizing equipment . Develop and monitor cleaning and maintenance schedule based on manufacturer's instructions . Therapeutic diet and meal compliance and Food and Nutrition Staff training During a kitchen observation and interview on 1/24/23 at 9:21 AM, [NAME] (CK) 2 had already prepared the pureed diet meals, prior to surveyor observation. The pureed diet lunch meal items including pureed vegetables, pureed hummus, pureed sausage, pureed pear, and pureed coleslaw were in individual 1x6-inch metal hotel shot pans inside the steamer warming. CK 2 stated there were eight residents on pureed diets and the lunch tray line service would start at 11:30 A.M. A review of the facility's therapeutic menu spreadsheet on Thursday, 1/26/23, indicated the lunch meal for the Regular diet included two meal options: 1) 4 ounces (oz.) Caesar Seabass ½ cup salad with cilantro Caesar dressing with a dinner roll, and 2) 4 oz. Grilled chicken sandwich with avocado on a Telera roll, set-up (lettuce, tomato, onion, and pickles), carrot raisin salad, and lemon ice. Residents on the Puree diet were to receive the choice of one two meal options: 1) 4 oz. puree fish, 4 oz. cooked carrots, 2 oz. puree dinner roll; 2) 4 oz. pureed chicken patty, 4 oz. carrot, serve coleslaw, No bread (later changed to 4 oz. bread by RD on 1/26/23 at 11:00 A.M.), and 4 oz. Italian ice or fruit smoothie. Two soups, including vegetable and butternut squash, were offered to residents on both the regular and pureed diets. During a kitchen observation and interview on 1/25/23 at 8:57 A.M., CK 1 prepared the lunch meal for 8 pureed diet entrees. After CK 1 was observed blending the first pureed diet entrée - tostada bowl ingredients together, he poured the substance into a 1x6 inch metal hotel shot pan. Next, he blended 4 cups of water, 1 cup of liquid eggs, and 2 oz cream of wheat to 8 cooked fish fillets for the second puree entrée- fish. Finally, CK 1 added a half cup of water to 4 cups of cooked rice to make pureed rice and blended, then repeated the same process for the pureed couscous. After he finished all pureed food preparation, CK 1 stated the pureed food texture should be mashed potato level thickness, and he placed the metal pans into the steamer at 9:29 A.M. CK 1 stated he was not trained on how to prepare the pureed diet foods, but he followed a recipe in the Puree Binder in the main kitchen. CK 1 used measuring utensils or scoops most times but not consistently throughout the pureed preparation. During a concurrent observation and interview in the satellite kitchen on 1/26/2023 at 12:41 P.M., the Dietary Aide (DA) 1 prepared Resident 2's lunch meal in four individual coffee mugs. DA 1 scooped 6 oz. of puree vegetable soup and poured into one coffee mug, then added water to fill the rim of the mug and stirred it up. DA 1 then scooped 4 oz. puree fish and 4 oz. cooked carrots, then placed in two separate coffee mugs. DA 1 added hot water to each of them and filled them to the rim with hot water, then stirred them up. DA 1 stated he prepared them to be a drinkable texture. DA 1 did not use any scoops or measuring utensil to determine the amount of water needed to liquify the pureed food poured into the mugs. DA 1 further stated he was not trained on how to prepare a drinkable liquified pureed diet. A review of Resident 2's lunch meal tray ticket indicated Diet: Regular, Consistency: Drinkable Puree, Moist; Honey Thick Liquids, Portion: Small .Devices: All Food & Beverages in Mugs, Dislikes: Straw; Likes: Puree Soup in Mug . According to the International Dysphagia Diet Standardisation Initiative (IDDSI) 2019, the Liquefied Pureed diet is considered a Level 3 - Liquidised Moderately Thick consistency which the texture can be drunk from a cup, eaten with a spoon but not thin as water. Furthermore, the IDDSI indicated the Level 3 diet is designed for residents who have difficulty eating solid food (including puree texture) from spoon or fork and liquefied adequately to flow freely. During a test tray observation and interview on 1/26/2023 at 12:50 P.M., with Registered Dietitian (RD) and the Food Service Director (FSD). The pureed fish tasted dry and bland, not flavorful. The FSD stated the pureed fish could use more seasoning. The RD stated the pureed soup texture was thin. The RD further stated and acknowledged the pureed diet foods needed to meet the nutrition needs of the residents on pureed diets, so texture and taste was important, as well as, avoiding choking risks. Both the RD and FSD acknowledged the action to warm the food multiple hours before trayline service could lead to dryness, altered taste, and a hardened food texture. Unsanitary facility staff entry into Satellite and Main kitchen During an observation and interview on 1/24/2023 at 9:01 A.M., the DSW was not able to verbalize the process for testing the dish machine sanitizer. The DSW held the strip container, pulled out a strip from the container, dipped the strip to the water of the washed utensils, and compared to the color indicators of the strip container. Per the DSW, the color was dark purple and at 200 ppm (parts per million). The DSW stated the color and level was okay. During an interview with the RD on 1/24/2023 at 9:10 A.M., the RD stated the test strip tested by the DSW should have been dark purple/gray and read 50-100 ppm. The RD further stated the DSW was trained on how to correctly test the dish machine sanitizing solution level and should know the proper process for unloading clean dishes from the dish machine using hand hygiene. During multiple observations in the satellite kitchen during the lunch meal service on 1/24/2023 at 11:50 A.M. and 12:55 P.M., Certified Nurse Assistant (CNA) 1 walked through the kitchen without a hair net. CNA 2 also entered the kitchen without putting on a hairnet and did not perform hand hygiene before engaging in tasks in the kitchen. During an observation and interview on 1/24/2023 at 12:55 P.M., CNA 1 walked in and out of the kitchen without a hair net. CNA 1 stated he wore a hair net earlier but took it off and forget to put another one on. CNA 1 further stated it was frustrating that he forgot to do something like put a hair net on. CNA 1 stated he was not trained on why he should wear a hair net and he did not fully know the food safety protocol in the satellite kitchen. According to the 2022 US FDA Code, Section 2-402.11 titled Hair Restraints-Effectiveness .FOOD EMPLOYEES shall wear .or use hair restraints such as hats, hair coverings or nets, rubber bands, or hair clips to keep their hair off the face and behind their shoulders, and clothing that covers body hair to protect exposed FOOD; clean EQUIPMENT, UTENSILS . A review of facility policy and procedure titled Food Safety and Sanitation dated 7/2022, indicated .c. Hair restraints are required and should cover all hair in the head . A review of facility policy and procedure titled Food Safety and Sanitation dated 7/2022 indicated, .d. Employees will wash their hands just before they work in the kitchen and after .touching . surfaces or items potential for contamination . A review of the culinary kitchen staff in-service training records from 2021-2022 there were no staff trainings on how to identify the correct sanitizing solution concentration level in the dish machine. According to the 2022 US FDA Food Code, Section 4-302.14 titled Sanitizing Solutions, Testing Devices, Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1.) The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2.) Too much sanitizer in the final rinse water could be toxic. During an interview with the RD and FSD on 1/27/2023 at 9:24 A.M., the RD stated resident food stored in the main kitchen refrigerators and freezers should have been accurately labeled and dated by kitchen staff. And expired foods should have been thrown according to food chart. The FSD stated he had not trained staff or provided an in-service on therapeutic diets preparation, including pureed diets because I could use more