**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of facility staff to resident physical abuse for one of three sampled residents (Resident 1) when * Resident 1 alleged that her caregiver (CNA) physically abused her. The facility staff tasked with conducting potential resident witness interviews, failed to provide the facility's Abuse Coordinator with an interview conducted with Resident 1's roommate (Resident 2), who was present during the time Resident 1 alleged to have been physically abused. This failure potentially inhibited the facility's ability to determine if resident abuse occurred and posed the risk for further abuse. Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 12/19/22, showed it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation occurs. Procedures for investigations include identifying and interviewing all involved people, including the alleged victim, alleged perpetrator, and witnesses who might have knowledge of the allegation. Medical record review for Resident 1 was initiated on 9/17/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had moderately impaired cognition. On 9/17/25 at 1550 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed in her room lying in her bed. Resident 1 stated approximately two weeks ago, on the night shift, her caregiver slapped her on the face, choked her, and squeezed her hands, resulting in pain to her hands. Resident 1 described the caregiver as being a female with blonde hair. Resident 1 stated she reported the incident to the facility staff. Resident 1 stated her roommate (Resident 2) was present during the incident. Medical record review for Resident 2 was initiated on 9/17/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 had moderately impaired cognition. On 9/17/25 at 1600 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed in her room lying on her bed. Resident 2 was asked if she witnessed any person slap or choke her roommate (Resident 1) or squeeze her roommate's hands. Resident 2 stated she had poor vision and had not seen anyone slap or choke Resident 1 or squeeze Resident 1's hands. Resident 2 stated she did hear Resident 1 yelling about being hit. On 9/17/25 at 1738 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator stated he served as the facility's Abuse Coordinator. The Administrator stated the facility conducted an investigation specific to Resident 1's allegation that a facility staff member choked, slapped, and squeezed Resident 1's feet. The Administrator stated the SSD and Social Services Assistant (SSA) conducted interviews of the facility staff and residents during the course of the facility's investigation. The Administrator stated at the conclusion of the facility's investigation, the facility was unable to substantiated Resident 1's allegation. Review of the facility's investigation was then conducted with the Administrator. The facility's investigation failed to show documentation Resident 1's roommate (Resident 2) was interviewed, or an attempt was made to interview Resident 2, specific to Resident 1's allegations. The Administrator verified the findings and stated an interview with Resident 2 should have been included as a component of the facility's investigation. The Administrator stated he had not realized (when reviewing the facility's investigation) Resident 2's interview was not included. The Administrator stated Resident 2 was a potential witness and in accordance with the facility's Abuse P&P, needed to be interviewed. The Administrator stated interviewing potential witnesses would help the facility determine whether abuse may have occurred. On 9/18/25 at 1121 hours, an interview, medical record review, and concurrent facility document review was conducted with the SSD. The SSD stated her assistant, the SSA, conducted the interviews of the Vietnamese speaking residents, specific to the facility's investigation of Resident 1's allegations. The SSD was asked if Resident 2 (Vietnamese speaking) was interviewed during the course of the facility's investigation of Resident 1's allegations. The SSD stated the SSA had interviewed Resident 2, however, the SSD did not provide Resident 2's interview to the Administrator (Abuse Coordinator). The SSD stated she had asked the MDS Coordinator if Resident 2 had the capacity to be interviewed. The SSD stated the MDS Coordinator told her Resident 2 had no capacity. The SSD stated she then placed the SSA's documentation of the interview the SSA conducted with Resident 2 in the facility's shred box. The SSD stated she did not provide Resident 2's interview to the Administrator (Abuse Coordinator). The SSD then reviewed Resident 2's MDS assessment dated [DATE], and verified Resident 2 was assessed as having moderately impaired cognition. The SSD stated the residents with moderately impaired cognition might have the capacity to provide information, specific to whether they have been the victim of an abuse or have witnessed another resident being abused. The SSD stated she should have included Resident 2's interview as a component of the facility's' investigation into Resident 1's allegation. The SSD stated all the potential witness interviews should have been provided to the facility's Abuse Coordinator, to ensure the Abuse Coordinator had all the information necessary to determine whether resident abuse occurred. On 9/18/25 at 1148 hours, an interview was conducted with the SSA. The SSA stated in accordance with the facility's investigation of Resident 1's allegation she was physically abused, the SSA conducted an interview with Resident 1's roommate (Resident 2). The SSA stated Resident 2 could verbalize her needs and had a general conversation specific to her needs. The SSA stated Resident 2 had the ability to articulate if someone were to abuse her. The SSA stated Resident 2 had impaired vision, however, if Resident 2 were to hear someone abuse her roommate (Resident 1) she could also articulate this information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of five final sampled residents (Resident 4) attained and maintained their highest practicable well-being. * The facility failed to continuously monitor Resident 4 after the resident had a witnessed fall. This failure had the potential for not providing the necessary care and services if the residents had a change in condition. Findings: Review of the facility's P&P titled Fall Prevention Program revised 12/28/23, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will assess the resident and document all assessments and actions. Medical record review for Resident 4 was initiated on 6/25/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 4/10/25, showed Resident 4 had no capacity to understand and make decisions. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had severe cognitive impairment and needed substantial/maximal assistance with mobility. Review of Resident 4's SBAR Communication Form dated 5/13/25, showed Resident 4 was being wheeled by the CNA to go to the dining area and the wheelchair got stuck in the carpet by the door to the patio which caused Resident 4 to slide off the wheelchair and fall forward. Resident 4 did not hit her head on the ground and did not sustain any injuries. The carpet was taken off the dining room right away. Review of Resident 4's plan of care initiated on 5/13/25, showed a care plan problem addressing Resident 4's fall incident on 5/13/25. The interventions included to monitor Resident 4 for pain or discomfort, vital signs, change in level of consciousness and notify the physician as needed. Further review of Resident 4's medical record failed to show documented evidence of continued monitoring/assessment for Resident 4 by the licensed nurses after the fall incident on 5/13/25. On 6/25/25 at 1108 hours, an observation and concurrent interview was conducted for Resident 4. Resident 4 was awake and sitting in the wheelchair inside the room. Resident 4 was unable to verbalize anything when asked about the fall incident happened on 5/13/25. Resident 4 was smiling and stated she was ok. On 6/25/25 at 1510 hours, a telephone interview for Resident 4 was conducted with CNA 2. CNA 2 verified the fall incident of Resident 4 on 5/13/25. CNA 2 stated Resident 4 was confused, could not follow the instructions, and was always trying to get out of the wheelchair. CNA 2 stated she was wheeling Resident 4 to the dining room and Resident 4 tried to stand up and because it was too fast, she could not grab Resident 4 right away. CNA 2 stated it was either the wheelchair or Resident 4's feet which got stuck in the door mat. CNA 2 stated everything happened so fast. CNA 2 stated Resident 4 did not hit her head on the ground and the nurse was there and came right away to assist. On 6/25/25 at 1630 hours, an interview and concurrent medical record review for Resident 4 was conducted with RN 1. RN 1 stated she witnessed Resident 4's fall incident on 5/13/25. RN 1 stated the wheelchair in which Resident 4 was seating got stuck in the door mat while being wheeled by CNA 2 in the dining area. RN 1 stated Resident 4 fell forward but did not hit her head on the ground. RN 1 stated a fall incident was considered a change in condition. RN 1 stated for a change in condition, the licensed nurse needed to monitor the resident every shift for 72 hours. RN 1 stated the licensed nurse should monitor the resident who had a fall for any changes in the resident's condition, vital signs, pain, and level of consciousness. RN 1 further stated it was important to continuously monitor the resident when there was a change in condition because based on the assessment, they could provide the proper care to the resident and would be able to notify the physician of any changes. RN 1 verified Resident 4 was not continuously monitored on 5/14 and 5/15/25 after Resident 4 fell on 5/13/25. On 6/26/25 at 1634 hours, an interview was conducted with the DON. The DON stated for any change in condition, the licensed nurses had to monitor the resident every shift for 72 hours for any changes in the mental status, vital signs, pain or discomfort, and skin. The DON further stated the importance of monitoring the resident continuously after a change in condition like fall was to assess right away if there were any changes in the resident's status, to be able to report to the physician, and to provide the necessary care to the resident. The DON was notified and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of one final sampled resident (Resident 75) reviewed for communication needs. * The facility failed to ensure Resident 75 was provided with the means to communicate his daily needs. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care. Findings: Review of the facility's P&P titled Effective Communication revised 10/2022 showed the following: - During the prescreening and admission process, as much information as possible will be obtained regarding the resident's current processes for communication; - Direct care staff will be educated on effective communication that reflects the needs of the resident population and needs of the staff, corresponds with the Facility Assessment; and - Staff will communicate with the resident, using techniques identified in their plan of care, and in accordance with his/her established routine for communication, as possible. Adaptive techniques include but are not limited to using sign language and using communication boards or writing materials. Medical record review for Resident 75 was initiated on 5/29/25. Resident 75 was admitted to the facility on [DATE]. Review of Resident 75's H&P examination dated 5/1/25, showed Resident 75 had the capacity to understand and make decisions. In addition, the H&P examination showed the resident's diagnoses included CVA and aphasia. Review of Resident 75's MDS assessment dated [DATE], showed the following: - Section B0600 Speech Clarity: 2, unclear speech- slurred or mumbled words; - Section B0700 Makes Self Understood: 1, usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time; and - Section C0500 Brief Interview for Mental Status (BIMS) score of 99 which meant Resident 75 was unable to complete the interview. However, section C 1000 for Cognitive Skills for Daily Decision-Making assessment showed code zero which meant independent. On 5/28/25 at 0839 hours, during the initial tour, Resident 75 was observed lying in bed, awake, alert and mumbled words with gestures. Greeted and communicated with Resident 75; however, Resident 75's words and gestures were incomprehensible. There was no visible sign of language interpreter information or communication board available in Resident 75's room. On 5/28/25 at 0845 hours, an observation of Resident 75 and concurrent interview was conducted with CNA 1. Resident 75 was observed mumbling words and gesturing to CNA 1. CNA 1 mentioned Resident 75 understood Vietnamese language only. CNA 1 was observed pointing at things and attempting to guess what Resident 75 was trying to tell her. CNA 1 was observed not using any communication/picture board with the resident. In addition, CNA 1 failed to inform the charge nurse to call the language interpreter line or requested another Vietnamese speaking staff to translate for Resident 75 to communicate his needs. When CNA 1 was asked how she could communicate and understand Resident 75, considering the language barrier between the two of them, CNA 1 stated she tried to understand Resident 75's wants and needs through Resident 75's gestures. When CNA 1 was asked if Resident 75 was provided with a communication board or the phone number to call the language interpreter line, CNA 1 stated Resident 75 was not provided with a communication board to use in his room and was not aware of the language interpreter line. On 5/28/25 at 0959 hours, an observation of Resident 75 and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 75 did not have any communication or picture board available at bedside or in his room, and the information for the language interpreter line was not available. Review of Resident 75's Social Service assessment dated [DATE], showed the following: - Orientation was alert and oriented x 3 (indicates a patient's level of consciousness and orientation); - Communication status impaired; - Primary language was Vietnamese, communicated by shaking and nodding his head; - Adequate hearing; and - Adequate eyesight and did not wear eyeglasses. Review of Resident 75's care plan for communication problem related to language barrier and no speech due to stroke dated 5/1/25, showed the goal was for Resident 75 to be able to make his needs known by communication board daily. The care plan interventions included to anticipate and meet the resident's needs, the resident preferred to communicate in Vietnamese, and to discuss with the resident/family concerns regarding the communication difficulty. However, the care plan interventions did not include a communication means for the staff and resident to use, including communication board and language interpreter line to achieve the established goal. On 5/30/25 at 1400 hours, an interview and concurrent medical record review for Resident 75 was conducted with RN 1. RN 1 was asked about the facility's process to communicate with non-English speaking or aphasic residents. RN 1 stated the facility provided a communication board to the residents, and the staff could use a language interpreter services line. When RN 1 was asked if all the staff were informed and aware on how to use the language interpreter line, RN 1 stated she thought so; however, she stated she was not 100% sure if all staff were aware that the facility provided the language interpreter line for any of the staff to use to communicate to non-English speaking residents. Resident 75's care plan for communication problem related to language barrier and no speech due to stroke was reviewed with RN 1 and she verified the facility failed to provide Resident 75 with the communication board to achieve the goal and ensure the interventions included the necessary means of communication be provided. Furthermore, RN 1 stated the implications for failure to provide the necessary means of communication was a delay in providing Resident 75's daily needs. On 6/2/25 at 1444 hours, an interview and concurrent medical record review for Resident 75 was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 75 was diagnosed with aphasia and the primary language was Vietnamese. Resident 75's MDS Section B assessment dated [DATE], was reviewed with the MDS Coordinator. The MDS Coordinator verified the MDS Section B assessments and stated without a Vietnamese staff interpreter, she was not able to understand Resident 75 through his gesturing and incomprehensible words. The MDS Coordinator did not mention about using or providing a communication board or could have called the facility's language interpreter line to communicate with Resident 75. The MDS Coordinator stated there was not a Vietnamese speaking staff working in every shift, mostly morning and evening shifts. Furthermore, the MDS Coordinator stated the nursing staff, social services, and activity department were responsible in providing the means of communication like a communication board to each of the resident who needed it. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator stated upon admission of each resident to the facility, the admitting nurse must assess the communication status of the resident and must provide the communication board if the resident spoke a different language other than English or aphasic. In addition, the Administrator stated the activity staff must check and follow up daily for the presence and availability of the communication board at the resident's bedside. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 914 was initiated on 5/28/25. Resident 914 was admitted to the facility on [DATE]. Review of Resident 914's Order Summary Report showed a physician's order dated 4/11/25, to administer sertraline 25 mg by mouth a day for depression. Review of Resident 914's MAR for May to June 2025 showed Resident 914 was administered the sertraline medication from 5/1 to 6/2/25 at 0900 hours. Further review of Resident 914's medical record failed to show the non-pharmacological interventions were implemented prior to administering the sertraline medication. On 6/2/25 at 1059 hours, an interview and concurrent medical record review for Resident 914 was conducted with RN 2. RN 2 verified the non-pharmacological interventions were not implemented prior to administering the sertraline medication to Resident 914. RN 2 stated the non-pharmacological interventions were implemented prior to administering psychotropic medications as needed but not for routine psychotropic medications. 4. Medical record review for Resident 93 was initiated on 5/28/25. Resident 93 was readmitted to the facility on [DATE]. Review of Resident 93's Order Summary Report showed the following physician's orders: - dated 3/28/25, to administer zolpidem by mouth at bedtime every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday for insomnia; and - dated 9/13/24, to monitor the hours of sleep and record the number of times the behavior was manifested every evening and night shift. Review of Resident 93's MAR for April and May 2025 showed Resident 93 was administered the zolpidem medications on 4/1 to 4/5, 4/7 to 4/12, 4/14 to 4/19, 4/21 to 4/26, 4/26 to 5/2, 5/5 to 5/10, 5/12 to 5/17, 5/19 to 5/24, and 5/26 to 5/31/25. a. Review of Resident 93's Monitor Record for April and May 2025 showed Resident 93's hours of sleep were ranged from four to ten hours. However, the record failed to show the number of times for the behavior manifested when Resident 93 had insomnia. b. Review of Resident 93's Psychopharmaceutical Summary Sheet for April 2025 related to the use of zolpidem medication showed the behavioral manifestation was hours of sleep. The summary sheet, under the column for the number of behavior episodes/shift showed one to four hours for 1500 to 2300 hours shift and three to seven hours for 2300 to 0700 hours shift. Further review of the summary sheet did not show the number of episodes of insomnia was accurately recorded. On 6/2/25 at 1622 hours, an interview and concurrent medical record review for Resident 93 was conducted with the DON. The DON verified the physician's order for the administration of the zolpidem medication did not show the behavioral manifestation of the insomnia which was inability to sleep. The DON stated the inability to sleep meant the resident's hours of sleep was less than six hours. The DON verified the licensed nurses were documenting Resident 93's hours of sleep for the evening and night shifts; however, they were not monitoring when the resident slept less than six hours. The DON further verified the monthly behavior summary was inaccurate since it did not show the number of episodes when Resident 93 slept less than six hours. 2. Review of the facility's P&P titled Use of Psychotropic Medication(s) revised 3/17/25, showed the Policy Explanation and Compliance Guidelines section with the following information: - Non-pharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication; and - The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as upon physical evaluation (routine and as needed). Medical record review for Resident 86 was initiated on 5/29/25. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's H&P examination dated 4/1/25, showed Resident 86 had the capacity to understand and make decisions. Review of Resident 86's Order Summary Report showed the following physician's orders: - dated 3/31/25, to administer venlafaxine hydrochloride (medication to treat depression) 37.5 mg one tablet by mouth one time a day for depression as manifested by verbalizing feeling sad; - dated 3/31/25, to administer buspirone hydrochloride (medication to treat anxiety) 10 mg one tablet by mouth three times a day for anxiety as manifested by verbalizing nervousness; - dated 4/9/25, to monitor for depression as manifested by verbalizing sadness and record the number of times the behavior was manifested every shift for venlafaxine; - dated 4/9/25, to monitor for anxiety as manifested by verbalizing feeling of nervousness, and record the number of times the behavior was manifested every shift; and - dated 4/9/25, to monitor for side effects related to use of psychotropic medications every shift for buspirone and venlafaxine in use. Review of Resident 86's plan of care showed the following: - a care plan problem revised 12/30/24, addressing Resident 86's use of antidepressant medication - venlafaxine medication related to depression as manifested by verbalized sadness; and - a care plan problem revised on 5/29/25, addressing Resident 86's use of antianxiety medication - buspirone medication related anxiety disorder. Further review of Resident 86's plan of care failed to show a care plan addressing the implementation of non-pharmacological interventions prior to administering the psychotropic medications when Resident 86 manifested the behavior of verbalizing sadness or nervousness. Review of Resident 86's MAR for 4/2025 and 5/2025 showed Resident 86's following manifested behaviors and medications received: - venlafaxine medication for feeling sad on 4/5, 4/11, 4/12, 4/14, 4/25, 4/26, 4/28, 5/2, 5/3, 5/5 and on 5/17/25 at 0900 hours; and - buspirone medication for verbalizing nervousness on 4/5, 4/11, 4/12, 4/14, 4/25, 4/26, 4/28, 5/2, 5/3, 5/5 and on 5/17/25 at 0900, 1300, and 1700 hours, and on 5/26/25 at 1700 hours. Further review of Resident 86's medical record failed to show documented evidence Resident 86 was provided with non-pharmacological interventions prior to administering the psychotropic medications when Resident 86 was observed with behavior of feeling sad or nervousness. Review of Resident 86's Monitor Record for 4/2025 and 5/2025 showed Resident 86 was not monitored for side effects related to the use of psychotropic medications on 4/12, 5/14, and 5/17/25, for the night shift, and 5/11 and 5/18/25, for the day shift. On 6/2/25 at 0900 hours, an observation and concurrent interview was conducted with Resident 86. Resident 86 was observed lying in bed and watching TV. Resident 86 stated at times, she felt sad, but it did not last long. Resident 86 stated at times, she felt very sleepy as well. Resident 86 stated she knew she was taking medications for sadness or anxiety. On 6/2/25 at 0932 hours, an interview for Resident 86 was conducted with CNA 7. CNA 7 stated she had not observed Resident 86 feeling sad or anxious. CNA 7 stated she had observed Resident 86 sleepy at times and she would report it to the nurses. On 6/2/25 at 0944 hours, an interview and concurrent medical record review for Resident 86 was conducted with LVN 6. LVN 6 stated Resident 86 could be sleepy at times, liked to just stay in the room and watch TV. LVN 6 stated she had not observed Resident 86 being sad or anxious. LVN 6 verified Resident 86 was taking the venlafaxine medication for depression and the buspirone medication for anxiety. LVN 6 stated when giving these kinds of medications, it was important to monitor if Resident 86 was having the behaviors related to the illness. LVN 6 stated if Resident 86 was manifesting the behaviors such as feeling sad or nervousness, Resident 86 should be provided first with non-pharmacological interventions such as modifying the environment to keep it quiet, let the resident get involved with other activities or massage. LVN 6 stated by providing non-pharmacological interventions first and if it helped Resident 86, the use of psychotropic medication could be avoided. LVN 6 stated the nurses should monitor the side effects of psychotropic medications to the residents. LVN 6 further stated if the side effects were present, the psychotropic medications dose might need to be decreased or discontinued. LVN 6 verified Resident 86 was not provided with non-pharmacological interventions during the times Resident 86 manifested the behavior of feeling sad or nervousness. LVN 6 also verified Resident 86 was not monitored for the side effects of psychotropic medications on April and May 2025. LVN 6 further stated if it was not documented, it was not done. On 6/2/25 at 1107 hours, an interview and concurrent medical record review for Resident 86 was conducted with RN 1. RN 1 stated if the resident was receiving the psychotropic medications, it was important to monitor the resident for manifestation of behaviors related to the illness and the side effects related to the use of psychotropic medications. RN 1 stated the monitoring was documented in the Monitor Record in the PCC. RN 1 stated if the side effects related to the use of psychotropic medications were present, the nurses needed to report it to the physician, and the physician could evaluate if the medications should be continued or not. RN 1 stated it was important to document the monitoring because it showed the nurse assessed the resident and if it was not documented then it was not done. RN 1 stated the examples of non-pharmacological interventions were redirecting the attention of the resident, 1:1 conversation with the resident, let the resident speak to the family member, providing quiet environment or playing music to calm the resident. RN 1 stated providing non-pharmacological interventions prior to administering the psychotropic medication when the resident was manifesting behaviors kike sadness or nervousness would help the staff to assess the need for the medications. RN 1 stated if the non-pharmacological interventions would help alleviate the behavior of the resident, the resident might not need the medications anymore, and they could avoid the use of too much psychotropic medications to the resident. RN 1 further stated the implementation of non-pharmacological interventions should be addressed in the plan of care as well. RN 1 verified the above findings. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON stated all the monitoring required and ordered should be documented because if it was not documented, it was not done. The DON stated the non-pharmacological interventions should be provided whether the psychotropic medications were given routinely or as needed when the resident was manifesting the behavior related to the illness prior to administering the medication. The DON was notified and aknowledged the above findings for Resident 86. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the freedom from unnecessary drugs for three of 23 final sampled residents (Residents 86, 93, and 914) and one nonsamples resident (Resident 15). * The facility failed to ensure an physician's order for the temazepam medication was obtained prior to administering the medication to Resident 15. * The facility failed to ensure the non-pharmacological interventions were implemented prior to administering the venlafaxine (antidepressant medication) and buspirone (antianxiety medication) medications, and to monitor the side effects of psychotropic medications to Resident 86. * The facility failed to ensure non-pharmacological interventions were implemented prior to administering the sertraline (antidepressant medication) to Resident 914. * The facility failed to ensure Resident 93 was accurately monitored for the number of episodes of insomnia related to the use of zolpidem (antidepressant medication). These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dosage of psychotropic medications. Findings: Review of the facility's P&P titled Use of Psychotropic Medication(s) revised 3/17/25, showed a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to antipsychotics, antidepressants, antianxiety, and hypnotics. The Policy Explanation and Compliance Guidelines section of the P&P showed, the psychotropics used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN order for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days unless the attending physician or prescribing practitioner believes it is appropriate to extend beyond 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications are administered by the licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards and practices. The procedure for administering medications includes the following: - Review of the MAR to identify the medication to be administered. - Compare the medication source (bubble pack, vial, etc.) with the MAR to verify the resident name, medication name, form, dose, route, and time. 1. Medical record review for Resident 15 was initiated on 5/28/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 1/29/25, showed Resident 15 had no capacity to understand and make decisions. Review of Resident 15's Order Summary Report dated 4/1 to 5/28/25, showed a physician's order to administer temazepam (medication used to treat insomnia) 7.5 mg capsule by mouth every 24 hours at bedtime for 14 days for insomnia manifested by the inability to sleep. Further review of Resident 15's Order Summary Report showed the physician's order for the 7.5 mg temazepam capsule was completed on 5/9/25. There was no active order for temazepam medication. However, review of Resident 15's Antibiotic or Controlled Drug Record log (undated) showed the temazepam 7.5 mg capsule was signed out on 5/26/25 at 2100 hours. Review of Resident 15's MAR for May 2025 showed no documented evidence the temazepam 7.5 mg capsule was administered to Resident 15 on 5/26/25, as listed on the Antibiotic or Controlled Drug Record log. On 5/28/25 at 1216 hours, an in interview and concurrent medical record review for Resident 15 was conducted with LVN 1. LVN 1 verified the above findings. On 5/28/25 at 1232 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the above findings and stated Resident 15 was administered the temazepam 7.5 mg capsule without an active physician's order. On 6/3/25 at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. they were were made aware and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one final sampled resident (Resident 90) reviewed for ADL care was provided with the necessary care and services to maintain their ADL capabilities. * The facility failed to ensure the care and services were provided to maintain good grooming and personal hygiene when Resident 90's left ear was observed with a large amount of brownish cerumen covering the left ear canal. This failure had the potential to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Activities of Daily Living (ADLs) revised on 12/19/22, showed the following: - The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL care do not deteriorate unless deterioration is unavoidable; - Care and services may consist of the following daily activities like bathing, dressing, grooming, oral care, transfer and/or ambulation, toileting, eating to include meals and snacks, and using speech, language, or other functional communication systems; - A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and - The facility will maintain individual objectives of the care plan and periodic review and evaluation. Medical record review for Resident 90 was initiated on 5/29/25. Resident 90 was readmitted to the facility on [DATE]. Review of Resident 90's MDS assessment dated [DATE], showed Resident 90's BIMS score was six, which meant severe cognitive impairment. On 5/28/25 at 1255 hours, during the dining observation, Resident 90 was observed sitting in his wheelchair and eating his lunch. After checking Resident 90's meal ticket, Resident 90 was observed with a large amount of brownish colored cerumen in the left ear canal. Further review of Resident 90's medical record failed to show an assessment, SBAR or change of condition documentation, notification of MD, and care plan were initiated to address Resident 90's left ear impacted cerumen. On 5/29/25 at 1350 hours, an observation of Resident 90 and concurrent interview was conducted with CNA 6. Resident 90 was observed sitting in his wheelchair, awake, and alert. CNA 6 was asked for assistance in checking Resident 90's left ear. Resident 90's left ear was observed with a large amount of brownish colored cerumen impacted in the ear canal. CNA 6 verified the above findings. CNA 6 was asked when Resident 90 was provided with personal hygiene including ear care. CNA 6 stated he provided ear care to Resident 90 after every shower schedule on Monday and Wednesday. CNA 6 stated he cleaned Resident 90's bilateral outer areas of his ears yesterday after the shower. Furthermore, CNA 6 was asked if he saw Resident 90's large, impacted cerumen in his left ear canal yesterday or today and he stated he did not see the large, impacted cerumen in his left ear canal yesterday or today. On 5/29/25 at 1400 hours, an observation of Resident 90 and concurrent interview was conducted with LVN 2. Resident 90's left ear was observed with a large amount of brownish colored cerumen impacted in the ear canal. LVN 2 verified the above findings. LVN 2 was asked who was responsible to chec Resident 90's ears for cleanliness and she stated the assigned CNAs and the licensed nurses must check Resident 90's ears and provide ear care every shift as part of personal hygiene. LVN 2 stated if any change of condition, like large and impacted cerumen, the licensed nurse must check and report the condition to the physician for any orders. LVN 2 stated the licensed nurses must complete an SBAR, carry out the physician's order, formulate a care plan, and document monitoring in the progress notes every shift for 72 hours. Furthermore, LVN 2 stated implications for cerumen impacted ears may cause infection or impairment of hearing. On 5/30/25 at 1037 hours, an interview and concurrent medical record review for Resident 90 was conducted with RN 1. RN 1 stated CNAs were responsible for the residents' personal hygiene from head to toe including cleanliness and providing the necessary care every shift. In addition, RN 1 stated the CNAs must document the personal hygiene provided to each of the resident every shift. On 5/30/25 at 1054 hours, an interview and concurrent medical record review for Resident 90 was conducted with the DSD. The DSD stated the CNAs must chart the ADL tasks in the EHR for each resident every shift in 24 hours. The DSD was asked about the importance of complete and accurate documentation and she stated the documentation must be completed to show care was provided and if not documented, then care was not rendered. The DSD stated she checked for completion and audited the CNAs' documentation in the EHR daily. Resident 90's ADL-Personal Hygiene task dated 5/17-5/29/25, was reviewed with the DSD. The document failed to show documentation of the evening shift on 5/20-5/21/25, and the night shift from 5/17-5/29/25. The DSD verified the above findings. On 5/30/25 at 1125 hours, an interview was conducted with the DON. The DON was asked about the facility's expectation to document each resident's ADL care including the personal hygiene. The DON stated there were three shifts and the CNAs were expected to document each resident's ADL care including the personal hygiene every shift. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Nurse Consultant stated the CNAs must document personal hygiene every shift. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Incidents and Accidents dated 12/19/22, showed in the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner. Review of the facility's Neurological Flowsheet form showed the neurological assessments were to be completed every 15 minutes x 4, every 30 minutes x 2, every hour x 2, every two hours x 2, every four hours x 4, and every eight hours x 3. The neurological assessment record included checking whether the resident was transferred to the acute care hospital or not, and if not, the licensed nurses were to document the resident's vital signs (blood pressure, temperature, pulse, respiration and pain level), pupil size and response light of the right and left eyes, motor response of the hand grasps, and motor functions of the extremities, level of consciousness, speech, and response to name, pain, environment. Medical record review for Resident 21 was initiated on 5/28/25. Resident 21 was admitted to the facility on [DATE]. a. Review of Resident 21's SBAR Communication Form dated 3/27/25, showed the CNA noted resident sitting on the floor on the left side of the bed. Review of Resident 21's Neurological Flowsheet - V3 dated 3/27/25, failed to show the neurological assessments were completed on 3/27/25 at 1730 and 2130 hours, 3/28/25 at 0530 hours, and 3/29/25 at 0530 hours (for a total of four assessments). b. Review of Resident 21's SBAR Communication Form dated 4/30/25, showed the resident was observed with a small discoloration to the coccyx (tailbone) area. Review of Resident 21's Progress Notes, under the nursing note, dated 4/30/25 at 1823 hours, showed a CNA found Resident 21 on the floor in the room. Review of Resident 21's Neurological Flowsheet - V3 dated 4/30/25, failed to show the neurological assessments were completed on 5/1/25 at 1630 hours, and 5/2/25 at 0830 and 1630 hours (for a total of three assessments). c. Review of Resident 21's SBAR Communication Form dated 5/1/25, showed Resident 21 was found in the restroom, on her knees, leaning to her left side, and complaining of lower back pain. Review of Resident 21's Radiology Results Report dated 5/1/25, showed Resident 21 sustained an acute, transverse, non-displaced fracture at S4 sacral segment. Review of Resident 21's Neurological Flowsheet - V3 dated 5/1/25, failed to show the neurological assessments were completed on 5/1/25 at 1600 and 2000 hours, and 5/2/25 at 2400 and 0400 hours (for a total of four assessments). On 10/12/22 at 1219 hours, an interview and concurrent medical record review for Resident 21 was conducted with RN 1. RN 1 stated for an unwitnessed fall, the neurological assessments were to be completed in the resident's electronic health record. RN 1 verified Resident 21's neurological assessments were not completed for Resident 21's unwitnessed falls on 3/27, 4/30, and 5/1/25. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of two residents reviewed for smoking (final sampled resident, Resident 50). In addition, the facility failed to assess following multiple unwitnessed falls for one of one final sampled resident (Resident 21) reviewed for falls. * The facility failed to complete the neurological assessments following unwitnessed falls on 3/27, 4/25 and 5/1/25, for Resident 21. * The facility failed to ensure the safe smoking practices were followed for Residents 50 when the resident was permitted to keep the cigarettes with his possession after being assessed as requiring supervision while smoking. These failures posed the risk of injuries from fire and serious injuries to the residents who smoked and to the other residents who resided in the facility. Furthermore, these failures had the potential to delay the detection and response to changes in neurological status post-fall for the residents. Findings: Review of the facility's P&P titled Resident Smoking - Smoke Free Facility revised on 12/19/22, showed the following: - All the residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment; - Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or resident is safe to smoke at all; - All safe smoking measures will be documented on each of the resident's care plan and communicated to all the staff, visitors and volunteers who will be responsible for supervising the residents while smoking. Supervision will be provided as indicated on each of the resident's care plan; and - Smoking materials of the residents requiring supervision with smoking will be maintained by the nursing staff. Medical record review for Resident 50 was initiated on 5/29/25. Resident 50 was readmitted to the facility on [DATE]. Review of Resident 50's H&P examination dated 3/9/25, showed Resident 50 had the capacity to understand and make decisions. Review of Resident 50's MDS assessment dated [DATE], showed Resident 50's BIMS score was 13, which meant the resident was cognitively intact. Review of Resident 50's Smoking Safety initial assessment dated [DATE], showed the following: - Risk factors for safety and concerns were impaired gait and balance and receiving medications that affect alertness and function; and - Resident may smoke independently. Review of Resident 50's care plan dated 4/16/25, showed the following interventions: - The resident's smoking supplies are stored in the nursing station; and - The resident requires supervision while smoking. On 5/28/25 at 0856 hours, during the initial tour, Resident 50 was observed lying in bed awake, alert and verbally responsive. Resident 50 stated he smoked twice a day and the staff supervised him while he smoked. On 5/28/25 at 0907 hours, an observation and concurrent interview for Resident 50 was conducted with LVN 5. LVN 5 was requested to check Resident 50's bedside drawer for smoking paraphernalia. A pack of sealed Clipper Cigars in Resident 50's bedside drawer was observed. LVN 5 verified the above findings. LVN 5 stated all the smoking paraphernalia like cigarettes and lighters must be kept at the nurse's station for safekeeping due to fire hazards. In addition, LVN 5 stated the CNAs and licensed nurses must check the residents' drawers and belongings for the smoking paraphernalia. LVN 5 stated he would place Resident 50's pack of cigars at the nurse's station for safekeeping. On 5/29/25 at 1500 hours, an interview and concurrent medical record review for Resident 50 was conducted with RN 1. RN 1 verified the initial Smoking Safety assessment dated [DATE], she completed for Resident 50 showed the resident had risk factors for safety. RN 1 also verified she recommended for Resident 50 to smoke independently after being assessed as having risk factors for safety. RN 1 stated the facility's process when a resident smoked included for a staff from the activity or nursing department to supervise every time the resident would smoke for smoking safety regardless if the resident may smoke independently or not. RN 1 stated the failure to observe safety smoking measures would lead to fire or burn injuries. Resident 50's care plan dated 4/16/25, addressing the interventions to store the smoking supplies at the nurse's station was reviewed with RN 1 and she stated the facility's policy for storage of the smoking paraphernalia was to store at the nurses' station in a plastic container for safekeeping. Furthermore, RN 1 stated all the staff must be educated regarding the safekeeping of the smoking paraphernalia at the nurses' station. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator stated the nursing staff must check the resident's room especially if the resident smoked including the cabinets or drawers every shift for any smoking paraphernalia. The DON stated there must be a staff present each time any resident smoked, regardless if the resident was independent. In addition, the DON stated all the residents required supervision while smoking. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 75) reviewed for catheter care received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of the indwelling urinary catheter. Findings: Review of the facility's P&P titled Urinary Catheter Use revised 12/19/22, showed the following: - If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes. Review of the facility's P&P titled Notification of Changes revised on 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include the following: - Significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental, or psychosocial status which may include life-threatening conditions or clinical complications; - Circumstances that require a need to alter treatment may include new treatment or discontinuation of current treatment due to adverse consequences, acute condition, and exacerbation of a chronic condition; and - The facility must still contact the resident's physician and notify the resident's representative, if known. Medical record review for Resident 75 was initiated on 5/29/25. Resident 75 was admitted to the facility on [DATE]. Review of Resident 75's H&P examination dated 5/1/25, showed Resident 75 had the capacity to understand and make decisions. On 5/28/25 at 0839 hours, during the initial tour, Resident 75 was observed lying in bed awake, alert, and aphasic. Resident 75 was observed with an indwelling urinary catheter connected to a urinary drainage bag placed on the side of the bed. The urinary drainage bag tubing was observed with tea colored urine and blood clots. On 5/28/25 at 0845 hours, an observation of Resident 75 and concurrent interview was conducted with CNA 1. Resident 75 was observed with tea colored urine and blood clots in the urinary catheter tubing. CNA 1 verified the above findings. CNA 1 stated she had the same observations yesterday between 1400-1430 hours, and she informed the assigned charge nurse. In addition, CNA 1 stated her responsibilities with Resident 75's indwelling urinary catheter were to provide catheter care, empty the drainage bag, and report any abnormal changes to the charge nurse. On 5/28/25 at 0913 hours, an observation of Resident 75 and concurrent interview was conducted with LVN 5. Resident 75 was observed with tea colored urine and blood clots in the urinary catheter tubing. LVN 5 verified the above findings. LVN 5 stated the charge nurse had informed him yesterday of Resident 75's blood in urinary drainage bag, and he flushed the indwelling urinary catheter and changed the urinary drainage bag. On 5/29/25 at 1401 hours, Resident 75 was observed lying in bed, awake, and alert with aphasia. Resident 75's urine in the urinary catheter tubing remained tea colored and dark blood tinged. Resident 75 did not show any signs of pain or discomfort. Review of Resident 75's Order Summary dated 5/30/25, showed the following: - dated 5/3/25, Indwelling Catheter: Foley Catheter size 16 French, balloon size 10 cc, to change for blockage, leaking, pulled out and excessive sedimentation; and change catheter drainage bag as needed and with every change of indwelling catheter as needed for BPH with obstructive uropathy; - dated 5/3/25, to irrigate with 60 ml every 24 hours as needed for hematuria; - dated 4/30/25, apixaban (anticoagulant) 5 mg one tablet by mouth two times a day for DVT; and monitoring for the side effects or adverse reactions of apixaban. Review of Resident 75's MAR dated 5/2025, failed to show for the presence of blood in urine under the monitoring for the dates of 5/27 to 5/30/25. Review of Resident 75's TAR dated 5/2025, showed LVN 5 irrigated Resident 75's indwelling urinary catheter on 5/27/25 at 1500 hours. Review of Resident 75 medical record conducted on 5/29/25, failed to show documentation of change of condition or in SBAR, notification to the physician and responsible party, care plan, and monitoring in the nurse's progress notes for 5/2025 which addressed Resident 75's tea colored urine and blood clots in the urinary catheter tubing. On 5/30/25 at 1405 hours, an interview and concurrent medical record review for Resident 75 was conducted with RN 1. RN 1 was asked about the facility's process to follow when a change of condition about a resident was identified. RN 1 stated the charge nurse must check the resident; RN must assess the resident; and licensed nurse must complete the SBAR, inform the physician and resident's Responsible Party, carry out the orders, and document in the resident's progress notes to monitor the resident every shift for 72 hours. RN 1 verified Resident 75's medical record failed to show documentation for SBAR regarding tea colored urine with blood clots, physician and responsible party notification, care plan, and monitoring in the resident's progress notes. RN 1 was informed about Resident 75's tea colored urine with blood clots in the urinary catheter tubing observed for the past two days and was previously verified by LVN 5. RN 1 stated she was not informed of Resident 75 experiencing abnormal urine color or blood clots in urine for the current month of May. Furthermore, RN 1 stated implications of failure to report signs of infection in the urine would lead to sepsis, low hemoglobin, and urgent blood transfusion. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The DON stated Resident 75 had hematuria two weeks ago; however, for any change of condition like another episode of hematuria or signs and symptoms of infection, the charge nurses must assess the resident, complete SBAR, inform the physician and responsible party, formulate a care plan, and document monitoring in the resident's progress notes every shift for 72 hours. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 5/28/25 at 1011 hours, 5/29/25 at 1040 hours, 5/30/25 at 1048 and 1334 hours, Resident 915 was observed in bed receiving oxygen at two liters per minute via nasal cannula. Medical record review for Resident 915 was initiated on 5/28/25. Resident 915 was admitted to the facility on [DATE]. Review of Resident 915's Order Summary Report showed a physician's order dated 5/16/25, to administer oxygen at two liters per minute via nasal cannula as needed for SOB or wheezing. Review of Resident 915's TAR for 5/2025 failed to show the administration of oxygen to Resident 21 was documented. Further review of Resident 915's medical record failed to show a documented evidence Resident 21 was monitored for shortness of breath or wheezing. On 5/30/25 at 1352 hours, an observation for Resident 915 and concurrent interview and medical record review was conducted with the DON. The DON verified Resident 915 was receiving oxygen at two liters per minute via nasal cannula. The DON further verified there was no documentation of the administration of oxygen to Resident 915 and monitored for shortness of breath or wheezing as an indication for the use of oxygen as per the physician's order. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 23 final sampled residents (Residents 84, 96, and 915) and one nonsampled resident (Resident 71) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Residents 84 and 96's oxygen therapy. * The facility failed to ensure the oxygen tubing for Resident 71 was labeled with the date. * The facility failed to ensure the administration of oxygen to Resident 915 was documented in the TAR. In addition, the facility failed to monitor Resident 915 for SOB or wheezing as an indication of the use of oxygen as per the physician's order. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen Administration date revised 5/20/24, showed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 1. On 5/28/25 at 1035 hours, during the initial tour of the facility, Resident 84 was observed lying in bed with the oxygen on via nasal cannula and transferred in a wheelchair, and the nasal cannula was removed from the nose but was attached to the oxygen concentrator machine and set at three and half liters per minute. During the observation, the oxygen tubing was labeled and dated; however, the resident propelled self out of the room. On 5/28/25 at 1254 hours, Resident 84 was observed lying in bed with the oxygen on via nasal cannula and was attached to the oxygen concentrator machine and set at four liters per minute. Medical record review for Resident 84 was initiated on 5/28/25. Resident 84 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 84's H&P examination dated 12/5/24, showed Resident 84 had fluctuating capacity to understand and make decisions. Review of Resident 84's Order Summary Report dated 5/31/25, showed a physician's order dated 2/14/25, to administer oxygen at two to three liters per minute via nasal cannula as needed for SOB or oxygen saturation level less than 90%. Review of Resident 84's Care Plan Report dated 1/17/25, showed a care plan focus addressing the resident's oxygen therapy. The interventions included to administer the oxygen via nasal cannula at two liters per minute for SOB or oxygen saturation level less than 90%. On 5/28/25 at 1301 hours, an observation, interview, and concurrent medical record review for Resident 84 was conducted with RN 1. RN 1 verified the above findings and stated the physician's order for the oxygen administration for Resident 84 should have been followed. 2. On 5/28/25 at 1250 hours, during the initial tour of the facility, Resident 96 was observed lying in bed with the oxygen via nasal cannula, which was attached to the oxygen concentrator machine and set at five liters per minute. During the observation, the oxygen tubing was labeled and dated. On 5/28/25 at 1304 hours, Resident 96 was observed sitting up in a wheelchair with the oxygen on via nasal cannula and was attached to the oxygen concentrator machine and set at four liters per minute. Medical record review for Resident 96 was initiated on 5/28/25. Resident 96 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 96's H&P examination dated 4/9/25, showed Resident 96 had the capacity to understand and make decisions. Review of Resident 96's Order Summary Report dated 5/30/25, showed a physician's order dated 4/7/25, to administer oxygen at two to three liters per minute via nasal cannula continuous to maintain oxygen saturation level greater than 90% every shift. Review of Resident 96's Care Plan Report dated 3/21/25, showed a care plan focus addressing the resident's use of oxygen due to altered respiratory status/difficulty breathing related to COPD, chronic respiratory failure with hypoxia, CHF, and dependence on supplemental oxygen. The interventions included to administer the oxygen via nasal cannula at two to three liters per minute continuous to maintain oxygen saturation level greater than 90%. On 5/28/25 at 1306 hours, an observation, interview, and concurrent medical record review for Resident 96 was conducted with RN 1. RN 1 verified the above findings and stated the physician's order for the oxygen administration for Resident 96 should have been followed. 3. Review of the facility's P&P titled Oxygen Administration revised 5/2024 showed oxygen is administered under the orders of a physician, except in the case of an emergency. Infection control measures include to change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. On 5/8/25 at 1053 hours, an observation of Resident 71 was conducted. Resident 71 was observed sitting in his manual wheelchair outside of his room, Room A. Resident 71 was observed with oxygen administered via nasal cannula at 2 l/min. Resident 71's nasal cannula tubing was undated. The portable oxygen tank was empty. On 5/8/25 at 1055 hours, an observation of Resident 71 and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 71's oxygen tubing was undated and the portable oxygen tank was empty. LVN 2 stated all oxygen tubing should be labeled with the date when it was changed. Medical record review for Resident 71 was initiated on 5/28/25. Resident 71 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 71's Order Summary Report dated 6/3/25, showed a physician's order dated 2/9/25, to administer oxygen at 2 l/min via nasal cannula continuously. On 6/3/25 at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure the competency of four of six licensed nurses (LVN 1, RN 1, DSD, and DON) observed in performing a control solution check with the glucometer. LVN 1, RN 1, the DSD, and DON were unable to demonstrate the competency in the quality control of the glucometer. This failure had the potential of not providing care to the residents in a safe and competent manner. Findings: Review of the glucometer manufacturer's information sheet titled Assure Platinum Blood Glucose Monitoring System Quality Assurance/Quality Control Reference Manual (undated) under the Quality Checks section showed the following: - To perform a control solution test, before testing with the Assure Platinum System for the first time, when a new bottle of test strips was opened, whenever meter or test strips may not be functioning properly, if the test results appear to be abnormally high or low, or are not consistent, when the test strip bottle has been left open or exposed to temperatures below 39 degrees F or above 86 degrees F, or humidity levels above 8%, to check technique, when the Assure Platinum Meter has been dropped or stored below 32 degrees F or above 122 degrees F, and each time the batteries are changed. Step one and two of the six step control solution check process were described as follows: Step 1: insert the test strip into the glucometer. The meter will turn on automatically. Step 2: Press the back and forward arrow buttons on the glucometer one at a time to enter the control solution mode. A control solution bottle icon will appear at the top right of the screen. If you do not enter the control solution mode, the control solution result will not be valid. Using the control solution mode will flag the result in the glucometer's memory. On 5/28/25 at 1033 hours, an inspection of Medication Cart 4 and concurrent facility document review was conducted with LVN 1. The Assure Platinum Blood Glucose Monitoring System: Quality Control Record dated 5/2025 showed the most recent quality check was performed during the 11 PM to 7 AM shift on 5/27/25. When asked about the process for performing the control solution check on the glucometer, LVN 1 was unable to state the steps for the control solution check process. LVN 1 was unable to state how to tell the difference between the values of a glucose check and the control solution check when displayed on the glucometer. Additionally, LVN 1 was unable to show the control solution check was performed on the glucometer on 5/27/25, as documented on the Quality Control Record. LVN 1 stated the licensed nurses on the 11 PM to 7 AM shift were responsible for performing the daily control solution checks on the glucometers. During the interview and review of the Quality Control Record dated May 2025 with RN 1, RN 1 was asked about the process for performing the control solution check on the glucometer. RN 1 was unable to state the process for performing the control solution check on the glucometer. RN 1 was unable to state how to tell the difference between the values of a glucose check and the control solution check when displayed on the glucometer. Additionally, RN 1 was unable to show the control solution check was performed on the glucometer on 5/27/25, as documented on the Quality Control Record. On 5/28/25 at 1142 hours, an interview was conducted with the DON. The DON was asked to verbalize the process for performing the control solution check on the glucometer. The DON was unable to verbalize the process for performing the control solution check on the glucometer. The DON was unable to show the control solution check was performed on the glucometer on 5/27/25, as documented on the Quality Control Record. On 5/28/25 at 1147 hours, an interview was conducted with the DSD. The DSD stated all the licensed staff were expected to have competency to perform the control solution check on the glucometers. The DSD was unable to show the control solution check was performed on the glucometer as documented on the Quality Control Log. The DSD stated the glucometer should display an icon of the control solution bottle on the right side of the glucometer screen to show the value was a control solution check and not a blood glucose result. When asked when the most recent inservice was provided to the licensed staff regarding the control solutions check for the glucometer, the DSD stated the inservice was provided last year by the former DSD. Review of the facility document titled Record of Inservice dated 12/5/24, showed the inservice titled Blood Glucose Monitoring: Assure Platinum blood glucose monitor solution test was conducted at the facility. LVN 1 and RN 1 were listed on the Record of Inservice as attendees. On 5/29/25 at 1033 hours, the facility document review and concurrent interview was conducted with LVN 1. LVN 1 verified she attended the inservice titled Blood Glucose Monitoring: Assure Platinum blood glucose monitor solution test. LVN 1 verified her name and signature were present on the Record of Inservice dated 12/5/24. On 5/29/25 at 1038 hours, a facility document review and concurrent interview was conducted with RN 1. RN 1 verified she attended the inservice titled Blood Glucose Monitoring: Assure Platinum blood glucose monitor solution test. RN 1 verified her name and signature were present on the Record of Inservice dated 12/5/24. On 5/29/25 at 1038 hours, a follow-up interview was conducted with the DON. The DON verified all the licensed staff were expected to know the procedure for performing the control solution checks on the glucometer. The DON stated she believed the control solutions tests were performed as shown on the Quality Control Log. The DON stated the staff performing the control solution checks may not have had the glucometer in the control solution mode while performing the control solution checks. The DON verified the values of blood glucose checks cannot be differentiated from control solution checks that were performed while the glucometer was not in the control solution mode. On 6/3/25 at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P dated [DATE], showed the following: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this stated, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; and - Compare medication source (bubble pack, vial, etc.) with the MAR to verify resident name, mediation name, form, dose, route and time. On [DATE] at 0834 hours, a medication administration observation for Resident 86 was conducted with LVN 7. LVN 7 prepared and administered the following medications to Resident 86 via GT: - One tablet of vitamin C (supplement) 500 mg; - One tablet of docusate sodium (stool softener) 100 mg; - One tablet of buspirone (antianxiety) 10 mg; - One tablet of famotidine (antacid) 20 mg; - One tablet of Lasix (diuretic) 20 mg - One tablet of lactobacillus (supplement); - One tablet of levothyroxine (synthetic thyroid hormone); - One tablet of magnesium oxide (supplement) 400 mg; - One tablet of metoclopramide (gut motility stimulator) 5 mg; - One tablet of Movantik (used for the treatment of opioid-induced constipation) 25 mg; - One tablet of multivitamins with minerals (supplement); - One tablet of venlafaxine (antidepressant) 37.5 mg; and - One tablet of metoprolol (antihypertensive) 50 mg. Medical record review for Resident 86 was initiated on [DATE]. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's Order Summary Report showed the following physician's orders: - dated [DATE], to administer ascorbic acid 500 mg one tablet orally in the morning; - dated [DATE], to administer buspirone 10 mg one tablet orally three times a day; - dated [DATE], to administer docusate sodium 100 mg one tablet orally two times a day; - dated [DATE], to administer famotidine 20 mg one tablet orally two times a day; - dated [DATE], to administer lactobacillus one tablet orally two times a day; - dated [DATE], to administer Lasix 20 mg one tablet orally one time a day; - dated [DATE], to administer levothyroxine 50 mcg one tablet orally one time a day; - dated [DATE], to administer MagOx 400 mg one tablet orally one time a day; - dated [DATE], to administer metoclopramide 5 mg one tablet orally two times a day; - dated [DATE], to administer metoprolol 50 mg one tablet orally two times a day; - dated [DATE], to administer Movantik 25 mg one tablet by mouth one time a day; - dated [DATE], to administer multi-vitamins with minerals one tablet one time a day; and - dated [DATE], to administer venlafaxine 37.5 mg one tablet orally two times a day. On [DATE] at 1312 hours, a follow-up interview and concurrent medical record review for Resident 86 was conducted with LVN 7. LVN 7 verified he gave the medications to Resident 86 via GT, and not orally as specified in the physician's order. LVN 7 stated he gave the medications via GT because Resident 86 preferred to get her medications via GT. LVN 7 further stated he used his judgement to use the GT because she was coughing a lot. On [DATE] at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided when: * The facility failed to ensure the complete documentation for the destruction of medications. * The facility failed to ensure LVN 7 administered the medications to Resident 86 via the correct route. LVN 7 administered the medications to Resident 86 via GT, and not orally as per the physician's order. These failures had the potential for drug diversion and to cause ineffective treatment and complications from the medications administered. Findings: Review of the facility's P&P titled Destruction of Unused Drugs revised [DATE], showed all the unused, contaminated, or expired prescription drugs shall be disposed of in accordance with the state laws and regulations. The section titled Policy Explanation and Compliance Guidelines showed the following: - The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist or the licensed nurse. - A destruction record must be maintained for all drugs destroyed. The actual destruction of drugs conducted by our facility must be witnessed by facility staff as per state requirements. The following information shall be included on this record: a. The name of the patient; b. The date the medication was destroyed; c. The prescription or lot number of the medication; d. The prescription name, strength, and quantity of the medication being destroyed; e. The method of destruction; f. The signature of the consultant pharmacist and registered nurse destroying the controlled medications; and g. The signature of the consultant pharmacist or licensed nurse destroying the non-controlled medications. 1.a. On [DATE] at 0954 hours, an inspection of Medication Storage room [ROOM NUMBER] and concurrent interview and facility document review was conducted with RN 1. The Medication Disposition Record/Pass Log dated 5/14 to [DATE], was reviewed with RN 1. The Medication Disposition Record/Pass Log failed to show a witness signature for the destruction of the following medications: - 30 tablets of clonidine (used to treat high blood pressure) Hcl (hydrochloride) 0.1 mg; - Six tablets of methotrexate (used to treat inflammatory conditions and cancer) 2.5 mg; and - 12 tablets of lisinopril (used to treat high blood pressure) 5 mg. RN 1 verified the above findings. On [DATE] at 1017 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the Medication Disposition Record/Pass Log dated 3/14 to [DATE], was missing the witness signature for the destruction of the medications listed above. The DON verified the log must show the signature of the licensed staff destroying the medications and the signature of the person who witnessed the destruction of the medications. b. On [DATE] at 1023 hours, an inspection of Medication Storage room [ROOM NUMBER] and concurrent interview and facility document review was conducted with RN 1. The Medication Disposition Record/Pass Log dated [DATE], was reviewed with RN 1. The Medication Disposition Record/Pass Log failed to show a witness signature for the destruction of the following medications: - Six capsules of gabapentin (prevents seizures and treats pain for conditions in the nervous system) 100 mg; - 16 capsules of gabapentin 100 mg; - 30 tablets of metformin hcl (used to treat high blood sugar levels for type 2 diabetes) 500 mg; - 25 tablets of metoprolol (used to treat high blood pressure) 25 mg; - 30 tablets of hydralazine (used to treat high blood pressure) 25 mg; - 25 tablets of metoprolol 50 mg; - 22 tablets of amlodipine (used to treat high blood pressure) 5 mg; - 21 tablets of metoprolol 25 mg; - 24 tablets of atenolol (used to treat high blood pressure) 50 mg; - 26 tablets of losartan (used to treat high blood pressure) 25 mg; - 12 tablets of atorvastatin (used to treat high cholesterol) 10 mg; and - 20 tablets of metoprolol 25 mg. RN 1 verified the above findings. Further review of the Medication Disposition Record/Pass Log showed two undated pages of the log which failed to show documentation of the method of disposition, date of disposition, signature of the licensed staff who disposed of the medications, and witness signature for the destruction for the following medications: - Seven tablets of diltiazem (used to treat high blood pressure) 30 mg; - 14 tablets of furosemide (used to help treat fluid retention and swelling that is caused by liver disease, kidney disease, or other medical conditions) 20 mg; - 28 tablets of divalproex (used to treat seizures) sodium ER 500 mg; - 28 tablets of Entresto (used to treat heart failure which occurs when the heart can't pump enough blood to meet the body's needs) 24 mg-26 mg; - 28 tablets of lithium (used to treat bipolar disorder) 300 mg; - Six tablets of Eliquis (blood thinner) 2.5 mg; - Eight capsules of gabapentin 100 mg; - 10 tablets of topiramate (used to treat and prevent seizures) 100 mg; - 28 tablets of topiramate 100 mg; - 18 tablets of trihexyphenidyl (used to treat muscle spasms and poor muscle control) 2 mg; and - 18 tablets of trihexyphenidyl 2 mg. RN 1 verified the above findings. On [DATE] at 1038 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the Medication Disposition Record/Pass Log dated [DATE], did not show the witness signature for the destruction of the medications listed above. The DON verified the log must have the signature of the licensed staff destroying the medication and the signature of the person who witnessed the destruction of the medication. The DON verified the two undated pages of the Medication Disposition Record/Pass Log did not show the method of disposition, the date of disposition, the signature of the licensed staff who disposed of the medications, and the witness signature for the destruction of the medications listed above. The DON verified all columns and rows on the Medication Disposition Record/Pass log require complete documentation for the destruction of medications. On [DATE] at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two final sampled residents (Residents 86 and 914) and two nonsampled residents (Residents 41 and 916) were free from the unnecessary medications. * The facility failed to ensure Resident 41 was not administered the metoprolol (antihypertensive) and amiodarone (antiarrythmic) medications without parameters when to hold or administer the medications. * The facility failed to ensure Resident 914 was not administered the carvedilol (antihypertensive medication) without monitoring the resident's blood pressure and heart rate as per the physician's order. * The facility failed to ensure Resident 916 was not administered the hydralazine (antihypertensive medication) when the SBP less than 160 mmHg as per the physician's order. * The facility failed to ensure the monitoring for signs and symptoms of bleeding was completed related to use of enoxaparin sodium medication (anticoagulant medication, use to prevent blood clots) to Resident 86. These failures had the potential for the residents to receive unnecessary medications and develop significant side effects. Findings: 1. On 5/30/25 at 0813 hours, a medication administration observation for Resident 41 was conducted with LVN 7. LVN 7 was observed administering one tablet of metoprolol 25 mg to Resident 41, without checking the blood pressure nor the heart rate. Medical record review for Resident 41 was initiated on 5/28/25. Resident 41 was readmitted to the facility on [DATE]. Review Resident 41's Order Summary Report showed a physician's orders dated 5/29/25: - To administer amiodarone 200 mg by mouth one time a day; and - To administer metoprolol medication 25 mg one tablet by mouth one time a day. There were no parameters of blood pressure or heart rate for when to give or hold the amiodarone and metoprolol medications. Review of Resident 41's MAR for 5/2025 showed Resident 41 was administered the metoprolol medication on 5/30/25, by LVN 7. The MAR did not show LVN 7 administered the amiodarone medication. On 5/30/25 at 1312 hours, an interview and concurrent medical record review for Resident 41 was conducted with LVN 7. LVN 7 verified he administered the amiodarone medication to Resident 41 without monitoring the resident's blood pressure and heart rate. When asked about the amiodarone medication, LVN 7 stated he administered the amiodarone medication at 1250 hours, but was not able to document in the MAR. LVN 7 verified there were no parameters of blood pressure or heart rate when to give or hold the amiodarone and metoprolol medications. 