training. The RD stated the pureed meal diet foods should have a mashed potato consistency and the liquefied puree diet should have a smoothie texture. The RD stated, The regular servings for a liquefied pureed diet are to be served and thinned with appropriate fluids for flavor and to ensure proper nutrients. The RD also stated it is important for the Cooks and Diet Aides be trained in how to correctly prepare the pureed diets. Per the RD, I did not provide the Cooks or Diet Aides with proper training on how to prepare the pureed diet meals. The RD stated she conducted monthly kitchen inspection audits and she discussed the findings for the main and satellite kitchens with the FSD, but not the Facility Administrator (FA). A review of the monthly facility documents from July-December 2022, titled Kitchen Inspections completed by the RD indicated, unlabeled and undated food items in the dry storage, walk-in refrigerators and walk-in freezers, incomplete ice machine cleaning logs, pink slime in ice machine, and dirty kitchen fans . A review of the RD's job description dated March 2018, indicated .Position title: Clinical-Nutritional Services Coordinator (RD/CDM) .will assist in directing the preparation and serving of regular meals and therapeutic diets, and maintain area and equipment in sanitary condition .keep kitchen clean, sanitary, safe, and orderly .monitor equipment maintenance, logs, and cleaning schedules .30. Provides inservices to the nursing and Culinary staff as required on nutritional topics .31.

Based on observations, interviews, and record review, the facility failed to ensure the kitchen staff obtained sufficient training to perform and competently when: 1. A Dishwasher (DSW) did not follow the proper procedure to clean dishes in the dish machine and was unable to demonstrate the correct process to test the dish machine sanitizer solution. 2. A DSW did not follow the manufacturer's guidelines for cleaning the Ice Machine. 3. Kitchen staff and non-kitchen staff did not follow food safety and sanitation practices by not wearing hair nets or performing hand hygiene when entering the satellite kitchen. 4. A DSW did not follow did not perform proper hand hygiene or change gloves after disposing the kitchen garbage and re-entering the kitchen. 5. Two Cooks and a Diet Aide were not trained on pureed diet preparation. These failures placed all residents at risk for developing a food-borne illness, and the potential for a choking hazard or altered nutrient intake for nine residents on pureed diets. Cross reference F800, F804, F812 Findings: 1. During a kitchen observation and interview on 1/24/2023 at 8:57 A.M., the dishwasher (DSW) was in the dirty sink area and wearing yellow gloves. The DSW rinsed and loaded the utensils and plates from the dirty sink area, grabbed a white cloth and dried his yellow gloves, went to the clean dish side, picked up the bowls, dried them with the white cloth and placed them in the clean dish rack. The DSW stated he was the only person working in the dishwasher area at the time. During an observation and interview on 1/24/2023 at 9:01 A.M., the DSW was not able to verbalize the process for testing the dish machine sanitizer. The DSW held the strip container, pulled out a strip from the container, dipped the strip to the water of the washed utensils, and compared to the color indicators of the strip container. Per the DSW, the color was dark purple and at 200 ppm (parts per million). The DSW stated the color and level was okay. During an interview with the RD on 1/24/2023 at 9:10 A.M., the RD stated the test strip tested by the DSW should have been dark purple/gray and read 50-100 ppm. The RD further stated the DSW was trained on how to correctly test the dish machine sanitizing solution level and should know the proper process for unloading clean dishes from the dish machine using hand hygiene. During multiple observations in the satellite kitchen during the lunch meal service on 1/24/2023 at 11:50 A.M. and 12:55 P.M., Certified Nurse Assistant (CNA) 1 walked through the kitchen without a hair net. CNA 2 also entered the kitchen without putting on a hairnet and did not perform hand hygiene before engaging in tasks in the kitchen. A review of the culinary kitchen staff in-service training records from 2021-2022 there were no staff trainings on how to identify the correct sanitizing solution concentration level in the dish machine. According to the 2022 US FDA Food Code, Section 4-302.14 titled Sanitizing Solutions, Testing Devices, Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1.) The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2.) Too much sanitizer in the final rinse water could be toxic. According to the 2022 US FDA Food Code, Section 4-501.17, titled Warewashing Equipment, Cleaning Agents; Failure to use detergents or cleaners in accordance with the manufacturer's label instructions could create safety concerns for the employee and consumer .chemical residues could find their way into food if detergents or cleaners are used carelessly. Equipment or utensils may not be cleaned if inappropriate or insufficient amounts of cleaners or detergents are used. According to the 2022 US FDA Food Code, Section 4-501.11, titled Good Repair and Proper Adjustment-Equipment. Adequate cleaning and sanitization of dishes and utensils using a warewashing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize . A review of the facility policy and procedure dated 7/2022, titled Cleaning Dishes/Dish Machine indicated, .2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes . 9. Dishes should be air dried on the dish racks, not dried with towels . 10. Inspect for cleanliness and dryness and put dishes away if clean (be sure hands are clean) . 2. During a kitchen observation and interview on 1/24/2023 at 9:57 A.M., with the dishwasher (DSW), the DSW stated he cleaned the facility's ice machine daily and the inside ice making parts monthly. Per the DSW, every month he stated he turned off the ice machine, emptied the ice bin, removed the water curtain inside the top part of the ice machine, then cleaned the ice machine with soap from the 3-compartment sink, a rag, and scrub brush. The DSW demonstrated his cleaning process by holding a green bucket with a scrub brush, filled with Butler Pan Power - For Manual Pot and Pan Washing soap, then the DSW opened the ice machine, removed the water curtain with brown calcified substances and washed it in the 3-compartment sink. Next, he wiped inside the ice bin and around the water trough ice making grid. Per the DSW, I document daily and monthly cleaning on the cleaning log and a company cleans it every six months. During a concurrent record review and interview with the RD on 1/24/2023 at 10:10 A.M., the RD stated the ice machine cleaning logs were initialed daily and signed at the end of the month by the kitchen staff who cleaned it. The RD acknowledged the December 2022 monthly cleaning log was not signed off, and further stated it should have been signed off. The RD acknowledged the DSW's ice machine cleaning process, and further stated the ice machine should be cleaned using the process recommended by the manufacturer. During a kitchen observation and interview on 1/24/2023 at 2:41 P.M. with Vendor (VD) 1, the RD and Foodservice Director (FSD), VD 1 stated the ice machine is cleaned every six months. VD 1 described the process the process to clean the ice machine and stated first, I turn the ice machine off, then remove the ice from the bin, then pour a mixture of descale lime remover solution inside the top of the machine and press the cleaning button. A Surveyor took a white paper towel and wiped the inside area of the ice chute and ice tray attached to the making part. The paper towel had dark brown sticky, slimy substances on it. The Foodservice Director (FSD) and RD acknowledged the dark brown dirt-like sediments and black grime substances on the paper towel. Both the FSD and RD stated the ice machine should not