2. Medical record review for Resident 914 was initiated on 5/28/25. Resident 914 was admitted to the facility on [DATE]. Review Resident 914's Order Summary Report showed a physician's order dated 5/28/25, to administer carvedilol 3.125 mg by mouth two times a day, and to hold the medication if SBP below 100 mmHg, or heart rate below 60 beats per minute. Review of Resident 914's MAR for May and June 2025 showed Resident 914 was administered the carvedilol medication on 5/29/25 at 1800 hours, 5/30 and 5/31/25 at 0800 and 1800 hours, and 6/1/25 at 0800 hours. Further review of the MAR did not show Resident 914's blood pressure and heart rate were checked when the resident was administered the carvedilol medication. On 6/2/25 at 1059 hours, an interview and concurrent medical record review for Resident 914 was conducted with RN 2. RN 2 verified Resident 914's blood pressure and heart rate were not checked when the resident was administered the carvedilol medication. RN 2 stated she clarified with the physician about the timing of the medication administration, and she had to re-enter the physician's order in the electronic health record; however, she did not include the required section for the licensed nurses were to document Resident 914's blood pressure and heart rate prior to administering the medication. 3. Medical record review for Resident 916 was initiated on 5/28/25. Resident 916 was admitted to the facility on [DATE]. Review Resident 916's Order Summary Report showed a physician's order dated 5/24/25, to administer hydralazine 25 mg by mouth two times a day, and to give if the SBP above 160 mmHg. Review of Resident 916's MAR for May and June 2025 showed Resident 916 was administered the hydralazine medication when the resident's SBP was below 160 mmHg as follows: - On 5/25/25 at 0900 hours, a blood pressure of 147/62 mmHg; - On 5/28/25 at 0900 hours, a blood pressure of 131/74 mmHg; - On 5/28/25 at 1800 hours, a blood pressure of 121/65 mmHg; - On 5/29/25 at 1800 hours, a blood pressure of 133/69 mmHg; - On 5/31/25 at 0900 hours, a blood pressure of 149/80 mmHg; and - On 6/1/25 at 0900 hours, a blood pressure of 119/52 mm Hg. On 6/2/25 at 1107 hours, an interview and concurrent medical record review for Resident 916 was conducted with RN 2. RN 2 verified Resident 916 was administered the hydralazine medication when the resident's SBP was below 160 mmHg. 4. According to DailyMed, the most common clinically adverse effect of the enoxaparin sodium injection medication was the risk of serious and potentially fatal bleeding. Local reactions at the injection site may occur such as swelling, redness, rounded lump, oozing of blood and skin necrosis occurring at either the injection site or distant from the injection site. Review of the facility's P&P titled High Risk Medication - Anticoagulants revised 12/19/22, showed the facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. The Policy Explanation and Compliance Guidelines section showed the resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with the anticoagulants include bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), fall in the hematocrit (volume of red blood cells which carries oxygen in the blood) or blood pressure, and thromboembolism (blood clots that causes obstruction of blood flow in the veins). Medical record review for Resident 86 was initiated on 5/29/25. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's H&P examination dated 4/1/25, showed Resident 86 had the capacity to understand and make decisions. Review of Resident 86's Order Summary Report showed the following physician's order: - dated 3/31/25, to inject enoxaparin sodium prefilled syringe 30 mg/0.3 ml subcutaneously one time a day for DVT prophylaxis; and - dated 4/9/25, monitor resident for any of the following: blood in the urine, blood in the stool, unusual bleeding after shaving, bleeding from the gums, bleeding from the nose, excessive bleeding from the wounds, large hemorrhagic area, petechiae every shift. If my initial N is noted, it means I've observed signs and symptoms, hold anticoagulants/antiplatelet dose and notify MD. If my initial Y is noted, it signifies the absence of the listed signs and symptoms Review of Resident 86's Care Plan revised 1/26/25, showed a care plan focus problem addressing Resident 86's on anticoagulant therapy. The interventions included to monitor/document/report as needed the adverse reactions of anticoagulant therapy: blood tinged or red blood in the urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in the vital signs. Review of Resident 86's MAR for 4/2025 and 5/2025 showed Resident 86 received enoxaparin sodium injection solution on the following dates and times: - from 4/1 to 4/30/25, at 0900 hours; and - from 5/1 to 5/31/25, at 0900 hours. Review of Resident 86's Monitor Record for April and May 2025 showed Resident 86 was not monitored for signs and symptoms of bleeding related to anticoagulant therapy on 4/12, 5/14, and 5/17/25, for the night shift, 5/11 and 5/18/25, for the day shift. Further review of the Monitor Record failed to show the shifts where the licensed nurses had their initial the Y or N. On 6/2/25 at 0944 hours, an interview and concurrent medical record review for Resident 86 was conducted with LVN 6. LVN 6 verified Resident 86 was still receiving the enoxaparin sodium injection medication daily. LVN 6 stated she had not observed Resident 86 experienced any signs and symptoms of bleeding. LVN 6 stated the nurses had to monitor any resident on blood thinner medication for signs and symptoms of bleeding such as bruising, blood in urine and stool, nosebleed and bleeding gums every shift and report to the physician. LVN 6 stated it was very important to monitor the resident for signs and symptoms of bleeding related to the blood thinner medication use to assess if the resident was tolerating the medication and for the nurses to be able to hold the medication and report to the physician if there were signs and symptoms of bleeding observed. LVN 6 stated they documented in the Monitor Record in the PCC for their monitoring. LVN 6 verified the nurses should note either Y' for no signs and symptoms of bleeding and N for with signs and symptoms of bleeding, the medication was held, and the physician was notified. LVN 6 further stated it was very important to document their assessment to show they did it because if it was not documented then it was not done. LVN 6 verified the above findings for Resident 86. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 86.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 54.29%. Two of the two licensed nurses (LVNs 7 and 8) who were observed during medication administration were found to have errors. * LVN 7 failed to administer the Eliquis (anticoagulant medication) medication to Resident 41. * LVN 7 failed to ensure the medications were not administered together when administering medications via the GT to Resident 86, and to flush the GT in between the medications and after the administration of the medications. * LVN 7 failed to administer the artificial tears to Resident 86. * LVN 8 failed to ensure Resident 6 received the correct amount of prescribed eye medication. * LVN 8 failed to ensure the GT was properly flushed in between the medication administration for Resident 99. These failures created the risk for the residents to have potential side effects or complications related to the medications. Findings: 1. On 5/30/25 at 0813 hours, a medication administration observation for Resident 41 was conducted with LVN 7. LVN 7 prepared and administered the following medications to Resident 41: - One tablet of iron (supplement) 325 mg; - One tablet of famotidine (antacid) 20 mg; - One tablet of gabapentin (nerve pain medication ) 300 mg; - One tablet of metoprolol (antihypertensive) 25 mg; - One tablet of Geri-kot (stool softener) 8.6 mg; and - One tablet of sodium chloride (supplement) one gram. LVN 7 stated the Lidocaine (local anesthetic) patch and Eliquis (anticoagulant) medications were missing for Resident 41. LVN 7 stated the two medications had been ordered from the pharmacy and should be delivered today. Medical record review for Resident 41 was initiated on 5/28/25. Resident 41 was readmitted to the facility on [DATE]. Review Resident 41's Order Summary Report showed the following physician's orders dated 5/29/25: - To administer amiodarone 200 mg by mouth one time a day; - To administer Eliquis 5 mg by mouth every twelve hours; - To administer famotidine 20 mg by mouth one time a day; - To administer ferrous sulfate 325 mg by mouth one time a day; - To administer gabapentin 300 mg by mouth three times a day; - To apply Lidocaine external patch 4% mg to the right hip topically one time a day; - To administer metoprolol 25 mg by mouth one time a day; - To administer Senna 8.6 mg by mouth one time a day; and - To administer sodium chloride 1 gram by mouth one time a day; On 5/30/25 at 1312 hours, an interview was conducted with LVN 7. LVN 7 verified the above findings. When asked about the medications that were not given during the medication administration observation for Resident 41, LVN 7 stated he already applied the Lidocaine patch to Resident 41 an hour after the initial medication administration observation. LVN 7 further stated he also administered the amiodarone medication at 1250 hours. When asked if he checked Resident 41's heart rate prior to administering the amiodarone medication, LVN 7 stated the CNA checked the resident's heart rate which was 82 bpm at 1130 hours. When asked about the Eliquis medication, LVN 7 stated he did not administer and missed the Eliquis medication. LVN 7 stated he had to find the Eliquis medication for Resident 41. 2. Review of the National Institute of Health's peer-reviewed journal titled Preventing Errors When Drugs Are Given via Enteral Feeding Tubes dated 10/2013 showed incompatibility between drugs being given together can be a problem. Mixing two or more drugs together, whether in solid or liquid forms, creates a brand-new, unknown entity with an unpredictable mechanism of release and bioavailability. Proper flushing of the GT before, during, and after each drug administration can help prevent problems. Review of the facility's P&P titled Medication Administration via Enteral Tube dated 12/19/22, showed the following: - Flush the enteral tube with at least 15 ml of water prior to administering medications unless otherwise ordered by prescriber; - Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe; - Flush tube again with at least 15 ml water taking into account the resident's volume status; - Repeat with the next medication (if appropriate); and - Flush the tube with a final flush of at least 15 ml of water to ensure drug delivery and clear the tube. Review of the facility's document titled Lesson Plan for Enteral Feeding Medication dated 2/19/25, showed the following: - Crush tablet or capsule separately, dissolving each medication in at least 10 ml of water; - Dilute liquid medication in 10-30 ml of warm water or enteral formula; - Dilute gastric irritants in water for highly concentrated solutions - Remove plunger from the syringe and connect the syringe to the tubing; - Flush the tube with at least 15 ml of water prior to medication administration; - Allow medication to flow down the tube via gravity; - Give gentle boosts with the plunger (approximately one inch down) if the medication will not flow by gravity. Repeat if necessary; - Administer each medication separately and flush with at least 15 ml of water or other appropriate liquid between each medication; - Flush the tube with at least 15 ml of water; -Leave head of the bed elevated to prevent aspiration of stomach contents. On 5/30/25 at 0834 hours, a medication administration observation for Resident 86 was conducted with LVN 7. LVN prepared the following medications for Resident 86: -One tablet of vitamin C (supplement) 500 mg; -One tablet of docusate sodium (stool softener) 100 mg; -One tablet of buspirone (antianxiety) 10 mg; -One tablet of famotidine (antacid) 20 mg; -One tablet of Lasix (diuretic) 20 mg -One tablet of lactobacillus (supplement); -One tablet of levothyroxine (synthetic thyroid hormone); -One tablet of magnesium oxide (supplement) 400 mg; -One tablet of metoclopramide (gut motility stimulator) 5 mg; -One tablet of Movantik (used for the treatment of opioid-induced constipation) 25 mg; -One tablet of multivitamins (supplement); -One tablet of venlafaxine (antidepressant) 37.5 mg; and -One tablet of metoprolol (antihypertensive) 50 mg. During the medication administration, the following was observed: - LVN 7 poured 10 ml of water to each medication cup to dissolve the crushed medications. - LVN 7 connected the syringe to the tubing, and flushed the GT with 30 ml water, then clamped the tubing. - LVN 7 poured the metoprolol medication, and added the multivitamins with minerals medication into the syringe, unclamped the tubing, flushed with 30 ml water and clamped the tubing. - LVN 7 poured the vitamin C medication, added the famotidine, Lasix, and the docusate sodium, unclamped the tubing, flushed with 15 ml water and clamped the tubing. - LVN 7 verified he was mixing the medications into the syringe connected to the tubing. LVN 7 stated if it is vitamin C in liquid form, that we do not mix. We do not mix the liquids. Also, based on my experience, there were no adverse effects when the medications were mixed together. There were no warning labels to not mix the medications together. - LVN 7 was observed scraping the multivitamin with minerals residue in the medication cup and added 5 ml of water, and also observed scraping the metoprolol residue in the medication cup and added 5 ml of water. - LVN 7 was observed mixing the venlafaxine medication, then added it to medication cup with the docusate sodium residue. - LVN 7 poured the buspirone medication, added the venlafaxine, levothyroxine, and reglan, lactobacillus, and magnesium medications, unclamped the tubing, flushed with 15 ml of water, and clamped the tubing. -LVN 7 poured the Movantik medication, then added medication residues of the multivitamin with minerals, docusate sodium and metoprolol medications, unclamped the tubing, flushed with 15 ml of water, and clamped the tubing. -LVN 7 poured the lactobacillus medication residue, flushed with 15 ml of water, clamped the tubing, and turned off the GT valve port. - LVN 7 started stacking the medication cups and stated she was done. A significant amount of medication residue was observed in the medication cups. LVN 7 verified there were medication residues in the medication cups. LVN 7 stated the residues were the magnesium oxide and docusate sodium medications. -LVN 7 was observed scraping the magnesium oxide residue in the medication cup and added 10 ml of water, and also observed scraping the docusate sodium residue in the medication cup and added 10 ml of water. Then, LVN 7 observed adding these two medications together in a bigger cup. -LVN 7 turned the GT valve port on, unclamped the tubing and the magnesium oxide and docusate sodium were administered via syringe push, then turned off the GT valve port. -LVN 7 was not observed flushing the tubing after the medication administration. -LVN 7 verified he was done with the medication administration, and there were no missing medications for Resident 86. Medical record review for Resident 86 was initiated on 5/28/25. Resident 86 was readmitted to the facility on [DATE]. Review of Resident 86's Order Summary Report showed the following physician's orders: - dated 3/31/25, may crush all crushable medications; - dated 3/31/25, to administer ascorbic acid 500 mg one tablet orally in the morning; - dated 3/31/25, to administer buspirone 10 mg one tablet orally three times a day; - dated 3/31/25, to administer docusate sodium 100 mg one tablet orally two times a day; - dated 3/31/25, to administer famotidine 20 mg one tablet orally two times a day; - dated 3/31/25, to administer lactobacillus one tablet orally two times a day; - dated 3/31/25, to administer Lasix 20 mg one tablet orally one time a day; - dated 3/31/25, to administer levothyroxine 50 mcg one tablet orally one time a day; - dated 3/31/25, to administer MagOx 400 mg one tablet orally one time a day; - dated 3/31/25, to administer metoclopramide 5 mg one tablet orally two times a day; - dated 3/31/25, to administer metoprolol 50 mg one tablet orally two times a day; - dated 4/5/25, to administer Movantik 25 mg one tablet by mouth one time a day; - dated 3/31/25, to administer multi-vitamins with minerals one tablet one time a day; - dated 3/31/25, to administer venlafaxine 37.5 mg one tablet orally two times a day; - dated 3/31/25, to administer artificial tears 1.4% one drop in both eyes two times a day; and - dated 3/31/25, to inject enoxaparin sodium 30 mg subcutaneously one time a day. On 5/30/25 at 1312 hours, an interview and concurrent medical record review for Resident 86 was conducted with LVN 7. LVN 7 verified the above findings. When asked if he had given any other medication to Resident 86 after the initial medication administration observation, LVN 7 stated he administered the enoxaparin medication just after the initial medication administration observation. LVN 7 was informed he missed giving the artificial tears to Resident 86. LVN 7 verified the findings. LVN 7stated he did not administer the artificial tears because the resident usually refused it. 3. Review of the facility's P&P titled Administration of Eye Drops or Ointments revised 12/19/22, showed under the Policy Explanation and Compliance Guidelines section, the nurse should verify the orders and labeling prior to administration and to compare the label with the order to verify correct medication, dose, route, and time of administration. On 5/30/25 at 0900 hours, a medication administration observation for Resident 6 was conducted with LVN 8. LVN 8 was observed instilling two drops of the Artificial Tears eye drops (medication use to lubricate the eyes) in both eyes of Resident 6. Medical record review of Resident 6 was initiated on 5/30/25. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed a physician's order dated 3/27/16, to instill artificial tears solution in both eyes one drop two times a day for dry eyes. Review of Resident 6's H&P examination dated 5/14/24, showed Resident 6 had the capacity to make medical decisions. On 5/30/25 at 1100 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 8. LVN 8 stated prior to administering any medication, the nurses should recheck for the correct medication, dose and route. LVN 8 further stated overdosing of any medication could give adverse reaction to the resident. LVN 8 acknowledged Resident 6 received two drops in both eyes of the artificial tears eye drops medication. On 5/30/25 at 1135 hours, an interview was conducted with RN 1. RN 1 stated the nurse should double check the right dosage of the medication to be administered to prevent medication error. RN 1 further stated overdosing of the medication might give adverse effects to the resident. RN 1 was notified and acknowledged the above findings for Resident 6. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON was notified and acknowledged the above findings for Resident 6. 4. On 5/30/25 at 0814 hours, a medication administration observation for Resident 99 was conducted with LVN 8. LVN 8 was observed administered the diluted plavix (medication use to prevent heart attack and other heart problems) medication followed by the multi-vite liquid (multivitamins supplement) via GT without flushing with water in between the medication administration. Medical record review of Resident 99 was initiated on 5/30/25. Resident 99 was readmitted to the facility on [DATE]. Review of Resident 99's H&P examination dated 4/18/24, showed Resident 99 did not have the capacity to understand and make decisions. Review of Resident 99's Order Summary Report, showed a physician's order dated 5/4/24, to flush the enteral tube with 15-30 ml of water before and after medication administration and 5 ml of water between each medication. On 5/30/25 at 1100 hours, an interview and concurrent medical record review for Resident 99 was conducted with LVN 8. LVN 8 stated when giving medication via GT, the medication should be given one at a time, then flush with 10 cc of water after each medication. LVN 8 stated flushing with water in between the medication administration would ensure the medication was properly delivered and to prevent interactions between the medications. LVN 8 verified there was no water flushing done in between administration of the plavix and multivitamins. On 5/30/25 at 1135 hours, an interview was conducted with RN 1. RN 1 stated it was the facility's protocol to flush the GT with a certain amount of water between medication administration to prevent blockages of the GT, ensure the medication was properly administered, and prevent adverse reactions between each medication. RN 1 was informed and acknowledged the above findings for Resident 99. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON was notified and acknowledged the above findings for Resident 99.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility documentation review, and facility P&P review, the facility failed to ensure the removal of the discontinued medications from one of six medication carts (Medication Cart 4) inspected. This failure had the potential to result in drug diversion of controlled medications and the administration of medication without a physician's order. Findings: Review of the facility's P&P titled Disposal of Medications and Medication-Related Supplies IE3: Discontinued Medications revised 1/2025 showed when the medications are expired, discontinued by a prescriber .the medications are marked as discontinued or stored in a separate location and later destroyed. The procedure for discontinued medications was described as follows: A. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designed solely for this purpose. B. Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt for an order to discontinue. On [DATE] at 1206 hours, an inspection of Medication Cart 4 and concurrent narcotic count was conducted with LVN 1. The Antibiotic or Controlled Drug Record log (undated) for Resident 15 showed 14 capsules of temazepam (used to treat insomnia) 7.5 mg medication were delivered to the facility on [DATE]. The log showed to give one 7.5 mg capsule of temazepam by mouth every 24 hours as needed for insomnia for 14 days at bedtime. The bubble pack for Resident 15's temazepam medication was observed in the controlled medications drawer in Medication Cart 4. During the narcotic count, an interview and concurrent medical record review for Resident 15 was conducted with LVN 1. LVN 1 verified Resident 15's temazepam 7.5 mg capsule medication remained in Medication Cart 4 without an active order, and the medication should have been removed. Medical record review for Resident 15 was initiated on [DATE]. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated [DATE], showed Resident 15 had no capacity to understand and make decisions. Review of Resident 15's Order Summary Report dated 4/1 to [DATE], showed a physician's order to administer temazepam 7.5 mg capsule by mouth every 24 hours at bedtime for 14 days for insomnia manifested by the inability to sleep. Further review of Resident 15's Order Summary Report showed the physician's order for the temazepam 7.5 mg capsule was completed on [DATE], and not an active order. Review of Resident 15's Order Summary Report dated [DATE], failed to show an active physician's order for the use of the temazepam medication. On [DATE] at 1225 hours, an interview was conducted with the DON at Medication Cart 4. The DON verified the above findings. On [DATE] at 1232 hours, a follow-up interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the above findings. The DON verified the bubble pack for Resident 15's temazepam medication should have been removed from Medication Cart 4 on [DATE], when the order was no longer active. On [DATE] at 1315 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. They were made aware and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for one final sampled resident (Resident 6) and one nonsampled resident (Resident 99) observed for medication administration, and one final sampled resident (Resident 75) observed for personal hygiene. * LVN 8 failed to perform hand hygiene prior to administering the eye medication to Resident 6 after touching the privacy curtain. * LVN 8 failed to perform hand hygiene and change gloves before administering the medication via GT after touching the enteral feeding pump to Resident 99. In addition, hand hygiene was not performed prior to donning new gloves after cleaning the medication tray and overbed table. * The facility failed to ensure CNA 1 performed hand hygiene when providing care to Resident 75. In addition, CNA 2 failed to perform hand hygiene and don appropriate PPE for Resident 75 when CNA 2 checked his brief and indwelling urinary catheter. These failures posed the risk for not controlling the transmission of infection to the other residents throughout the facility. Findings: Review of the facility's P&P titled Hand Hygiene revised 12/19/22, showed all the staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The Policy Explanation and Compliance Guidelines section showed the use of gloves does not replace hand hygiene prior to donning new gloves, and immediately after removing gloves. Review of the facility's P&P titled Administration of Eye Drops or Ointments revised 12/19/22, showed the Policy Explanation and Compliance Guidelines section showing for the staff to wash hands or utilize alcohol-based hand rub and apply gloves. 1. On 5/30/25 at 0900 hours, a medication administration observation for Resident 6 was conducted with LVN 8. LVN 8 was observed touching the privacy curtain to close it to provide privacy to Resident 6 with the gloves on. After touching the privacy curtain, LVN 8 went ahead and instilled the eye drop medications in Resident 6's eyes without performing hand hygiene and changing gloves. 2. On 5/30/25 at 0814 hours, a medication administration observation for Resident 99 was conducted with LVN 8. LVN 8 was observed cleaning the medication tray and overbed table with gloves on. After cleaning, LVN 8 changed her gloves but failed to perform hand hygiene prior to donning new pair of gloves. LVN 8 was also observed touching the enteral feeding pump to stop it and checked Resident 99's GT right after, without removing her gloves, performing hand hygiene and donning new gloves. On 5/30/25 at 1100 hours, an interview for Residents 6 and 99 was conducted with LVN 8. LVN 8 stated it was important to perform hand hygiene after removing gloves or after touching any equipment at the bedside or surrounding prior to administering the medications and checking the tubing attached to the resident like the GT to prevent contamination. LVN 8 acknowledged the above findings. On 5/30/25 at 1135 hours, an interview was conducted with RN 1. RN 1 stated just changing gloves was not acceptable in the process of hand hygiene. RN 1 stated every time the staff needed to change gloves, hand hygiene needed to be performed prior to donning new gloves. RN 1 stated before administering medications in all forms, the nurse needed to perform hand hygiene after the nurse was in contact with the resident's surrounding or equipment to prevent transmission of infection. On 6/3/25 at 1310 hours, an interview was conducted with the IP. The IP stated the expectation was always to perform hand hygiene either hand washing or using the hand sanitizer as applicable prior to donning any PPEs. The IP stated the nurses needed to perform hand hygiene before giving the medications to the resident after they touched any equipment in the room and surrounding because if it was not done, they were putting the residents at risk for transmission of infection. The IP was informed of and acknowledged the above findings. On 6/3/25 at 1400 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 75 was initiated on 5/29/25. Resident 75 was admitted to the facility on [DATE]. Review of Resident 75's H&P examination dated 5/1/25, showed Resident 75 had the capacity to understand and make decisions. Review of Resident 75's Order Summary dated 5/30/25, showed the following: - dated 5/3/25, Indwelling Catheter: Foley Catheter size 16 French, balloon size 10 cc, to change for blockage, leaking, pulled out and excessive sedimentation. Change catheter drainage bag as needed and with every change of indwelling catheter as needed for BPH with obstructive uropathy - dated 5/16/25, Enhanced Barrier Precaution related to Foley catheter, to apply enhanced barrier precaution to prevent the spread of infections for specific care activities such as morning and evening care, toileting, changing incontinence briefs, caring for devices, giving medical treatments, wound care, mobility assistance, preparing to leave the room, cleaning and disinfecting the environment. On 5/28/25 at 0845 hours, during the initial tour, Resident 75 was observed lying in bed, awake, alert and aphasic. CNA 1 entered the room and Resident 75 was observed attempting to communicate with CNA 1 through gesturing, pointing, and mumbled speech. CNA 1 pointed to the receptable for soiled or used gown and Resident 75 nodded his head to agree. CNA 1 picked up the gown receptacle bin without wearing gloves and moved it next to the PPE cart. CNA 1 proceeded to touch the curtain then touched Resident 75's left leg without performing hand hygiene. CNA 1 verified the above findings. CNA 1 stated she must perform hand hygiene before touching the resident and after touching any dirty trash or gown receptacle bin. In addition, CNA 1 stated failure to perform proper hand hygiene when providing resident's care will cause the spread of infection. On 5/29/25 at 1415 hours, an observation and concurrent interview was conducted with CNA 2. Resident 75 was observed lying in bed awake, alert, and aphasic. Resident 75 was greeted and observed with facial grimacing, then pointed to his brief. CNA 2 was requested to provided assistance to Resident 75. CNA 2 entered Resident 75's room with the EBP signage without performing hand hygiene and attempted to communicate with Resident 75. Resident 75 was observed with facial grimacing and pointed to his brief. CNA 2 opened Resident 75's brief without wearing gloves and gown to check the indwelling urinary catheter. CNA 2 proceeded to close Resident 75's brief then touched the bedside table without performing hand hygiene. CNA 2 verified the above findings. Furthermore, CNA 2 stated she must perform hand hygiene and don appropriate PPE for the residents who were on EBP. On 6/3/25 at 1400 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The DON stated all the staff must perform proper hand hygiene before, in between, and after providing care to each resident. The DON stated all the staff must wash their hands or perform hand hygiene after touching dirty items like the trash receptacle. In addition, the DON stated all the staff must wear appropriate PPE for residents on EBP when providing care. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particles or residues. * The facility failed to ensure the kitchen utensils had smooth cleanable surface and in good condition. * The facility failed to ensure the heavy-duty blender used for puree preparation, the scoops used for food portioning, and the plastic bucket containers used for the fruits and food storage were air dried prior to storing and stacking. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the ice machine drainpipe had an air gap and not touching the drain. * The facility failed to ensure the ice machine utilized for residents and staff was maintained in a sanitary condition. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 5/28/25, showed 96 of 110 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed any dish, tray, or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The following was observed: - Two stainless steel knives with black handles were observed dirty and had fuzzy films. - One stainless steel peeler with black handle was observed dirty and had dry, brownish discoloration. - One stainless steel spatula with white handle was observed dirty and had dry, white crusted residue. - Two stainless steel whisk was observed dirty and had dry, crusted residue. - One stainless steel tong was observed dirty and had dry, crusted residue. - One slotted stainless steel serving spoon was observed dirty and had dry brownish residue on the handle. The Dietary Manager acknowledged the above findings and stated the dirty utensils had to be washed again to prevent food contamination. 2. Review of the facility's P&P titled Dish and Utensil Procedure date revised 3/3/20, showed the chipped or cracked dishes, trays shall be discarded. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The following was observed: - One stainless steel whisk with gray rubber handle cracked and partially burnt. - One stainless steel tong with red handle was observed worn out with partially melted handle. - One rubber spatula with red handle was observed worn out, discolored, had chipped and cracked edges and handle was partially melted. - One plastic white rice paddle was observed with partially melted handle. - One stainless steel spatula with black handle was partially melted. The Dietary Manager acknowledged the above findings and stated all the worn-out utensils and dishes should have been discarded and replaced. 3. Review of the facility's P&P titled Dish and Utensil Procedure date revised 3/3/20, showed the dishes, trays, and utensils shall be air dried before storage. Do not towel dry. In addition, review of the facility's P&P titled Dry Storage- Dishes and Utensils revised 2/1/12, showed the dishes must be stored to promote air drying i.e. use dish racks or trays with plastic mesh that allow air to circulate, and air dry the dishes. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The following was observed: - One heavy-duty blender stored on the counter shelf was observed still wet with visible water inside and on the lid. - Two clear plastic bucket containers used for fruits and food storage were observed wet with visible water inside and stacked on top of each other. - One stainless steel serving spoon was observed wet with visible water and had dry watermarks. - Two stainless steel serving scoop with green handles were observed wet with visible water. - One stainless steel scoop with blue handle use for food portioning was stored wet with visible water. - One stainless steel scoop with green handle use for food portioning was stored wet with visible water. - Two stainless steel scoop with gray handles use for food portioning were stored wet with visible water. - One stainless steel spatula with black handle was stored wet with visible water. The Dietary Manager verified the above findings and stated the blender and utensils should have been air dried prior to storage. 4. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed the cutting boards need to be washed and sanitized between each use. Replace cutting boards once lined with knife marks and they are unsanitizable. Color-coded cutting boards are desirable designating boards for raw products versus cooked products. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 5/28/25 at 0805 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. The green, red, brown, and yellow cutting boards were observed fuzzy, heavily marred and had deep grooves. The Dietary Manager verified the findings and stated the cutting boards were changed every three months and should have been replaced for infection control purposes because it could not be thoroughly cleaned. 5. Review of the facility's P&P titled Hoods and Filters revised 8/31/18, showed hoods must be kept free of grease and dust at all times. Because of potentially high fire hazard, it is important that hood filters be part of a strictly enforced cleaning schedule and be free of grease and dust at all times. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 5/28/25 at 0805 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Manager. The kitchen hood over the stove was observed with black, greasy, dirt residue. The Dietary Manager acknowledged the finding and stated the dietary staff cleaned the hood once a week and an outside company serviced for the kitchen hood was conducted on 1/2025. 6. Review of the facility's P&P titled Backflow Prevention/Air Gap revised 8/15/17, showed an air gap is the space between the faucet and flood rim or the space between the drain and the floor drain. According to the USDA 2017 Food Code, Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On 5/28/25 at 0842 hours, during the initial kitchen tour, an inspection of the ice machine was conducted with the Dietary Manager. The drain pipe was observed resting on the ground and touching the drain. The Dietary Manager acknowledged the findings. On 5/28/25 at 0848 hours, an inspection of the ice machine was conducted with the Director of Plant Operations. The drain pipe was observed resting on the ground and touching the drain. The Director of Plant Operations acknowledged the findings and stated the drain pipe should have been fixed to prevent any backflow. 7. Review of the facility's P&P titled Ice Machine revised 10/18/18, showed the cleaning and sanitizing of internal components of the ice machine should follow EPA-registered label use instructions and is usually done by the maintenance department or by a contracted ice machine maintenance company. Per Food Code the internal components must be cleaned and sanitized per manufacturer's guidelines, county or state regulations and not less than twice per year. According to the USDA Food Code 2017, Section 4-601.11, the equipment food-contact surfaces and utensils shall be clean to sight and touch. On 5/28/25 at 0848 hours, an observation, interview, and concurrent facility record review was conducted with the Director of Plant Operations. The Director of Plant Operations stated the facility had one ice machine for the residents' use located in the resident's dining room. The Director of Plant Operations stated he was in charge of the cleaning and maintenance of the ice machine. Review of the Ice Machine Cleaning/Maintenance log showed the ice machine was last cleaned and sanitized on 5/20/25, and the filter was due to be replaced on 8/15/25. Observation of the internal panel of the ice machine was conducted with the Director of Plant Operations. The internal panel of the ice machine adjacent to the water curtain located directly above the ice bin, was observed with a brownish residue. The Director of Plant Operations verified the above findings and stated the ice machine needed to be cleaned because a contaminated ice could cause illnesses. On 6/3/25 at 1452 hours, the DON and Administrator were informed of the above findings. The DON and Administrator was asked if they would serve the ice from the dirty ice machine to the residents and they replied, no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure themedical records were complete and accurately maintained for two of ten sampled residents (Residents 9 and 10). * Residents 9 and 10's medical records failed to show the monitoring of the residents' locations was completed on 3/9, 3/10, and 3/12/25. These failures had the potential for the residents' care needs to not be met as their medical information was inaccurate and incomplete. Findings: Review of the facility's P&P titled Falling Star Program dated 8/1/18,showed the resident safety committee/interdisciplinary team will determine placement of the residents into the Falling Star Program to reduce the incidence of falls/injury for each resident in the program. Nursing staff will do every hour monitoring as followed and log completion. 1. Medical record review for Resident 9 was initiated on 3/13/25. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 had moderate cognitive impairment and needed substantial/maximal assistance with mobility. Review of Resident 9's Order Summary Report showed a physician's order dated 2/19/25, for the resident to be on the falling star program. Review of Resident 9's Care Plan revised on 3/13/25, showed a care plan focus problem addressing Resident 9's high risk for falls. The interventions included the falling star program and to follow facility's fall protocol. Review of Resident 9's Progress Note dated 2/15/25, showed Resident 9 was found on the floor at 1506 hours lying on his left side with head on the blanket. Resident 9 sustained a two centimeters abrasion on top of the head with minimal bleeding. Review of Resident's 9's Falling Star record for March 2025 showed no documented evidence Resident 9 was monitored for the resident's location on the following dates: - 3/9/25, from 0000 hours to 0300 hours; - 3/10/25, from 0000 hours to 0600 hours; and - 3/12/25, from 0800 hours to 2300 hours. On 3/13/25 at 1330 hours, an observation of Resident 9 and concurrent interview was conducted with FM 1. Resident 9 was observed awake and lying in the bed. There was a pink sign with star and letter A observed posted outside Resident 9's room. FM 1 stated Resident 9 fell last February. On 3/13/25 at 1455 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 9 was confused at times and needed assistance with mobility. CNA 6 stated the facility had the falling star program for residents who were high risk for fall and who fell. CNA 6 stated the CNAs had to check the resident every hour and record in the falling star form the location of the resident. CNA 6 stated they had been doing the monitoring for a long time. CNA 6 stated the falling star record could either be given to the CNA by the nurses at the start of the shift or the outgoing CNAcould pass it to the incoming CNA to continue recording the monitoring of the resident. CNA 6 further stated CNAs would be reminded during the huddle of the residents who were in the falling star program and there was a pink signage with the star and the resident's bed identifier outside the room. CNA 6 verified he worked on 3/12/25. CNA 6 stated he did not fill up the falling star record for his shift on 3/12/25 because he did not receive the form from the charge nurse. CNA 6 stated he checked the resident every hour during his shift on 3/12/25, but did not document it. 2. Medical record review for Resident 10 was initiated on 3/13/25. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P evaluation dated 1/29/25, showed Resident 10 had no capacity to understand and make decisions. Review of Resident 10's MDS assessment dated [DATE], showed Resident 10 needed substantial/ maximal assistance with mobility. Review of Resident 10's Order Summary Report showed a physician's order dated 1/30/25, for the falling star program. Review of Resident 10's Care Plan revised on 2/3/25, showed a care plan focus problem addressing Resident 10's high risk for falls. The interventions included the falling star program and to follow facility's fall protocol. Review of Resident 10's Progress Note dated 2/1/25 at 0624 hours, showed Resident 10 was found by the housekeeping sitting on the floor in front of the closet. Resident 10 was observed with discoloration to right side of the forehead without any bleeding or swelling. Review of Resident's 10's Falling Star record for March 2025 showed no documented evidence Resident 10 was monitored for the resident's location on the following dates: - 3/9/25, from 0000 hours to 0300 hours; - 3/10/25, from 0000 hours to 0600 hours; and - 3/12/25, from 0800 hours to 2300 hours. On 3/13/25 at 1405 hours, an observation was conducted with Resident 10. Resident 10 was awake and sitting in the wheelchair inside the room. The pink signage with the star and letter B was observed outside the room of Resident 10. On 3/13/25 at 1425 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 10 could be confused at times and would not follow instructions. CNA 5 stated Resident 10 was in the falling star program. CNA 5 stated when the resident was in the falling star program, she had to check the resident every hour and record the resident's location in the falling star record paper. CNA 5 stated after the shift she would pass it to the next shift's CNA. CNA 5 further stated if she knew the resident was high risk for fall and did not get the form, she would ask the charge nurse for the form. CNA 5 stated she was not assigned to Resident 10 on 3/12/25. CNA 5 verified the missing documentation for monitoring in the Falling Star record for March 2025. CNA 5 stated it could mean the CNA did not check the resident or forgot to fill in the form. On 3/13/25 at 1520 hours, an interview and concurrent facility documentreview was conducted with LVN 3 for Residents 9 and 10. LVN 3 stated the falling star program was implemented for those residents who had a fall incident or who were high risk for fall. LVN 3 stated part of the falling star program was for the CNAs to monitor the resident every hour and to record the resident's location in the falling star paper form. LVN 3 stated the CNA also had to sign their initial in each hour. LVN 3 stated all CNAs were aware of this responsibility. LVN 3 verified the missing monitoring in the falling star records for Resident 9 and 10. LVN 3 further stated if the monitoring was not documented it could mean the CNA did not check the resident or forgot to fill in the form. On 3/14/25 at 1536 hours, an interview was conducted with the DON. The DON stated the falling star program was implemented in 2018 as part of the facility's fall prevention program. The DON stated the falling star program was implemented for those residents who had a fall incident or who were high risk for fall. The DON stated the pink signage with the star and the resident's bed identifier should be posted outside the room of the resident and the CNA will fill in the falling star form. The DON stated the CNAs had to check and record every hour the location of the resident and sign with their initial each hour. The DON further stated if the falling star record was left blank, the CNA did not do the monitoring and the CNA had to be given an in-service training regarding the falling star program. The DON was notified and acknowledged the above findings for Residents 9 and 10.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to administer the medications as ordered by the physician for one of four sampled residents (Resident 3). * Resident 3 had a physician's order for insulin glargine (a medication used to treat diabetes) to be given at bedtime, with parameters to hold if the blood sugar levels were less than 120 mg/dl. There was no documented evidence the blood sugar level was checked to determine whether to administer or hold the insulin as ordered. This failure put Resident 3 at risk of complications. Findings: Medical record review for Resident 3 was initiated on 1/2/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's Order Summary Report showed an order dated 12/26/23, for insulin glargine 100 unit/ml 6 units subcutaneously (under the skin) at bedtime for DM and to hold if the blood sugar levels were less than 120 mg/dl. Review of Resident 3's Medication Administration Record showed Resident 3 received insulin glargine as ordered from 1/1 - 1/4/24; however, there was no documented evidence of blood sugar levels. On 1/5/24 at 1137 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 3 had an order for insulin glargine at bedtime with the instructions to hold if the blood sugar levels were less than 120 mg/dl. LVN 1 was asked to show documentation the blood sugar levels were checked prior to the insulin administration and was unable to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of one of 24 final sampled residents (Resident 422). * The facility failed to ensure Resident 422's call light was within the resident's reach. This failure created the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22 showed the staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light, and staff will ensure the call light is within reach of resident and secured, as needed. On 5/16/23 at 0920 hours, Resident 422 was observed seated in the wheelchair in her room, on the right side of the bed. Resident 422's call light button was observed underneath the pillows on the left side of the bed, which was away from Resident 422 and not within her reach. When asked if she could reach her call light button, Resident 422 answered no. Resident 422 stated it would be nice when they get a resident up, they should also make sure the call light is within reach. When asked if this had happened before, Resident 422 answered yes, and stated she had asked her roommate to press the call light for her. Resident 422 stated her roommate spoke another language so she would do a hand gesture to her roommate to press the call light. On 5/16/23 at 0939 hours, an observation for Resident 422 and concurrent interview was conducted with LVN 7. Resident 422 was observed seated in the wheelchair in her room, on the right side of the bed. Resident 422's call light button was observed underneath the pillows on the left side of the bed, which was away from Resident 422, and not within her reach. LVN 7 verified the above findings. Medical record review for Resident 422 was initiated on 5/16/23. The medical record showed Resident 422 was readmitted to the facility on [DATE]. Resident 422 had moderate cognitive impairment and required limited to extensive assistance from one to two staff members for ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of 24 final sampled residents (Residents 20, 54, and 77) had copies of their advance directive (written instruction, recognized under State law, relating to the provision of health care when the individual is incapacitated) in their medical records. This failure had the potential to go against the health care wishes of the Residents 20, 54, and 77. Findings: Review of the facility's P&P titled Advance Directives revised 9/23/20, showed the Social Services staff will place a copy of the completed advance directive in the resident's medical record. 1. Medical record review for Resident 54 was initiated on 5/16/23. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's H&P Examination dated 1/2/23, showed Resident 54 had the capacity to understand and make decisions. Review of the MDS Quarterly assessment dated [DATE], showed Resident 54 was cognitively intact. Review of the Physician Orders for Life Sustaining Treatment (POLST) form prepared on 4/6/23, showed Resident 54's advance directive was not available. Review of the Social Services Assessments dated 1/4, 3/14, and 3/17/23, showed no documentation showing the facility had reviewed the advance directives with Resident 54. On 5/17/23 at 1147 hours, an interview and concurrent medical review was conducted with the Social Services Director. When asked what the process was for advance directives, the Social Services Director stated they reviewed the status of the resident's advance directive upon admission and quarterly. If a resident had an advance directive, they would ask the resident or family to bring the advance directive to the facility. When asked about their process to monitor the status of advance directives, the Social Services Director stated they would document the resident's advance directive status in the medical record under the Social Worker Assessment and Progress Notes. When asked about Resident 54's advance directive, the Social Services Director stated Resident 54 did not have an advance directive. Upon review of the Social Services Assessments dated 1/4, 3/14, and 3/17/23, the Social Services Director verified there was no documentation to show the advance directives were discussed or offered to Resident 54. On 5/17/23 at 1549 hours, an interview was conducted with Resident 54. When asked if the resident knew what an advance directive was, he stated yes and further stated his advance directive was with his daughter. When asked if the facility had discussed the advance directives with him, he stated the facility never asked him about his advance directive. On 5/17/23 at 1617 hours, an interview was conducted with Resident 54's daughter. When asked regarding the advance directives, she stated her father filled one out years ago. When asked if the facility discussed the resident's advance directives with her, she stated no one from the facility had discussed or asked her about Resident 54's advance directive. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were informed and acknowledged the above findings. 2. Medical record review for Resident 77 was initiated on 5/16/23. Resident 77 was admitted to the facility on [DATE]. Review of the POLST form prepared on 12/1/20, showed Resident 77's advance directive was not available. Review of the Social Services assessment dated [DATE], showed Resident 77 had an advance directive. On 5/17/23 at 1147 hours, an interview and concurrent medical record review was conducted with the Social Services Director. When asked about the advance directive process, she stated the Social Services Department would ensure the residents' advance directives and POLST match; the POLST should reflect a resident's healthcare directive. When asked about Resident 77's advance directive, the Social Services Director stated Resident 77 had an advance directive. However, upon concurrent review of Resident 77's documents and electronic medical record, the Social Services Director verified there was no copy of Resident 77's advance directive available in the medical record. The Social Services Director stated she had a copy of Resident 77's advance directive in her office. On 5/17/23 at 1510 hours, an interview was conducted with LVN 4. When asked about the advance directives, she stated the advance directives showed a resident's wish for their care when they were no longer able to make decisions. When asked where she could find the information regarding a resident's advance directive, LVN 4 stated she would look in the resident's paper medical record. On 5/19/23 at 1552 hours, an interview was conducted with LVN 11. When asked where she looked to find information regarding a resident's advance directive, she stated she looked in the paper and electronic medical records. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were informed and acknowledged the above findings. 3. Medical record review for Resident 20 was initiated on 5/16/23. Resident 12 was admitted to the facility on [DATE]. Review of the POLST dated 1/28/21, showed Resident 20 had formulated an advance directive. Review of Resident 20's Progress Notes showing Social Service Assessment - Quarterly dated 4/26/23, showed Resident 20 had a POA (Power of Attorney) for healthcare. However, review of Resident 20's medical record failed to show a copy of the resident's advance directive. On 5/17/23 at 1147 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD was informed and verified the above findings. The SSD stated she asked the residents or the residents' representative regarding an advance directive upon admission. The SSD also stated she tried to follow-up to get a copy of the advance directive within one week. When asked for a copy of Resident 20's advance directive, the SSD verified it was not in the resident's medical record. The SSD was observed going to her office with a pile of copies of advance directives in a folder and could not find a copy of Resident 20's advance directive. On 5/17/23 at 1243 hours, an interview and concurrent medical record review was conducted with the Medical Records Director and the SSD. The SSD asked the Medical Records Director to search the overflow medical records for a copy of Resident 20's advance directive. The Medical Records Director could not find a copy of Resident 20's advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure a significant change of status assessment was completed with 14 days after a significant change in the resident's physical or mental condition had been determined for one of 24 final sampled residents (Resident 101). This had the potential of not providing the appropriate care and services to Resident 101 based on the resident's current status. Findings: According to CMS's RAI 3.0 Manual dated October 2019, Chapter Two: Significant Change in Status Assessment (SCSA), showed the SCSA is a comprehensive assessment for resident that must be completed when the IDT had determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting, 2. Impacts more than one area of the resident's health status, and 3. Requires interdisciplinary review and/or revision of the care plan. According to CMS's RAI 3.0 Manual dated October 2019, Chapter Two: Significant Change in Status Assessment (SCSA), under section Assessment Management Requirements and Tips for SCSA, showed an SCSA is appropriate when there is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessment and the resident's condition and the resident's condition is not expected to return to baseline within two weeks. According to CMS's RAI 3.0 Manual dated October 2019, Chapter Two: Significant Change in Status Assessment (SCSA), under the section for Guidelines to Assist in Deciding if a change is significant or not, showed the following: - A condition is defined as self-limiting when the condition will normally resolve itself without further intervention or by staff implementing standard disease-related clinical interventions. If the condition has not resolved within two weeks, staff should begin an Significant Change in Status Assessment. - An Significant Change in Status Assessment is appropriate if there are either two or more areas of decline or two or more areas of improvement. In this example, a resident with a 5% weight loss in 30 days would not generally require an Significant Change in Status Assessment unless a second area of decline accompanies it This situation should be documented in the resident's clinical record along with the plan for subsequent monitoring and, if the problem persist or worsened, an Significant Change in Status Assessment may be warranted. - An Significant Change in Status Assessment is appropriate if there is a consistent pattern of changes with either two or more areas of decline or two or more areas of improvement. - Decline in two or more of, but not limited to the following: emergence of unplanned weight loss problem (5% in 30 days or 10% in 180 days), and emergence of new pressure at stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status. According to the National Pressure Injury Advisory Panel (NPIAPI), the pressure ulcer stages are defined as follows: - Stage 1 (one) Pressure Injury: Non-blanchable erythema (redness) of intact skin - Stage 2 (two) Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Review of the facility's P&P titled Weight Management Policy revised on 12/19/22, showed under Section 6. Weight Analysis, the newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in one month (30 days), b. 7.5% change in weight in three months (90 days), and c. 10% change in weight in six months (180 days). The RD will also document weight change notes for residents who have a five pounds weight loss or gain in one week. For weekly weight changes, the RD will complete a weight change note for any resident with a 3% weight loss or gain in one week. Medical record review for Resident 101 was initiated on 5/16/23. Resident 101 was admitted to the facility on [DATE]. Review of Resident 101's Quarterly MDS dated [DATE], showed Resident 101 had no weight loss of 5% or more in the last month or 10% or more in last 6 months, and had no one or more unhealed pressure ulcers(s) at Stage 1 or higher, but Resident 101 had MASD (inflammation or skin erosion caused by prolonged exposure to a source of moisture). Review of the facility document titled Monthly Weights Record for January 2023 showed Resident 101 weighed 100 pounds and had a weight loss of 8.3% in one month and 10.7% in 3 months. The documented weight for Resident 101 in October and December 2022 were 112 pounds and 109 pounds, respectively. Review of the RDN's Weight Changes Progress Note for Resident 101 dated 1/4/23, showed Resident 101's current body weight of 100 pounds (weight loss of nine pounds/8.3% in one month and weight loss of 12 pound/10.7% in three months). Further review of the RDN's Weight Changes Progress Note showed Resident 101 had a sacrococcyx MASD and significant weight loss and unintentional possible related enteral feed meeting lower range of estimated need. The RDN recommended to increase Resident 101's GT feeding rate to 60 ml per hour to run for 20 hours and continue to monitor for significant weight change. Review of Resident 101's medical record did not show the facility conducted an Interdisciplinary Care Conference or Weight Variance Care Conference for Resident 101's significant weight loss in one month and three months. Review of Resident 101's Skin Only Evaluation dated 1/18/23, showed Resident 101 had a new identified Stage 2 pressure ulcer on the sacrococcyx. Review of the RDN's Weight Changes Progress Note for Resident 101 dated 1/20/23, showed Resident 101's current body weight of 98 pounds (weight loss of 5 pounds/4.8% in one week). Review of the RDN's Weight Changes Progress Note further showed Resident 101 had Stage 2 sacrococcyx pressure ulcer and significant unintentional weight loss in one week, unintentional secondary to wound. The RDN recommended to increase Resident 101's GT feeding to 65 ml per hour to run for 20 hours and weekly weights for two weeks. Review of Resident 101's Interdisciplinary Care Conference - Skin Alteration Care Conference record dated 1/20/23, showed a brief description of wound status of Stage 2 sacrococcyx pressure ulcer due to worsening MASD. On 5/22/23 at 0918 hours, an interview and concurrent record review was conducted with the MDS Coordinator. The MDS Coordinator stated significant change in status assessment should be done when there were two significant declines in the resident status. The MDS Coordinator verified Resident 101 had a significant weight loss of 8.3% in one month and an MASD that progressed to Stage 2 pressure ulcer/injury. When asked if the significant change in status assessment was done for Resident 101, the MDS Coordinator stated a significant change in status assessment was not done due to the change was not considered significant when the interventions from the RDN were in-placed and effective. On 5/23/23 at 1330 hours, an interview and a concurrent record review was conducted with the DON. The DON verified Resident 101 had significant changes in January 2023 evidenced by an MASD that progressed to Stage 2 pressure ulcer/injury and a significant weight loss of 8.3% in one month. When asked if the significant change in status assessment should have been done by the MDS Coordinator, the DON further stated the significant change in status assessment should have been done as per the regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 24 final sampled residents (Resident 18, 45, 107, and 422). * The facility failed to develop a care plan problem to address Resident 422's use of apixaban (anticoagulant medication) and Melatonin (medication to aid with sleep). * The facility failed to ensure a care plan problem addressing Resident 422's use of lorazepam (antianxiety medication) was accurate to reflect the resident's behavior manifestation as ordered by the physician. * The facility failed to ensure a care plan problem addressing the dialysis access site was accurate to reflect Resident 18's dialysis access site. * The facility failed to ensure a care plan problem to address the use of foot cradle, the resident's noncompliance, and any alternatives to the use of foot cradle for wound management for Resident 107. * The facility failed to ensure a care plan problem addressing Resident 45's use of apixaban and aspirin (blood thinner) was accurate and resident centered. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 9/2/22, showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeliness to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Further review of the facility's P&P showed the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well -being, and resident specific interventions that reflect the resident's needs. and preferences and align with the resident's cultural identity, as indicated. 1. Medical record review for Resident 422's was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. a. Review of Resident 422's Order Summary Report showed a physician's orders dated 5/8/23, to administer apixaban 5 mg one tablet by mouth two times daily for atrial ibrillation (irregular heart rate) and melatonin 5 mg one tablet by mouth PRN for HS for 14 days for insomnia manifested by inability to sleep. Review of Resident 422's MAR for May 2023 showed melatonin 5 mg was administered on 5/10, 5/22, 5/16, 5/17, and 5/18/23. Review of Resident 422's plan of care failed to show a care plan problem was developed to address the use of apixaban and melatonin. On 5/17/23 at 1515 hours, an interview and concurrent medical review was conducted with the DON. The DON verified there was no care plan problem developed to address Resident 422's apixaban and melatonin use. b. Medical record review for Resident 422's was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer lorazepam (medication to relieve anxiety) 0.5 mg one tablet by mouth every six hours as needed for anxiety manifested by inability to relax for 14 days. Review of the care plan problem revised on 4/5/22, showed Resident 422 used lorazepam related to anxiety disorder, PTSD, bipolar disorder, schizophrenia manifested by verbalization of nervousness. However, Resident 422's care plan problem was not accurately address Resident 422's target behavior as ordered by the physician. On 5/17/23 at 1515 hours, an interview and concurrent medical review was conducted with the DON. The DON verified the care plan problem did not address Resident 422's anxiety manifested by inability to relax. 4. Medical record review for Resident 45 was initiated on 5/16/23. Resident 45 was initially admitted to the facility on [DATE]. Review of Resident 45's Order Summary Report dated 5/23/23, showed the following orders: - Apiarian (an anticoagulant medication) 5 mg oral tablet one tablet by mouth two times a day - Aspirin (a blood thinner medication) EC Delayed Release 81 mg oral tablet one tablet by mouth one time a day Review of Resident 45's Care Plan initiated on 2/7/22, showed a care plan problem addressing Resident 45's risk for bruising and bleeding. The nursing intervention included for Resident 45 to avoid the use of aspirin. On 5/23/23 at 1110 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 verified Resident 45 had been taking aspirin daily as per the MAR for the month of May 2023. LVN 10 verified Resident 45's care plan intervention showed for the resident to avoid the use of aspirin. On 5/23/23 at 1344 hours, an interview and concurrent medical record review was conducted with the DON. When asked, the DON stated the care plans should be specific to each resident and the staff were to review and update the care plan. The DON verified Resident 45's care plan was not resident centered since Resident 45 was taking aspirin daily. The DON further stated the care plan intervention may have populated from the care plan template. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were notified and acknowledged the above findings. 