have those substances there. The FSD further stated the ice machine should be visibly clean. During a review of the ice machine's manufacturer's guidelines, the cleaning instructions indicated .water trough can be removed and the manufacturer's ice machine cleaner and sanitizer are the only products approved for use in the ice machines. According to the 2022 US FDA Food Code, Section 3-303.11, titled Ice Used as Exterior Coolant, Prohibited as Ingredient, Ice that has been in contact with unsanitized surfaces .may contain pathogens and other contaminants if this ice is then used as a food ingredient, it could be contaminated . According to the 2022 US FDA Food Code, Section 4-204.17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. According to the 2022 US FDA Food Code, Section 4-501.11 Good Repair and Proper Adjustment. (Equipment) Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. A review of the facility's policy and procedure dated 7/24/2020, titled Equipment Sanitation indicated, .Equipment in the Culinary department will be maintained in a sanitary manner . Culinary Director is responsible for maintenance, safety and sanitation of equipment .Develop policies and procedures for cleaning and sanitizing equipment . Develop and monitor cleaning and maintenance schedule based on manufacturer's instructions . 3. During multiple observations in the satellite kitchen during the lunch meal service on 1/24/2023 at 11:50 A.M. and 11:55 A.M., Certified Nurse Assistant (CNA) 1 walked through the kitchen without a hair net. CNA 2 also entered the kitchen without putting on a hairnet and did not perform hand hygiene before engaging in tasks in the kitchen. During an observation and interview on 1/24/2023 at 12:55 P.M., CNA 1 walked in and out of the kitchen without a hair net. CNA 1 stated he wore a hair net earlier but took it off and forget to put another one on. CNA 1 further stated it was frustrating that he forgot to do something like put a hair net on. CNA 1 stated he was not trained on why he should wear a hair net and he did not fully know the food safety protocol in the satellite kitchen. According to the 2022 US FDA Code, Section 2-402.11 titled Hair Restraints-Effectiveness .FOOD EMPLOYEES shall wear .or use hair restraints such as hats, hair coverings or nets, rubber bands, or hair clips to keep their hair off the face and behind their shoulders, and clothing that covers body hair to protect exposed FOOD; clean EQUIPMENT, UTENSILS . A review of facility policy and procedure titled Food Safety and Sanitation dated 7/2022, indicated .c. Hair restraints are required and should cover all hair in the head . A review of facility policy and procedure titled Food Safety and Sanitation dated 7/2022 indicated, .d. Employees will wash their hands just before they work in the kitchen and after .touching . surfaces or items potential for contamination . A review of policy and procedure titled Hand Washing dated 7/2022 indicated, Employees will wash hands as frequently as needed throughout the day using proper hand washing procedure . a. When entering the kitchen . f. After handling soiled equipment or utensils . i. Before donning disposable gloves .and after gloves are removed .j. After engaging in other activities that contaminate the hands. 4. During an observation and interview on 1/25/2023 at 1:40 P.M. with the DSW, the DSW took out the trash to the dumpsters, then pushed it back into the kitchen, and filled the trash bin with a new trash bag. After the DSW reentered the kitchen, he did not remove the soiled gloves or perform hand hygiene by washing his hands after he walked through the kitchen pass food preparation areas and exposed food. Per DSW, he should have washed his hands when he reentered the kitchen. The RD and FSD acknowledged that DSW should have removed his gloves, perform hand washings and put on new gloves when he reentered the kitchen after he took out the trash to the dumpster. According to the 2022 US FDA Food Code. Annex 3 titled Garbage disposal: . The failure of food-handlers to wash hands in certain situations (such as after using the toilet, handling raw meat, cleaning spills, or carrying garbage), wear clean disposable gloves .is responsible for the foodborne transmission of these pathogens. Non-foodborne routes of transmission, such as from one person to another, are also major contributors in the spread of these pathogens . According to the 2022 US FDA Food Code, Section 2-301.11 titled Clean Condition .The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code . According to the 2022 US FDA Food Code, Section 2-301.14 titled When to Wash .The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after .activities listed .Employees must wash their hands after any activity which may result in contamination of the hands . A review of facility policy and procedure titled Food Safety and Sanitation, dated 7/2022 indicated, .d. Employees will wash their hands just before they work in the kitchen and after .touching . surfaces or items potential for contamination . A review of policy and procedure titled Hand Washing 7/2022 indicated, Employees will wash hands as frequently as needed throughout the day using proper hand washing procedure . a. When entering the kitchen . f. After handling soiled equipment or utensils . i. Before donning disposable gloves .and after gloves are removed .j. After engaging in other activities that contaminate the hands . 5. During an observation and interview on 1/25/2023 at 8:53 A.M., with [NAME] (CK) 1. CK 1 was observed preparing the ingredients for the pureed food. CK 2 assisted CK 1 in the preparation of the pureed food. CK 1 stated he was preparing ten puree entrée portions. The ingredients for puree were already measured and placed in the container for 8 portions. Per CK 1, he followed the pureed instructions in the binder. The food ingredients used were measured per the preparation instructions, but there was no measurement for the water amount. CK 1 added 7 ounces of water to the pureed meat entrée and alternate entrée. CK 1 stated the consistency should be like mashed potatoes. During a review of the facility's therapeutic menu spreadsheet for the lunch meal on Thursday, 1/26/23, the Regular diet included two meal options: 1) 4 ounces (oz.) Caesar Seabass ½ cup salad with cilantro Caesar dressing with a dinner roll, and 2) 4 oz. Grilled chicken sandwich with avocado, set-up (lettuce, tomato, onion, and pickles), carrot raisin salad, and lemon ice. The Puree diet indicated had the following two meal options: 1) 4 oz. puree fish, 4 oz. cooked carrots, 2 oz. puree dinner roll; 2) 4 oz. pureed chicken patty, 4 oz. carrot, serve coleslaw, No bread (later changed to 4 oz. bread by RD on 1/26/23), and 4 oz. Italian ice or fruit smoothie. The two soups offered to both the regular and pureed diets included vegetable and butternut squash soups. During a satellite kitchen observation and interview with DA 1 on 1/26/23 at 12:36 PM, DA 1 was observed preparing a liquified pureed meal for a Resident on liquified puree diet. DA 1 used a #8 scoop (4 oz.) to scoop the entrée food item, and the two side food items and place them into three separate coffee mugs. DA 1 then poured hot water into each coffee mug and filled it nearly to the rim. He stirred each of them. DA 1 stated he does not measure the amount of water he puts in the liquified puree diet food. DA 1 stated the consistency was drinkable like juice. DA 1 stated he was not trained on how to make a liquified puree diet. During a test tray observation and interview with the RD and FSD on 1/26/23 at 12:55 P.M., the RD stated the regular pureed soup texture was thin. The RD further stated it was important for the residents to receive the correct food texture to prevent the risk of choking or other health outcomes. A review of a kitchen staff in-service training dated 4/2022 on Diet Textures and Consistencies did not include CK 1 and CK 2. The content did not include liquified puree diets. During an interview with the RD and the FSD on 1/27/2023 at 9:24 A.M., the FSD stated he had huddles with kitchen staff on food safety and sanitation topics but did not have include therapeutic diets, including pureed diets. The RD stated the pureed meals should typically have a mashed potato consistency and the liquified puree diet should have a smoothie texture. Per the RD, I did not provide the cooks training on how to prepare meals for the therapeutic diets, including the pureed. According to authors' Steele et al. in the 2015 Dysphagia journal article titled The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review, .texture-modified foods and thickened liquids has become a cornerstone of clinical practice to address dysphagia (swallowing impairment). In the case of liquids .thin liquids (such as water) pose safety challenges for people with dysphagia because they flow quickly . A review of the undated facility document titled Pureed Diet, indicated Indications- This diet is a modification of the Regular Diet for those who have severe problems chewing and swallowing .all foods must be the consistency of mashed potatoes. Fluids should be allowed thickness only as allowed by physician's orders .

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. Expired ground meat was in the main kitchen PARVE (Jewish term that refers to neutral foods that may be eaten with milk and dairy or meats) walk-in refrigerator. 2. A dirty filter with gray lint, dust and black scum was inside the PARVE walk-in refrigerator's that contained uncovered pans of vegetables and meat. 3. The dish machine sanitizer solution was outside of the correct chemical range and tested at 200 ppm (parts per million); and the Dishwasher (DSW) could not correctly test the sanitizer. 4. The Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 5. [NAME] and flour were in large bulk unlabeled and dated in plastic bin containers. 6. A large plastic bin with 24 mighty shakes were found without the correct label and date in the satellite kitchen's reach-in refrigerator. 7. A case of vegetable egg rolls and case of rainbow sherbet ice cream were not labeled, dated, or covered properly in the walk-in freezer. 8. Kitchen and non-kitchen staff did not perform hand washing or wear hair nets when entering the satellite kitchen. 9. A DSW did not perform proper hand hygiene or change gloves after disposing the kitchen garbage. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Cross reference F800 and F802 Findings: 1. During a kitchen observation and interview on 1/24/2023 at 8:36 A.M. with the Registered Dietitian (RD), there was a clear container was labeled Ground Beef, Prep Date: 1/16/2023, Use by: 1/19/2023 in the meat refrigerator. The RD stated the ground meat was expired and should have been thrown away. A review of the facility's policy and procedure titled Food storage dated 7/2022 indicated, .12. Refrigerated food storage: .f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded . According the 2022 US FDA Food Code, Section 3-602.11 titled Food Labels, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . 2. During a main kitchen observation on 1/24/2023 at 8:47 A.M., inside the Parve walk-in refrigerator there were seven large hotel metal pans of uncovered vegetables including zucchini squash, parsley, green beans, and raw chicken. The evaporator fan inside the walk-in refrigerator was filled with gray lint, dust, and black scum. The RD acknowledged the dirty evaporator fan and stated it should have been clean to avoid getting dirt on the uncovered food. A review of the facility's policy and procedure dated 7/24/2020 titled Equipment Sanitation indicated, .Equipment in the Culinary department will be maintained in a sanitary manner . Culinary Director is responsible for maintenance, safety and sanitation of equipment .Develop policies and procedures for cleaning and sanitizing equipment . Develop and monitor cleaning and maintenance schedule based on manufacturer's instructions . 3. During a kitchen observation and interview on 1/24/2023 at 8:57 A.M., Dishwasher (DSW) 1 was in the dirty sink area and wearing yellow gloves. DSW 1 rinsed and loaded the utensils and plates from the dirty sink area, grabbed a white cloth and dried his yellow gloves, went to the clean area and picked up the bowls, dried the bowls with the white cloth and placed them in the container. DSW 1 stated he was the only person working in the dishwasher area. During an observation and interview on 1/24/2023 at 9:01 A.M., DSW 1 was not able to verbalize the process for testing the dish machine sanitizer. DSW 1 held the strip container, pulled out a strip from the container, dipped the strip to the water of the washed utensils, and compared to the color indicators of the strip container. Per DSW 1 the color was dark purple and was 200 ppm level and was okay. During an interview on 1/24/2023 at 9:10 A.M. with the RD, the RD stated that DSW 1 was trained on how to test the dish machine sanitizer and should know the process and the correct level. A review of the culinary kitchen staff in-service training records from 2021- 2022 indicated the correct sanitizing solution proportion to water in both the 3-compartment sink and dish machine was not provided. According to the 2022 US FDA Food Code, Section 4-302.14 titled Sanitizing Solutions, Testing Devices, Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1.) The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2.) Too much sanitizer in the final rinse water could be toxic. According to the 2022 US FDA Food Code, Section 4-501.17, titled Warewashing Equipment, Cleaning Agents; Failure to use detergents or cleaners in accordance with the manufacturer's label instructions could create safety concerns for the employee and consumer .chemical residues could find their way into food if detergents or cleaners are used carelessly. Equipment or utensils may not be cleaned if inappropriate or insufficient amounts of cleaners or detergents are used. According to the 2022 US FDA Food Code, Section 4-501.11, titled Good Repair and Proper Adjustment. (Equipment) Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk . Adequate cleaning and sanitization of dishes and utensils using a warewashing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize . A review of the facility's policy and procedure dated 7/2022, titled Cleaning Dishes/Dish Machine indicated, .2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes . 9. Dishes should be air dried on the dish racks, not dried with towels . 10. Inspect for cleanliness and dryness and put dishes away if clean (be sure hands are clean) . 4. During a kitchen observation and interview on 1/24/2023 at 9:57 A.M., the DSW 1 stated he cleaned the outside of ice machine every day. Per DSW 1, every month he would turn off the ice machine, empty the ice, clean the ice machine with soap using scrub. DSW 1 was observed holding a green bucket with a scrub, filled the bucket with Butler Pan Power - For Manual Pot and Pan Washing. DSW 1 opened the ice machine and removed the water curtain and stated he observed brown calcified substances. Per DSW 1, he does not know how to remove the water trough and he would document his daily and monthly cleaning in the log. He further stated the ice machine is cleaned every six months by a company. During a concurrent interview and record review on 1/24/2023 at 10:10 A.M., with the RD, the RD stated the ice machine daily cleaning logs were initialed by the kitchen staff who cleaned it and signed at the end of the month. The RD acknowledged the December 2022 monthly cleaning log was not signed off, and further stated it should have been signed off. During a kitchen observation and interview with Vendor (VD) 1, the RD and Foodservice Director (FSD) on 1/24/2023 at 2:41 P.M., VD 1 described the process he used to clean the ice machine. VD 1 stated he turned the ice machine off, removed the ice from the bin, and pour a mixture of descale lime remover solution