2. Review of the facility's P&P titled Comprehensive Care Plans revised on 9/2/22, showed the comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest, practicable physical, mental, and psychosocial well-being. Medical record review for Resident 18 was initiated on 5/16/23. Resident 18 was readmitted on [DATE], with the diagnosis of End Stage Renal Disease required hemodialysis. Review of Resident 18's Order Summary Report dated May 2023 showed a physician's order dated 5/16/23, for Resident 18's left groin central catheter hemodialysis access dressing site changes at the dialysis center and as needed, and to monitor the access site for signs and symptoms of infection every shift. Review of Resident 18's Plan of Care showed a care plan problem for hemodialysis revised on 10/22/22, showed an intervention to leave AV fistula/graft dressing in place for 48 hours or as indicated by dialysis center after dialysis treatment, unless soiled or if bleeding has occurred; if bleeding excessively, apply direct pressure over shunt site and notify the physician. However, Resident 18's dialysis access site was a left groin central catheter. On 5/19/23 at 0948 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings and stated Resident 18 did not have an AV fistula or graft. RN 1 stated Resident 18's dialysis access site was documented inaccurately in the care plan problem. On 5/19/23 at 0959 hours, the DON was informed and acknowledged the above findings. 3. On 5/16/23 at 0829 hours, and 5/17/23 at 1103 hours, Resident 107 was observed lying in bed with his bilateral lower extremities covered with a blanket. Resident 107's bed had a metal foot cradle (a frame installed at the foot of the bed to keep sheets/blankets off the legs/feet). However, Resident 107's blanket was not placed over the foot cradle. Medical record review for Resident 107 was initiated on 5/16/23. Resident was admitted to the facility on [DATE]. Review of Resident 107's H&P examination dated 3/24/23, showed Resident 107 had the capacity to understand and make decisions. Review of Resident 107's Order Summary Report for the month of May 2023 showed a physician's order dated 4/23/23, to provide treatment to the open wound status post amputation to the right foot by cleansing with normal saline (salt solution), pat dry, apply Manuka honey (monofloral honey with potential wound repair and antibacterial activities), apply calcium alginate (antimicrobial), apply skin barrier ointment to peri-wound, cover with ABD (a three layer pad with moisture barrier) pad, and secure with Kerlix (used to wrap around wound), then re-evaluate. Review of Resident 107's Comprehensive Plan of Care failed to show documented evidence of using a foot cradle as an intervention for the resident's wound management. On 5/17/23 at 1103 hours, an interview was conducted with Resident 107. Resident 107 stated he did not like the foot cradle because the blanket was always a mess. On 5/17/23 at 1112 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified Resident 107's blanket was not over the foot cradle because Resident 107 wanted the blanket to cover his legs and not over the foot cradle. CNA 2 further stated she told the treatment nurse about Resident 107's noncompliance with the use of the foot cradle. On 5/17/23 at 1123 hours, an interview and a concurrent electronic medical record review was conducted with LVN 6. LVN 6 stated the foot cradle was used to take off the pressure from Resident 107's right foot surgical wound. LVN 6 verified he was aware of Resident 107's noncompliance with the use of the foot cradle. In addition, LVN 6 acknowledged the care plan did not include the use of a foot cradle. On 5/17/23 at 1618 hours, an interview and a concurrent electronic medical record review was conducted with the DON. The DON verified the above findings and stated Resident 107's foot cradle was used as a preventative pressure relieving device intervention to promote healing to Resident 107's right foot surgical wound. The DON stated the foot cradle was discussed during the IDT care conference on 4/3/23, to use as a nursing measure. However, the DON was unable to provide documented evidence the foot cradle was discussed during the IDT care conference on 4/3/23. Resident 107's Comprehensive Plan of Care did not include the use of foot cradle, the resident's noncompliance with the use of foot cradle, and any alternatives to the foot cradle for wound management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 24 final sampled residents (Resident 51). * The facility failed to follow the physician's order to record Resident 51's I&O every shift for 30 days. This failure had the potential risk of not providing the appropriate care for Resident 51. Medical record review for Resident 51 was initiated on 5/16/23. Resident 51 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 51's Order Summary Report showed a physician's order dated 4/26/23, to record I&O every shift for 30 days. However, further review of Resident 51's medical record failed to show documented evidence the resident's I&O was recorded as per the physician's order. On 5/23/23 at 1415 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 51 had a physician's order to record I&O for 30 days; however, there was no documented evidence the resident's I&O was recorded as per the physician's order. On 5/23/23 at 1445 hours, an interview and a concurrent record review was conducted with the Medical Records Director. The Medical Records Director provided paper records of Resident 51's I&O from 4/26 to 5/1/23. When asked to provide documented evidence of Resident 51's I&O after 5/1/23, the Medical Record Director stated Resident 51's I&O was recorded only for seven days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 24 final sampled residents (Resident 101) was provided with the appropriate bed to promote the healing of the pressure injury. This failure posed the risk for Resident 101's pressure injury to deteriorate and develop additional pressure injuries. Findings: According to the National Pressure Injury Advisory Panel, Stage 4 pressure injury (ulcer) is defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough (non-viable fibrous yellow tissue) and/or eschar (dead tissue) may be visible and undermining and/or tunneling often occur. Review of the Invacare microAir MA600 Alternating Pressure Low Air Loss (LAL) Mattress System User Manual showed MicroAir MA600 Air Mattress Therapy System is recommended for use in the prevention and treatment of decubitus (pressure) ulcer Stage 1 to 3. For higher risk patient, please contact Invacare for additional product offerings to address higher risk patients. On 5/16/23 at 1026 hours, 5/17/23 at 1118 hours, 5/18/23 at 1008 hours, and 5/19/23 at 0911 hours, Resident 101 was observed lying on the Invacare microAir MA600 LAL mattress. Medical record review for Resident 101 was initiated on 5/16/23. Resident 101 was admitted to the facility on [DATE]. Resident 101 had a diagnosis of Stage 4 pressure ulcer to the sacral region. Review of Resident 101's Order Summary Report for May 2023 showed a physician's order dated 1/11/23, to provide low air loss mattress with bilateral wing for skin maintenance, check placement and functioning every shift. Review of Resident 101's Care Plan created 1/18/23, showed a care plan problem addressing pressure ulcer to the sacrococcyx (a bone formed by fusion of the sacrum and coccyx). The intervention included to use a pressure reducing device on the bed. Review of Resident 101's Braden Scale for Predicting Pressure Ulcer Risk dated 3/14/23, showed Resident 101 was a very high risk for pressure injury development. Review of Resident 101's Skin Only Evaluation dated 1/25, 4/26, 5/3, and 5/10/23, showed Resident had a Stage 4 pressure ulcer/injury to the sacrococcyx. On 5/19/23 at 1639 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 101 had a Stage 4 pressure ulcer/injury to the sacrococcyx and used an Invacare microAir MA600 LAL mattress. On 5/19/23 at 1650 hours, an interview and concurrent medical record review and Invacare microAir MA600 User Manual review was conducted with the DON. The DON verified Resident 101 was a very high risk for pressure ulcer and had a Stage 4 pressure ulcer/injury to the sacrococcyx. When asked if the Invacare microAir MA600 LAL mattress was appropriate, the DON acknowledged the Invacare microAir MA600 LAL mattress was not appropriate for Resident 101's Stage 4 pressure ulcer/injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 24 final sampled residents (Residents 87 and 96) were provided with the necessary indwelling urinary catheter care to prevent UTI. This failure had the potential to put Residents 87 and 96 at risk for UTI. Findings: Review of the facility's P&P titled Catheter Care revised on 12/19/22, showed it is the policy of the facility to ensure that residents with indwelling urinary catheters received appropriate catheter care and maintain their dignity and privacy when indwelling catheter is in use. Catheter care will be preformed every shift and as needed by nursing personnel. The procedure for catheter care are as follows: - Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). - Use new part of the cloth or different cloth for each side. - With new moistened cloth, starting at the urinary meatus moving out. - Document care and report any concerns noted to the nurse on duty and physician. 1. Medical record review for Resident 96 was initiated on 5/16/23. Resident 96 was admitted to the facility on [DATE]. Review of Resident 96's Order Recap Report dated 5/23/23, showed a physician's order dated 3/15/23, to use an indwelling urinary catheter. However, there was no documented evidence an indwelling urinary catheter care had been performed since 3/15/23. During an observation on 5/16/23 at 1145 hours, Resident 96's indwelling urinary catheter tubing was observed with blood. On 5/16/23 at 1223 hours, an interview was conducted with Resident 96's family member. When asked about Resident 96's indwelling urinary catheter, she stated Resident 96 had a UTI in the past. On 5/19/23 at 1007 hours, an interview was conducted with LVN 6. When asked who was responsible for performing indwelling urinary catheter care, LVN 6 stated it was performed by the CNAs. When asked if he knew where would the CNAs document indwelling urinary catheter care, he replied he was not sure. On 5/19/23 at 1350 hours, an interview was conducted with CNA 5. When asked where would they document indwelling urinary catheter care, she stated they would document the catheter care in the resident's medical record; however, not all residents' medical records had a section to document catheter care. CNA 5 further stated they just would not document catheter care. On 5/19/23 at 1445 hours, an interview was conducted with CNA 6. When asked where would the CNAs document catheter care performed, CNA 6 stated they would document in the resident's medical record under PRN Catheter. CNA 6 further stated the PRN Catheter section was new and she had not seen that feature before until today. Further review of the medical record showed the CNA's task for catheter care every shift and PRN. However, there was no documented evidence indwelling urinary catheter care was provided to Resident 96 prior to 5/19/23. On 5/23/23 at 0840 hours, CNA 4 was observed removing linen and towels from a fully stocked linen cart across Resident 96's room. On 5/23/23 at 0845 hours, an observation of indwelling urinary catheter care for Resident 96 and concurrent interview was conducted with CNA 4. CNA 4 cleaned Resident 96's perineal area using one moistened towel with a back and forth motion. CNA 4 proceeded to wipe Resident 96's indwelling urinary catheter tubing. When asked if she was provided with in-service training on indwelling urinary catheter care, CNA 4 replied yes. When asked if she was trained to use multiple towels when performing indwelling urinary catheter care, CNA 4 replied she was instructed to use a lot of towels; however, sometimes, the facility did not have enough towels. Review of the facility's in-service records titled Proper Perineal Care & UTI Prevention for Non-Cath and Residents With Catheters dated 3/28/23, showed CNA 4 was provided with in-service training on the facility's catheter care P&P. On 5/23/23 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. After the DON had reviewed Resident 96's medical record, the DON verified there was no documented evidence catheter care was performed prior to 5/19/23. When asked what the process was for indwelling urinary catheter care, she stated the staff must use soap, water, and a different towel when cleaning the sections of the perineal area and indwelling urinary catheter. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were notified and acknowledged the above findings. 2. On 5/16/23 at 0911 hours, 5/17/23 at 1109 hours, and 5/18/23 at 1018 hours, Resident 87 was observed with indwelling urinary catheter with the drainage bag hanging on the bed rails. Review of Resident 87's medical record was initiated on 5/16/23. Resident 87 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 87's had diagnoses of ALS and neuromuscular dysfunction of bladder. Review of Resident 87's Indwelling Catheter assessment dated [DATE], showed Resident 87 had an indwelling urinary catheter for neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problem). Review of Resident 87's Order Summary Report for May 2023 showed a physician's order dated 4/30/23, to use an indwelling urinary catheter; change for blockage leaking, pulled out excessive sedimentation, and change catheter drainage bag as needed and with every change of indwelling urinary catheter. Review of Resident 87's Care Plan revised on 1/24/23, showed a care plan problem addressing urinary retention, diagnosis of neurogenic bladder, and indwelling urinary catheter in placed. The interventions included to perform indwelling urinary catheter care. However, review of Resident 87's medical record failed to show documented evidence indwelling urinary catheter was performed as per Resident 87's care plan. On 5/19/23 at 1023 hours, an interview was conducted with LVN 6. LVN 6 verified Resident 87 was admitted with an indwelling urinary catheter and indwelling urinary catheter care was provided by the CNAs; however, LVN 6 did not know where the CNAs would document Resident 87's indwelling urinary catheter care. On 5/23/23 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 87 was admitted on [DATE], with an indwelling urinary catheter. Review of Resident 87's CNA's Task showed to provide catheter care every shift and PRN. However, further review of Resident 87's CNA's Task showed Resident 87's indwelling urinary catheter care was provided on 5/19/23, during the evening shift (1500 hours to 2300 hours). On 5/23/23 at 1504 hours, an interview was conducted with the Medical Records Director. The Medical Records Director verified there was no documented evidence indwelling urinary catheter care was performed on Resident 87 prior to 5/19/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of the 24 final sampled residents (Resident 99) received the appropriate treatment and services to prevent the occurrences of complications from GT feeding. * The facility failed to ensure Resident 99's head of bed was elevated during GT feeding to reduce the risk of aspiration. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Care and Treatment of Feeding Tubes revised on 9/2/22, showed it is a policy of the facility to utilize feeding tubes in accordance with the current clinical standards of practice, with the interventions to prevent complications to the extent possible. On 5/16/23 at 1606 hours, an observation of CNA 1 performing care to Resident 99 was conducted. CNA 1 was noted to be fixing Resident 99's diaper and bed. However, Resident 99's head of bed was not elevated while the GT feeding was turned on. CNA 1 elevated Resident 99's head only after the care was done. On 5/16/23 at 1612 hours, an interview was conducted with CNA 1. CNA 1 verified Resident 99's head of bed was not elevated when providing care and Resident 99's GT feeding was turned on. When asked if Resident 99's head was supposed to be positioned flat on bed while GT feeding was running, CNA 1 stated being not aware of the resident head's position during the tube feeding. Review of Resident 99's medical record was initiated on 5/16/23. Resident 99 was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Resident 99's Order Summary report showed a physician's order dated 5/3/23, to administer a continuous enteral feeding formula, Diabetisource at 45 ml/hour to run for 20 hours starting at 12 noon time until the entire volume infused. Review of the facility's Record of In-service training provided to the CNAs dated 12/27 and 12/28/22, showed a lesson plan on the Care of Patient's on GT feeding. The lesson plan included a course content explaining the need to elevate the resident's head of bed at an appropriate angle during feeding to reduce the risk of aspiration. On 5/19/23 at 1416 hours, an interview was conducted with LVN 13. When asked if Resident 99's head of bed had to be positioned a certain way while the GT feeding was running or turned on, LVN 13 stated Resident 99's head of bed should be elevated while the GT feeding was infusing to prevent aspiration. On 5/23/23 at 1507 hours, an interview and concurrent employee record review was conducted with the DSD. The DSD verified CNA 1 had an Initial/Annual Competency Evaluation done 9/27/22, including the care of residents with multiple tubing, ventilator, IV, GT, and oxygen. The DSD further stated the CNAs were aware when the GT feeding was infusing, the head of bed should not be low due to the risk of aspiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to one of 24 final sampled residents (Resident 20). * The licensed nurse failed to clarify with the physician regarding two different orders for pain scale for Resident 20. In addition, the medication prescribed for moderate pain was administered for a severe pain, and there were no documented non-pharmacological interventions provided to Resident 20 prior to the administration of the pain medication. These failures posed the risk of Resident 20's pain not being managed appropriately. Findings: Review of the facility's P&P titled Pain Management revised on 2/2022 showed the following steps for the staff to complete: - Following the implementation of non-pharmacological intervention, the licensed nurse may administer pharmacological interventions as ordered and document medication administered on the MAR; - The licensed nurse will complete the Pain Flow Sheet for residents receiving PRN pain medication to evaluate the effectiveness of the medication regimen; - Each shift the licensed nurse will assess the resident for pain and document the results on the MAR using the 0-10 pain scale. The shift pain score will indicate the highest pain level that occurred on that shift; - If there is a new onset of pain, worsening of pain, new pain medication, pain medication change, and/ or other, the licensed nurse will complete the COMS - Vitals and Pain Only Evaluation and notify the attending physician and IDT for further recommendations; and - The facility staff will utilize non-pharmacological interventions to help reduce pain level as much as possible. Medical record review for Resident 20 was initiated on 5/16/23. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's MDS dated [DATE], showed Resident 20 was cognitively intact. a. Review of Resident 20's Order Summary Report showed the following physician's orders: - dated 4/2/21, to monitor for the resident's pain intensity before, during, and after the treatment using the following pain scale rating: 0 = no pain, 1 to 4 = mild, 5 to 7 = moderate, 8 to 9 = severe, and 10 = very severe pain, every shift; - dated 1/18/22, to monitor for the resident's pain intensity before, during, and after the treatment using the following pain scale rating: 0 = no pain, 1 to 4 = mild, 5 to 7 = moderate, 8 to 9 = severe, and 10 = very severe pain, every 24 hours as needed; and - dated 11/21/22, to administer Ultram (narcotic opioid medication used to treat moderate to severe pain) 50 mg one tablet every six hours as needed for moderate pain levels 4 to 7. However, Resident 20's pain scale rating in the above orders on 4/2/21 and 1/18/22 were inconsistent with the order dated 11/21/22, for moderate pain. Further review of Resident 20's medical record failed to show documented evidence the pain scale rating orders were clarified with the physician. b. Review of Resident 20's MAR for May 2023 showed Resident 20 was administered Ultram for the pain level above 7. Further review the MAR showed Resident 20 was administered Ultram on 5/1, 5/2, 5/9, 5/10, 5/15, 5/16, and 5/19/23, and the documented pain level ranged from 4 to 9 or mild to severe pain using the pain scale rating above; however, the physician order to administer Ultram was for moderate pain only. c. Review of Resident 20's Progress Notes showing a late entry for COMS - Vitals and Pain Only Evaluation dated 1/24/22, showed the resident complained of back pain daily and non-pharmacological interventions did not provide relief. However, the notes including the evaluation did not show what non-pharmacological interventions were provided to Resident 20. Review of Resident 20's plan of care showed a care plan problem dated 9/15/22, to address acute pain/chronic pain. The interventions included to medicate with PRN medications if non-medication interventions were ineffective and to utilize non-pharmacological interventions for pain relief. Review of Resident 20's Progress Notes dated 5/2/23, showed the resident had pain or was hurting anytime in the last five days, and the pain intensity level was moderate. However, the documentation failed to include any non-pharmacological interventions that were provided to Resident 20. Further review of Resident 20's medical record failed to show documented evidence any non-pharmacological interventions being implemented by the staff before administering the pharmacological interventions to the resident. On 5/19/23 at 0956 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified there were two different pain scale rating used for moderate pain per the physician's orders. LVN 7 verified the Ultram medication was for moderate pain of 4 to 7 pain rating scale; however, the Ultram medication was given for 8 to 9 pain rating scale. LVN 7 stated she needed to clarify the pain rating scale in the physician's order for Ultram medication. On 5/19/23 at 1039 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified the above findings. RN 1 stated non-pharmacological interventions were initiated during the pain assessment upon admission and implemented prior to the administration of the pain medication. RN 1 verified there was no non-pharmacological interventions provided for Resident 20.