to the machine and press the cleaning button. A Surveyor took a white paper towel and wiped the inside area of the ice chute and ice tray attached to the making part. The paper towel had dark brown crusty, semi-grimy substances on it. The FSD and RD acknowledged the dirt and grime substances on the paper towel. Both the FSD and RD stated it should not be there and the machine should be visibly clean. During a review of the ice machine's manufacturer's guidelines, the cleaning instructions indicated .water trough can be removed and the manufacturer's ice machine cleaner and sanitizer are the only products approved for use in (manufacturer's name) ice machines. According to the 2022 US FDA Food Code, Section 3-303.11, titled Ice Used as Exterior Coolant, Prohibited as Ingredient, Ice that has been in contact with unsanitized surfaces .may contain pathogens and other contaminants if this ice is then used as a food ingredient, it could be contaminated . According to the 2022 US FDA Food Code, Section 4-204.17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. According to the 2022 US FDA Food Code, Section 4-501.11 Good Repair and Proper Adjustment. (Equipment) Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. A review of the facility's policy and procedure dated 7/24/2020, titled Equipment Sanitation indicated, .Equipment in the Culinary department will be maintained in a sanitary manner . Culinary Director is responsible for maintenance, safety and sanitation of equipment .Develop policies and procedures for cleaning and sanitizing equipment . Develop and monitor cleaning and maintenance schedule based on manufacturer's instructions . 5. During the kitchen observation on 1/24/23 at 10:12 A.M, two large plastic bin containers were inside the dry storage, one contained rice and the other had white flour. The large containers were unlabeled and undated. The FSD stated the large bins should have been labeled and dated because they recently arrived in the last food delivery a couple of days ago. A review of the facility's policy and procedure titled Food storage dated 7/2022 indicated, .12. Refrigerated food storage: .f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded . According the 2022 US FDA Food Code, Section 3-602.11 titled Food Labels, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . 6. During a concurrent observation and interview on 1/25/2023 at 11:25 A.M. in the satellite kitchen, a medium sized clear plastic bin with 24 mighty shakes were found in the reach-in refrigerator. The bin was labeled and dated Prep Date: 1/18/2023, Use By: 2/18/2023. Dietary Aide (DA) 2 stated the mighty shakes used by date should have been 14 days from the time it was thawed from the freezer. During an interview on 1/25/2023 at 11:48 A.M., the RD stated the mighty shakes should have been dated 14 days after it was transferred from the freezer to the reach-in refrigerator. A review of the Mighty Shakes label manufacturer's instructions dated 1/18/2013 indicated, .Storage after open: Refrigerated, Shelf life after open: Up to 14 days @ 34 - 40 degrees . A review of the facility's policy and procedure titled Food storage dated 7/2022 indicated, .12. Refrigerated food storage: .f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded . 7. During an observation on 1/24/2023 at 9:41 A.M. in the walk-in freezer, there was an opened case of vegetable eggrolls with exposed content and without a label and date. A large carton of classic Rainbow Sherbet was mislabeled that read Prep Date: 7-24, Use By: 9-24. The sherbet had a broken lid cover and exposed content was observed on the rim and sides. A review of facility's policy and procedure titled Food storage, dated 7/2022 indicated, .13. Frozen Foods: .c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded . According to the 2022 US FDA Food Code, Section 3-602.11 titled Food Labels .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . 8. During the survey period from 1/24/23-1/26/23, multiple observations were conducted in the satellite kitchen. On 1/24/2023 at 11:50 A.M., an observation of Certified Nurse Assistant (CNA) 1 was conducted. CNA 1 walked through the kitchen without a hair net. Also, CNA 2 staff entered the kitchen and did not perform hand hygiene or use a hair net. During an observation and interview on 1/24/2023 at 12:55 P.M., CNA 1 was observed again going in and out of the kitchen without a hair net. CNA 1 stated he wore a hair net earlier and was running in and out of the kitchen to take care of a resident's food request. CNA 1 further stated it was frustrating that he forgot to do something like put on a hair net, but I was not trained on why wear one. CNA 1 also stated he did not fully know the protocol in the kitchen. According to the 2022 US FDA Code, Section 2-402.11 titled Hair Restraints-Effectiveness .FOOD EMPLOYEES shall wear short hair or use hair restraints such as hats, hair coverings or nets, rubber bands, or hair clips to keep their hair off the face and behind their shoulders, and clothing that covers body hair to protect exposed FOOD; clean EQUIPMENT, UTENSILS . A review of facility's policy and procedure titled Food Safety and Sanitation dated 7/2022, indicated .c. Hair restraints are required and should cover all hair in the head . A review of facility's policy and procedure titled Food Safety and Sanitation dated 7/2022 indicated, .d. Employees will wash their hands just before they work in the kitchen and after .touching . surfaces or items potential for contamination . A review of facility's policy and procedure titled Hand Washing dated 7/2022 indicated, Employees will wash hands as frequently as needed through the day using proper hand washing procedure . a. When entering the kitchen . f. After handling soiled equipment or utensils . i. Before donning disposable gloves .and after gloves are removed .j. After engaging in other activities that contaminate the hands. 9. During an observation and interview on 1/25/2023 at 1:40 P.M. with DSW 1, DSW 1 took out the trash to the dumpsters, then pushed it back into the kitchen, and filled the trash bin with a new trash bag. After DSW 1 reentered the kitchen, he did not remove the soiled gloves or perform hand hygiene by washing his hands after he walked through the kitchen pass food preparation areas and exposed food. Per DSW 1, he should have washed his hands when he reentered the kitchen. The RD and FSD acknowledged that DSW should have removed his gloves, perform hand washings and put on new gloves when he reentered the kitchen after he took out the trash to the dumpster. According to the 2022 US FDA Food Code. Annex 3 titled Garbage disposal: . The failure of food-handlers to wash hands in certain situations (such as after using the toilet, handling raw meat, cleaning spills, or carrying garbage), wear clean disposable gloves .is responsible for the foodborne transmission of these pathogens. Non-foodborne routes of transmission, such as from one person to another, are also major contributors in the spread of these pathogens . According to the 2022 US FDA Food Code, Section 2-301.11 titled Clean Condition .The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code . According to the 2022 US FDA Food Code, Section 2-301.14 titled When to Wash .The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after .activities . Employees must wash their ands after any activity which may result in contamination of the hands . A review of facility's policy and procedure titled Food Safety and Sanitation, dated 7/2022 indicated, .d. Employees will wash their hands just before they work in the kitchen and after .touching . surfaces or items potential for contamination . A review of facility's policy and procedure titled Hand Washing dated 7/2022 indicated, Employees will wash hands as frequently as needed through the day using proper hand washing procedure . a. When entering the kitchen . f. After handling soiled equipment or utensils . i. Before donning disposable gloves .and after gloves are removed .j. After engaging in other activities that contaminate the hands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for the use of a bed alarm (a device that triggers a sound when the resident moves) for one of one sampled resident (3). This deficient practice placed Resident 3 at risk to not receive consistent care. In addition, there was no on-going monitoring and evaluation for continued use of the bed alarm. Findings: Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses to include convulsions (seizures), per the Resident Face Sheet. According to the comprehensive resident assessment, completed on 4/26/19, Resident 3 scored 14 of 15 points on the BIMS (screening tool used to assess thinking and reasoning), indicating no impairment. Resident 3 required supervision with daily activities, and assistance with transfers and walking. On 8/13/19 at 9 A.M., Resident 3 was observed lying in bed. A black box with blinking lights, approximately 8 by 15 cm, was attached to the bed side rail. Resident 3 did not wish to be interviewed. On 8/13/19 at 10:56 A.M., LN 11 was interviewed. LN 11 stated the black box was part of Resident 3's bed alarm. LN 11 stated Resident 3 had a bed alarm because of a fall on 4/9/19 following a seizure. On 8/15/19 at 10:08 A.M., Resident 3's health record was reviewed with LN 11. LN 11 was unable to find a physician's order for the bed alarm. There was no evidence the use of the bed alarm had been monitored or reviewed by the inter-disciplinary team since readmission on [DATE]. On 8/15/19, a separate review of Resident 3's Clinical Documentation-[NAME] Weekly Summary notes indicated a bed alarm had been used consistently from 4/17/19 to 8/7/19. There was no evidence a care plan had been developed for the bed alarm. On 8/15/19 at 11:03 A.M., the CN was interviewed. The CN stated she was not aware Resident 3 had a bed alarm until 8/14/19. The CN stated there should have been a physician's order and a care plan for Resident 3's bed alarm. According to the facility's policy, Care Plans, Comprehensive Person-Centered, revised 12/16, . 8, the comprehensive, person-centered care plan will: . g. Incorporate identified problem areas; c. Define current treatments e. Make decisions about care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the proper procedure to assess the effectiveness of a nebulizer treatment that was administered to one of one resident (13), reviewed for breathing treatments. This failure had the potential to affect Resident 13's respiratory status and physical well being. Findings: Resident 13 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 8/15/19 at 11:10 A.M., during the medication administration observation, a nebulizer treatment for Resident 13 was conducted by LN 5. Prior to treatment, LN 5 did not obtain a respiratory rate or listen to the resident's lungs. Following the breathing treatment, LN 5 did not obtain a respiratory rate or listen to the resident's lungs. On 8/15/19 at 1:00 P.M., an interview was conducted with CN. CN stated lung fields should be evaluated before and after a breathing treatment. CN stated a pulse and respiratory rate should also be included. Review of the facility's policy, titled Administering Medications through a Small Volume (Handheld) Nebulizer, dated October 2010, .6. Obtain baseline pulse, respiratory rate and lung sound 26. Obtain post-treatment pulse, respiratory rate and lung sounds . Per [NAME], Manual of Nursing, eighth edition, Respiratory Disorders; documents nursing interventions for improving airway clearance to include, .Auscultate the chest before and after administration of aerosol bronchodilators [a medication used to open the airways]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Adequately assess a resident's fall risk for one of four residents (18) reviewed for accidents; and 2. Perform timely and consistent neurological assessments for one of four residents (18) reviewed for accidents, after Resident 18 sustained a head injury. These failures had the potential to put Resident 18 at a higher risk for falls, and for Resident 18 to have an undetected, untreated head injury. Findings: 1. Resident 18 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's diseases (a progressive mental deterioration), per the facility's Resident Face Sheet. On 8/13/19 at 8:17 A.M., Resident 18 was observed in a geri-chair (a padded medical reclining chair with elevated leg rest) in her room. Resident 18's eyes were closed and she did not respond to voice or touch. On 8/13/19 at 11:26 A.M., an interview was conducted with Resident 18's RP. The RP reported Resident 18 fell from her bed a few months ago. On 8/14/19 at 8:30 A.M., a review of Resident 18's medical record was conducted. Resident 18's Care Plan, titled Falls, dated 2/23/18, indicated Resident 18 was at risk for falls due to cognitive impairment (difficulty thinking and understanding), vision impairment (vision loss), and poor safety awareness. Resident 18's Fall Risk Assessments, dated 12/10/18, 3/12/19, and 6/10/19, listed the resident as having Adequate vision. Resident 18's quarterly MDS, dated [DATE], and her annual MDS, dated [DATE], for vision assessment, listed the resident's vision as severely impaired. On 8/15/19 at 8:07 A.M., Resident 18's medical record was reviewed with the SN. The SN stated Fall Risk Assessments were important in order to evaluate a resident's fall risk. The SN stated once fall risk assessments were reviewed, interventions were put in place to prevent future falls. The SN reviewed Resident 18's fall risks assessments and stated the assessment for vision was incorrect, because Resident 18 had poor vision. The SN stated residents with higher scores had more interventions added to their plan of care, because their risk of falls was higher. The SN stated if Resident 18's vision assessment was correct, the resident's fall risk score would have been higher. According to the facility's policy, titled Falls Risk Management, revised May 2019, The nursing staff will identify those residents at risk for falls, based on the .Assessment . 6. Assessment data shall be used to identify underlying Medical conditions that may increase the risk of injury from falls . 10. A Resident-centered care plan will be developed . 2. Resident 18 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's diseases (a progressive mental deterioration), per the facility's Resident Face Sheet. On 8/13/19 at 8:17 A.M., Resident 18 was observed in a geri-chair (a padded medical reclining chair with elevated leg rest) in her room. Resident 18's eyes were closed and she did not respond to voice or touch. On 8/13/19 at 11:26 A.M., an interview was conducted with Resident 18's RP. The RP reported Resident 18 fell from her bed a few months ago. On 8/14/19, a review of resident 18's medical record was conducted. Per the facility's nursing notes, dated 3/20/19 at 10:36 A.M., Resident sustained a hematoma (a collection of blood that leaks into the tissue) after being transferred from the chair to the bed via hoyer lift (hydraulic equipment use to lift and move residents). Resident rolled on to her side and hit forehead, sustaining raised hematoma 3x3 (size) on right side of forehead. Resident 18's neurological exams (handgrips, leg pushes, alertness, orientation, pupil size and pupil reaction to light-an assessment to detect changes in the brain) were reviewed from 3/20/19 through 3/23/19. The neurological exams were conducted once every eight hours and varied in assessment responses. On 3/21/19 and 3/23/19, the day shift (7 A.M. to 3 P.M.) assessed pupil size and pupil reaction as n/a (not applicable). The assessment for leg pushes on the evening and night shift had varied entries such as baseline, +, =. On 8/15/19 at 8:07 A.M., Resident 18's neurological assessment was reviewed with the SN. The SN stated residents with head injuries or unwitnessed falls should have neurological exams at least for 72 hours. The SN stated neurological exams start at specific time intervals such as every 15 minutes, every hour, every four hours and then every eight hours. The SN stated the purpose for specific time intervals assessments was to detect abnormal neurological symptoms early, so medical interventions could be implemented. On 08/15/19 at 10:25 A.M., an interview was conducted with the CN. The CN stated Resident 18 should have had more frequent neurological exams, because of her forehead injury. The CN stated if Resident 18 had a serious head injury, there would have been a delay in detecting it. According to the facility's policy, titled Neurological Assessment, revised October 2010, .1. Neurological assessments are indicated: . c. Following a fall or other accident/injury involving trauma to the head; .2. When assessing neurological status, always include frequent vital signs .This may be indicative of increasing intracranial pressure (ICP)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician's order to monitor oxygen saturation levels (a percentage of oxygen measured in the blood by a medical device-called a pulse oximeter, clipped to the finger), for one of two resident's (139) reviewed for oxygen administration. This failure had the potential for Resident 139 to receive oxygen when not required. Findings: Resident 139 was admitted to the facility on [DATE], with diagnoses which included congested heart failure (fluid buildup around the heart), per the facility's Resident Face Sheet. On 8/13/19 at 8:57 A.M., Resident 139 was observed in her room, sitting in a wheelchair eating breakfast. Resident 139's oxygen condenser (a machine that delivers oxygen) was set at 2 liters of oxygen per minute, delivered by nasal cannula (plastic tubing which delivers oxygen to the nose). On 8/13/19, a review of Resident 139's medical record was conducted. Per the physician's order, dated 8/4/19, .Oxygen @ 2 liters/min (minute) via nasal cannula to maintain . sat (saturations) at or greater then 92% (normal 96-98%) .check oxygen saturation level Q (every) shift on room air (without oxygen) . On 8/15/19 at 9:24 A.M., CNA 1 was observed obtaining Resident 139's vital signs (blood pressure, pulse rate, oxygen saturation, and temperature). CNA 1 placed the pulse oximeter on Resident 139's right index finger, while the resident was receiving 2 liters of oxygen via nasal cannula. CNA 1 stated the purpose of the pulse oximeter was to take the resident's pulse. CNA 1 stated Resident 139's pulse was 115. On 8/15/19 at 9:59 A.M., an interview and record review was conducted with the DSD. The DSD stated he trained the CNAs on performing basic vital signs, but he had not provided the CNAs with detailed education regarding pulse oximeters or oxygen saturations. The DSD stated per the physician's order, Resident 139's oxygen saturation should have been tested while the resident was off oxygen, to get an accurate reading. On 8/15/19 at 10:17 A.M., an interview and record review was conducted with the CN. The CN stated if oxygen was ordered prn, the oxygen saturations should always be tested on room air, because the resident might not need the oxygen. The CN stated testing Resident 139's oxygen saturation while on oxygen, did not provide the physician or the LNs with an accurate account of the resident's current pulmonary (lung) status. Resident 139's documentation for oxygen saturations from 8/4/19 through 8/14/19, was reviewed by the CN. The CN stated all the documented saturations of 98-100% were performed by CNAs. The CN stated she could tell by the saturation levels, the tests were performed while the resident was on oxygen. The other documented levels, signed off by LNs ranged between 90-94%, which were more accurate with not being on oxygen. The facility's policy, titled Oxygen, undated, did not address or provide guidance on performing oxygen saturations readings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacy consultant (PC) identified monthly medication irregularities (identification of potential adverse drug effects) for one of six residents (12), reviewed for unnecessary medications. This failure had the potential for Resident 12 to receive unnecessary medications, and experience adverse drug effects. Findings: Resident 12 was admitted to the facility on [DATE], with diagnoses which included dementia (a decline in memory and reasoning), per the facility's Resident Face Sheet. On 8/14/19, a record review was conducted for Resident 12. Per the physician's orders, dated 5/24/19, .Ativan 0.5 mg (milligrams) every two hours as needed for moderate anxiety .Ativan 1 mg as needed for severe anxiety every two hours .monitor resident behavior AEB (as exhibited by) anxiety, restlessness . Resident 12's MAR was reviewed for documented episodes of anxiety. Resident 12 displayed anxiety and agitation five times from 6/1/19 through 8/14/19. Resident 12's MAR was reviewed for the administration of Ativan. Ativan 0.5 mg was administered 14 times from 6/1/19 through 8/14/19. Ativan 1 mg was administered five times from 6/1/19 through 8/14/19. The physician progress notes, dated 7/11/19, did not indicate a justification or rationale for the use of Ativan. On 8/14/19 at 1:17 P.M., an interview was conducted with LN 5. LN 5 stated when Ativan was used for anxiety prn, it must be re-evaluated every 14 days, to determine if its continued use was necessary. On 8/15/19, a review of the facility's Medication Regime Review (MRR-a book containing residents' names and their medications, which are reviewed on a monthly basis by the facility's pharmacy consultant) was conducted. On 5/22/19, the PC made a recommendation to Resident 12's PMD, Clarify stop date for prn lorazapam (ativan). There was no documented evidence in June and July's MRR for the continued administration of Resident 12' Ativan. On 8/15/19 at 9:30 A.M., an interview was conducted with the PC. The PC stated any prn psychotropic medication should be reviewed every 14-days. The PC stated if a physician wanted to continue the use of the prn psychotropic medication, the physician must write a justification for why the medication should be continued. The PC stated she made a recommendation May 2019, to Resident 12's PMD asking clarification of the 14 day use of Ativan. The PC stated she did not re-write the recommendation in June or July's MRR. The PC could not verify if the PMD ever received her initial recommendation in May, and she felt notifying the PMD once was sufficient. According to the facility's policy, titled Antipsychotic Medication Use, revised December 2016, .12. All antipsychotropic medications will be used within the dosage guidelines listed .or clinical justification will be documented for dosages that exceed the listed guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess for appropriate use of a psychotropic (medication capable of affecting the mind, emotions, and behavior) medications for one of six residents (12) reviewed for unnecessary medications. This failure had the potential to delay identification of serious or life-threatening adverse effects from the psychotropic medication. Findings: 1. Resident 12 was admitted to the facility on [DATE], with diagnoses which included dementia (a decline in memory and reasoning), per the facility's Resident Face Sheet. On 8/14/19, a record review was conducted for Resident 12. Per the physician's orders, dated 5/24/19, .Ativan (a medication to treat anxiety) 0.5 mg (milligrams) every two hours as needed for moderate anxiety . Ativan 1 mg as needed for severe anxiety every two hours or for severe shortness of breath, or if Roxanol ineffective (morphine sulfate, a medication for severe pain) .monitor resident behavior AEB (as exhibited by) anxiety, restlessness . Resident 12's MAR was reviewed for episodes of anxiety. Resident 12 displayed anxiety and agitation five times from 6/1/19 through 8/14/19. There was no documented evidence non-pharmalogical interventions (approaches to refocus behavior without medication) were implemented prior to the administration of Ativan. Resident 12's MAR was reviewed for the administration of Ativan. Ativan 0.5 mg was administered 14 times from 6/1/19 through 8/14/19. Ativan 1 mg was administered five times from 6/1/19 through 8/14/19. There was no documented evidence Roxanol was administered from 6/1/19 through 8/14/19. The physician progress notes, dated 7/11/19, did not indicate a justification or rationale for the use of Ativan. On 8/14/19 at 1:17 P.M., an interview was conducted with LN 5. LN 5 stated when Ativan was used for anxiety prn, it must be re-evaluated every 14 days, to determine if its continued use was necessary. On 8/15/19 at 1:19 P.M., an interview was conducted with the MD. The MD stated prn psychotropic medications had a 14-day limit. The MD stated it was the facility's responsibility to monitor the resident's behavior, the frequency of the administered medications, and the necessity of the medications continued use. Per the facility's policy titled Antipsychotropic Medication Use, revised December 2014, .14.PRN orders for psychotropic medication beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotropic medication will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. 16. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of the any interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently offer bedtime snacks to eight of 11 residents reviewed for evening snacks. This failure had the potential to result in residents not having adequate nourishment between the evening meal and breakfast the following day. Findings: On 8/14/19, interviews were conducted with six confidential residents (CR- 1, 2, 3, 4, 5, 6). Five of the six CR's stated they were not offered snacks in the evening. CR 1 stated she asked staff for something to eat once and was provided cheese, crackers, and hot tea. CR 1 stated the snack was excellent and she would not mind having it again. CR 1 stated when first admitted , the RD asked her if she would like a snack in the evening. CR 1 stated she did not want something every night, but she would want a snack every now and then. CR 2 stated evening snacks had never been offered to her. CR 2 stated she did not know she could have a snack at night. CR 4 stated he was unaware there was a snack station next to the nurse's station. CR 4 stated he had never been offered a bedtime snack, and it would be a nice. CR 5 stated snacks in the evening had not been offered and he would like that. CR 6 stated she had been offered snacks in the past, but it was not routinely offered. On 8/14/19 at 3:03 P.M., the CSM was interviewed. The CSM stated snacks were placed in the small refrigerator in the south dining room and were stocked at the alcove near the nurses' station. Resident-specific snacks were labeled and dated. The CSM stated snacks were available, should a resident request a snack. On 8/14/19 at 3:21 P.M., an interview was conducted with CNA 5. CNA 5 stated evening snacks were delivered around 7 P.M., and stored in the refrigerators or at the snack station. CNA 5 stated some snacks were labeled with residents' names, and the specific snacks would be provided to those residents. CNA 5 stated a snack was available for residents who requested a snack. On 8/14/19 at 3:39 P.M., an interview was conducted with LN 4. LN 4 stated CNAs distribute snacks to the resident's on the snack list, who have requested bedtime snacks. LN 4 did not know if residents who were not on the list, were offered snacks. On 8/14/19, at 3:41 P.M., a list of the residents who requested evening snacks was reviewed. The list contained 25 residents out of a census of 44. On 8/15/19 at 11:46 A.M., an interview was conducted with Resident 138, who was not on the facility's list for receiving evening snacks. Resident 138 stated she had never been offered an evening snack, and she would like that. On 8/15/19, a record review was conducted for Resident 138. Resident 138 was admitted on [DATE], per the facility's Resident Face Sheet. Resident 138's BIMS (a cognitive assessment tool) dated 8/15/19, had a score of 15 (indicating cognitively intact). On 8/15/19 at 11:56 A.M., an interview was conducted with Resident 144, who was not on the facility's list for receiving evening snacks. Resident 144 stated he was admitted two days ago, and had not been offered any nighttime snacks. On 8/15/19 at 11:58 A.M., an interview was conducted with Resident 145, who was not on the facility's list for receiving evening snacks. Resident 145 stated she had not been offered any snacks in the evening time. Resident 145 stated she would like to be offered something, and she thought a snack was a good idea. On 8/15/19, a record review was conducted for Resident 145. Resident 145 was admitted on [DATE], per the facility's Resident Face Sheet. Resident 145's BIMS score, dated 8/8/19, was 13 (indicating cognitively intact). According to the facility's policy, titled Snacks (Between Meals and Bedtime), Servings, dated September 2010, The purpose of this procedure is to provide the resident's with adequate nutrition . Documentation .1. The date and time the snack was served . 7. If the resident refused the snack, the reason(s) why .

Based on observation, interview, and record review, the facility failed to ensure an employee performed hand hygiene between plating resident food and touching potentially contaminated equipment. This failure had the potential for food contamination and to expose residents to food-borne illnesses. Findings: On 8/13/19 at 12:20 P.M., during lunch service in the main dining room, FSW 1 was observed touching and plating ready-to-eat foods (RTE-foods that do not need further preparation before eating) from a steam table using gloved hands. FSW 1 left the food service area and walked to the cold service counter. FSW 1 was observed opening two refrigerators using the same gloved hands, removing food items, and touching serving dishes and utensils. FSW 1 returned to the steam table area and began to plate RTE. FSW 1 did not change gloves between tasks. On 8/13/19 at 12:45 P.M., FSW 1 was interviewed. FSW 1 acknowledged she did not perform proper hand hygiene between plating food and touching equipment. FSW 1 stated she should have removed her gloves, washed her hands, and put on clean gloves before she resumed plating the residents' food. On 8/13/19 at 12:51 P.M., the RD was interviewed. The RD stated FSW 1 should have performed proper hand hygiene before she returned to plating food from the steam table. 3-304.11 Food Contact with Equipment and Utensils. Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. They may also be passed on by consumers or employees directly, or indirectly from used tableware or food containers. Some pathogenic microorganisms survive outside the body for considerable periods of time. Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. The handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination. 3-304.15 Gloves, Use Limitation. Refer to the public health reason for § 3-304.11. Gloves used in touching ready-to-eat food are defined as a utensil and must meet the applicable requirements related to utensil construction, good repair, cleaning, and storage. Multiuse gloves, especially when used repeatedly and soiled, can become breeding grounds for pathogens that could be transferred to food. Soiled gloves can directly contaminate food if stored with ready-to-eat food or may indirectly contaminate food if stored with articles that will be used in contact with food. Multiuse gloves must be washed, rinsed, and sanitized between activities that contaminate the gloves. Hands must be washed before donning gloves. Gloves must be discarded when soil or other contaminants enter the inside of the glove. Slash-resistant gloves are not easily cleaned and sanitized. Their use with ready-to-eat foods could contaminate the food. According to the facility's policy, Hand-Hygiene - CDC Guidelines, revised 4/23/19, All staff will use the hand-hygiene techniques Change Gloves when switching tasks.