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the licensed nurse coordinated with the physician regarding the sevelamer carbonate (a medication that can lower the amount of phosphorus in the blood of residents receiving kidney dialysis) scheduled at the time when the resident was out to the dialysis center for one of 24 final sampled residents (Resident 18). Resident 18 did not receive the medication as ordered by the physician on the dialysis days. This failure posed the risk for Resident 18 to not be provided with the appropriate care and treatment and sustained possible medical complications that could had been avoided when the physician's order was followed. Findings: Review of the facility's P&P titled Hemodialysis revised on 9/2/22, showed the licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as the used of the dialysis communication record or other forms that will include, but not limited to the timely medication administration (initiated, held, or discontinued) by the nursing home. Medical record review for Resident 18 was initiated on 5/16/23. Resident 18 was readmitted on [DATE], with the diagnosis of End Stage Renal Disease requiring hemodialysis. Review of Resident 18's Order Summary Report for May 2023 showed a physician's order dated 12/10/22, for Resident 18 to receive hemodialysis treatment on Tuesdays, Thursdays, and Saturdays, with a chair time of 1300 hours; and to be picked up by transportation from the facility at 1130 hours. In addition, there was a physician's order dated 4/14/23, for Resident 18 be administered sevelamer carbonate 800 mg by mouth three times a day with meals. Review of Resident 18's MAR for May of 2023 showed the sevelamer carbonate medication scheduled at 1300 hours, was not administered during dialysis days on 5/4, 5/6, 5/11, 5/13, and 5/18/23. There was no documented evidence the nursing staff had coordinated with the physician on what to do for the sevelamer carbonate medication scheduled at 1300 hours on those dialysis days. On 5/19/23 at 0945 hours, an interview and a concurrent electronic medical record review was conducted with LVN 1. LVN 1 stated Resident 18 was out of the facility on Tuesdays, Thursdays, and Saturdays for dialysis. LVN 1 stated Resident 18 had left the facility for dialysis at around 1130 hours. LVN 1 was informed and verified the above findings and stated there was no physician's order to hold Resident 18's sevelamer carbonate medication when she was out for dialysis, nor did LVN 1 notify the physician of the sevelamer carbonate not being given to Resident 18. LVN 1 stated he did not know he had to notify the physician if he did not administer the sevelamer carbonate to Resident 18 when the resident was out of the facility receiving her dialysis treatment. On 5/19/23 at 0959 hours, an interview and a concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings and stated it was important for Resident 18 to receive all her scheduled medications to prevent complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical records review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 24 final sampled residents (Resident 5) and three nonsampled residents (Residents 22, 90, and 822). * The facility failed to ensure Resident 22's Lactulose (medication to treat constipation) was administered as ordered. * The facility failed to ensure the Norco (controlled pain medication) for Resident 5 was documented in MAR when administered. * The facility failed to ensure the Norco for Resident 90 was documented in the MAR when administered. * The facility failed to ensure the medications were not left unattended by a licensed nurse during medication administration. * The facility failed to ensure the wasting of controlled medication was performed by two licensed nurses. These failures posed the risk for possible complications, delay in interventions and treatments, and risk for diversion of controlled medication. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated 10/2017 showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Review of the facility's P&P titled Preparation and General Guidelines: Controlled Medications dated 8/2014 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: date and time of administration; amount administered; signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply; and the initials of the nurse administering the dose on the MAR after the medication is administered. Review of the facility's P&P titled Medication Storage in the Facility: Storage of Medications dated 4/2008, showed only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 1. Medical record review for Resident 22 was initiated on 5/16/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Order Summary Report showed a physician's order dated 6/29/22, to administer Lactulose Solution 20 gm/30 ml via GT one time for bowel management and to hold for loose stool. On 5/16/23 at 0817 hours, a medication administration observation and concurrent interview for Resident 22 was conducted with LVN 8. LVN 8 did not administer the Lactulose as ordered. LVN 8 verified she did not administer the Lactulose because the facility did not have the medication available at the time of medication administration. 2.a. Medical Record review for Resident 5 was initiated on 5/16/23. Resident 5 was admitted to the facility on [DATE]. Review of the Order Summary report showed a physician's order dated 5/06/23, to administer Norco Oral Tablet 5-325 mg (hydrocodone- acetaminophen) one tablet via GT every 6 hours as needed for moderate pain to severe pain NTE 3 gm/24 hrs of APAP (acetaminophen) from all sources. Review of Resident 5's Antibiotic or Controlled Drug Record for the use of Norco (hydrocodone-acetaminophen)showed Norco 5-325 mg one tablet on 5/12/23 at 2030 hours, and one tablet on 5/13/23 at 0300 hours, were signed out on the narcotic count sheet. Review of Resident 5's MAR for May 2023 failed to show documentation of Norco 5-325 being administered to Resident 5 on 5/12/23 at 2020 hours, and 5/13/23 at 0300 hours. On 5/17/23 at 0922 hours, an interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified Resident 5's Antibiotic or Controlled Drug Record showed the Norco was signed out on 5/12/23 at 2030 hours, and 5/13/23 at 0300 hours. However, the Norco 5-325 was not documented as administered in Resident 5's MAR. b. Medical Record review for Resident 90 was initiated on 5/16/23. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 90's Order Summary Report showed a physician's order dated 5/5/23, to administer hydrocodone-acetaminophen (Norco) 5-325 one tablet via GT every 6 hours as needed for moderate pain to severe pain, NTE 3 gm/24 hrs of APAP from all sources. Review of Resident 90's Antibiotic or Controlled Drug Record for Norco showed Norco 5-325 was signed out on 5/10/23 at 2200 hours. Review of Resident 90's MAR for May 2023 failed to show documentation of Norco 5-325 being administered to Resident 90 on 5/10/23 at 2200 hours. On 5/17/23 at 0922 hours, and interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified Resident 90's Antibiotic or Controlled Drug Record showed the Norco was signed out on 5/10/23 at 2200 hours. However, it was not documented as administered in Resident 90's MAR. 3. Medical record review for Resident 22 was initiated on 5/16/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Order Summary report showed the physician's orders for the following medications: - Symmetrel 50 mg/5 ml 20 ml via GT for Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) - amlodipine 10 mg one tablet via GT for hypertension (high blood pressure) - Folic Acid 400 mcg via GT as supplement - Lansoprazole (medication to help reduce high levels of acid in the stomach) 30 mg one capsule via GT - Keppra (levetiracetam) 100 mg/ml 5 ml via GT for seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements and state of awareness) - Lisinopril (to treat high blood pressure) 5 mg one table via GT - Metformin (to treat high sugar level in the blood) 500 mg one tablet via GT - MVI + minerals 5 ml (multivitamins with minerals) via GT as supplement - metoprolol tartrate (to treat high blood pressure) 25 mg via GT - Ultra B-100 complex one tablet via GT as supplement - Oyster shell Calcium 500 mg and Vitamin D 5 mcg via GT as supplement On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 was conducted with LVN 8. LVN 8 prepared the liquid medication and crushed tablet medications to administer to Resident 22. LVN 8 was observed to have turned her back three times away from the medications, to get gloves, stethoscope, and spoons, leaving the prepared medication in the cups on top of the over bed table and unattended. On 5/16/23 at 1448 hours, an interview was conducted with LVN 8. LVN 8 acknowledged the findings and stated she should not have left the medications unattended. 4. Medical record review for Resident 822 was initiated on 5/19/23. Resident 822 was admitted to the facility on [DATE], and discharged on 2/28/23. Review of Resident 822's Antibiotic or Controlled Drug Record for alprazolam (medication to treat anxiety) 0.25 mg tablet showed on 2/28/23, with no time documented, one alprazolam tablet was signed as wasted by one licensed nurse. On 5/19/23 at 1109 hours, an interview and concurrent medical record review was conducted with the DON. The DON verifed one tablet of alprazolam 0.25 mg was signed and wasted by one licensed nurse, but it should have been signed by two licensed nurses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility P&P review, and facility document review, the Pharmacy Consultant failed to identify and recommend for monitoring of the side effects for enoxaparin (anticoagulant medication which reduces the chance of getting blood clots) for one of 24 final sampled residents (Resident 92). This failure had the potential risk of providing Resident 92 unnecessary medication and the potential for the development of significant side effects. Findings: Review of the facility's P&P titled Consultant Pharmacist Reports IIIA1: Medication Regimen Review (Monthly Report) dated 6/2021 showed the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimized adverse consequences relation to medication therapy. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing and/or prescriber as appropriate. If no irregularities are found, the consultant pharmacist will provide documentation. According to Lexicomp (online drug reference), enoxaparin sodium is an anticoagulant medication. The adverse effects section showed the list of adverse effects including major bleeding. The Warning/Cautions section showed concerns related to adverse effects which include bleeding. Medical record review for Resident 92 was initiated on 5/17/23. Resident 92 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 92's Order Summary Report for May 2023 showed a physician's order dated 2/22/23, to administer enoxaparin sodium injection solution prefilled syringe 40 mg/0.4 ml 0.4 ml subcutaneously one time a day for DVT prophylaxis. The physician's order for enoxaparin sodium did not include the monitoring of side effects. Review of Resident 92's Pharmacy Consultant's Medication Regimen Review for 2/15, 3/15, and 4/20/23, did not show the recommendations for Resident 92 to be monitored for the side effects of enoxaparin sodium. On 5/18/23 at 1508 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant verified he conducted a medication regimen review for Resident 92. The Pharmacy Consultant was asked if he had recommendations for Resident 92's enoxaparin sodium order. The Pharmacy Consultant reviewed his data and stated he did not see documentation of recommendations for the resident's enoxaparin sodium medication. The Pharmacy Consultant stated he would initially assess the residents and their medications before providing recommendations, but he would normally recommend side effects monitoring for anticoagulant medications. Cross reference to F757.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure three of 24 final sampled residents (Residents 77, 92, and 422) were free from unnecessary medications. * The facility failed to monitor for signs and symptoms of bleeding related to Residents 422 and 77's use of apixaban (anticoagulant medication used to prevent blood clots). * The facility failed to monitor for signs and symptoms of side effects related to Resident 422's use of Reglan (medication used to treat nausea and vomiting). * The facility failed to monitor for signs and symptoms of bleeding related to Resident 92's use of enoxaparin (anticoagulant medication used to prevent blood clots). * The facility failed to ensure Resident 422's anti-bacterial medication order had a stop date. These failures had the potential for residents to receive unnecessary medications and develop significant adverse effects, and risk of adverse effects from prolonged use of the medication. Findings: 1. According the Lexicomp, Apixaban is an anticoagulant and may increase the risk of bleeding (hemorrhage), including severe and potentially fatal major bleeding. a. Medical record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer apixaban oral tablet 5 mg one tablet by mouth two times a day related to unspecified atrial fibrillation. The Order Summary Report did not include a physician's order to monitor for the side effects of the apixaban. b. Medical Record Review for Resident 77 was initiated on 5/16/23. Resident 77 was admitted to the facility on [DATE], and readmitted on 3/16 and 11/23/22. Review of Resident 77's Order Summary report showed a physician's order dated 2/4/23, to administer Eliquis (brand name for apixaban) tablet 5 mg one tablet enterally one time a day for atrial fibrillation. The Order Summary Report did not include a physician's order to monitor for the side effects of the Eliquis. On 5/19/23 at 0835 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified there was no physician's order to monitor Resident 77 for the adverse effects of the Eliquis. On 5/19/23 at 1012 hours, a telephone interview and concurrent medical record review was conducted with the facility's Pharmacy Consultant. The Pharmacy Consultant acknowledged and verified that the facility did not have a physician's order to monitor for the adverse effects of the blood thinners ordered for for Residents 422 and 77. 2. Medical record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the drug information sheet from Lexicomp showed Reglan can cause tardive dyskinesia, a serious movement disorder that is often irreversible, which include trouble controlling body movements or problems with tongue, face, mouth, or jaw-like tongue sticking out, puffing cheeks, mouth puckering or chewing, extrapyramidal symptoms (trouble controlling body movements, twitching, change in balance, trouble swallowing or speaking), neuroleptic malignant syndrome (fever, muscle cramps or stiffness, dizziness, very bad headache, confusion, change in thinking, fast hearbeat, heartbeat that does not feel normal, or are seating a lot). Review of Resident 422's Order Summary Report showed an order dated 5/8/23, to administer Reglan Oral 5 mg tablet (metoclopramide HCl) one tablet by mouth every 6 hours as needed for nausea and vomiting. The Order Summary Report for Resident 422 did not include the monitoring of adverse effects of the medication. On 5/18/23 at 1329 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the facility did not monitor for the adverse effects of Reglan. 3. Medical record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer rifaximin (antibiotic) oral tablet 550 mg one tablet by mouth two times a day for SIBO-Small Bowel intestinal Bacterial Overgrowth. The Order Summary Report did not include a stop date for Resident 422's rifaximin. Review of the drug information sheet from Lexicomp showed rifaximin for small intestinal bacterial overgrowth (off label use) is administered by mouth, 550 mg three times daily for 14 days. A concern for potential risk of development of antimicrobial resistance with prolonged rifaximin use or repeated courses of treatment. On 518/23 at 1105 hours, an interview and concurrent medical record review was conducted with LVN 7. When asked if an antibiotic used to treat bacterial infection needed to have a duration, LVN 7 stated yes. 4. Review of Lexicomp, an online reference for clinical drug information, showed precautions and concerns related to the adverse effects of enoxaparin sodium included bleeding and residents should be monitored closely for signs and symptoms of bleeding. Review of the facility's P&P titled High Risk Medication-Anticoagulants revised 9/2/22, showed the resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), fall in hematocrit or blood pressure, and thromboembolism. Medical record review for Resident 92 was initiated on 5/17/23. Resident 92 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 92's Order Summary Report for May 2023 showed a physician's order dated 2/22/23, to administer enoxaparin sodium injection solution prefilled syringe 40 mg/0.4 ml inject 0.4 ml subcutaneously one time a day for DVT prophylaxis. The physician's order for enoxaparin sodium did not include monitoring for side effects. Review of Resident 92's MAR dated April and May 2023 failed to show documentation the signs and symptoms of bleeding related to the use of enoxaparin sodium were being monitored. Review of Resident 92's plan of care failed to show a care plan problem was developed for the use enoxaparin sodium medication. On 5/17/23 at 1545 hours, an interview and concurrent electronic medical record review was conducted with LVN 9. LVN 9 stated there should be monitoring for the signs and symptoms of bleeding related to the use of enoxaparin for Resident 92. LVN 9 verified he could not find the monitoring of the adverse effects for the use of enoxaparin sodium medication in the MAR or the care plan. On 5/17/23 at 1618 hours, an interview and a concurrent electronic medical record review was conducted with the DON. The DON acknowledged the above findings and stated the facility did not need an order for monitoring of the adverse effects for enoxaparin, but it needed to be included in the care plan problem. The DON confirmed Resident 92 did not have a care plan problem for the use of enoxaparin sodium. Cross reference to F756.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview, medical record review, and facility P&P review, the facility failed to ensure two of 24 final sampled residents (Residents 77 and 422) were free from unnecessary psychotropic medications (any drug which afftects brain activities associated with mental processes and behavior). * The facility failed to ensure the non-pharmacological interventions were provided to Resident 422 for the use of lorazepam PRN and melatonin. In addition, the facility failed to ensure a rationale was documented for extending the duration of the use of lorazepam for Resident 422. * The facility failed to ensure non-pharmacological interventions were provided to Resident 77 for the use of clonazepam (antianxiety medication). These failures had the potential for residents to develop significant adverse effects from the medications and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medication revised on 9/2/22, showed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Further review of the P&P showed non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 1.a. Medical Record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to facility on 10/15/19, and readmitted on [DATE] and 5/8/23. Review of Resident 422's Order Summary Report showed a physician;s order dated 4/4/23, Ativan (brand name for lorazepam) 0.5 mg one tablet by mouth every six hours PRN for anxiety manifested by verbalization of nervousness for 14 days. Review of Resident 422's Order Summary report showed a physician's order dated 5/8/23, to administer lorazepam oral tablet 0.5 mg one tablet by mouth every six hours PRN for anxiety manifested by inability to relax for 14 days. Review of Resident 422's MAR showed on 4/7, 4/12, 4/13, 5/2, 5/3 , 5/9, 5/10, 5/11 , 5/15, and 5/16/23, the lorazepam 0.5 mg one tablet was documented as administered. The MAR failed to show non-pharmacological interventions were implemented prior to the administration of the lorazepam medication. b. Medical Record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to facility on 10/15/19, and readmitted on [DATE] and 5/8/23. Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer melatonin oral tablet 5 mg one tablet by mouth PRN for HS for 14 days for insomnia manifested by inability to sleep. Review of Resident 422's MAR showed on 5/10, 5/11, and 5/16/23, melatonin oral tablet 5 mg was administered to the resident. The MAR failed to show non-pharmacological interventions were implemented prior to the administration of the medication. On 5/19/23 at 0825 hours an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified non-pharmacological interventions were not being implemented prior to administering the medication. 2. Medical Record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to facility on 10/15/19, and readmitted on [DATE] and 5/8/23. Review of Resident 422's Order Summary Report showed a physician's order dated 2/20/23 to administer lorazepam tablet 0.5 mg one tablet by mouth every 6 hours as needed for anxiety for 14 days manifested by verbalization of nervousness. Further review of the Order Summary Report showed the lorazepam was ordered again for 14 days on 3/22, 4/4, and 5/8/22. Further review of Resident 422's medical record failed to show documentation from the physician for the rationale for extending the use of lorazepam PRN beyond 14 days. On 5/8/23 at 1329 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no physician's documentation of the rationale to extend/renew the order for the use of antianxiety medication. 3. Medical Record review for Resident 77 was initiated on 5/18/23. Resident 77 was admitted to facility on 12/1/20, and readmitted on 3/16 and 11/23/22. Review of Resident 77's Order Summary Report showed a physician's order dated 2/3/23, to administer clonazepam tablet 0.5 mg one tablet two times a day for anxiety manifested by restlessness. Review of Resident 77's MAR showed on 3/1 to 3/31, 4/1 to 4/30, and 5/1 to 5/16/23, clonazepam tablet 0.5 mg one tablet was administered twice a day to the resident. The MAR failed to show non-pharmacological interventions were implemented prior to the administration of the medication. On 5/19/23 at 0825 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified non-pharmacological interventions were not being implemented prior to administering the medication.

Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.33%. Two of two licensed nurses (LVNs 7 and 8) were found to have made errors during the medication administration. * Resident 22 had the physician's order to mix lanzoprazole (a medication which reduces the amount of acid in the stomach) with apple sauce/apple juice; however, LVN 8 mixed the medication with water instead of apple juice as ordered. * Resident 22 had the physician's order for lactulose (medication to treat constipation); however, LVN 8 did not administer the medication as ordered. * Resident 22 had the physician's order for Oscal and D3 500/200 (supplement); however, LVN 8 did not administer the correct dose as ordered. * Resident 422 had the physician's orders for diltiazem ER (an extended release antihypertensive medication) and potassium chloride ER (an extended release potassium supplement); however LVN 7 crushed these extended release medications to administer to the resident. * Resident 422 was administered with the crushed medications; however, LVN 7 left the crushed medication residue in the medication cup. * Resident 422 had the physician's order for diclofenac sodium gel (medication ointment to relieve pain); however, LVN 7 did not administer the medication as ordered. These failures resulted in the residents not receiving the prescribed medications as ordered by the physician, posed the risk of adverse effects, and had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Preparation and General Guidelines: Medication Adinistration-General Guidelines dated 10/2017, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of the facility's P&P also showed long-acting or enteric coated dosage forms should generally not be crushed; an alternative should be sought. 1. On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 was conducted with LVN 8. LVN 8 administered Resident 22's Lanzoprazole via GT mixed with water. However, review of the Order Summary Report showed a physician's order dated 10/13/22, for Lansoprazole Capsule Delayed Release 30 mg one capsule via GT, to mix with applesauce/apple juice. According to Lexicomp, lanzoprazole capsule can be opened and the granules mixed with 40 ml of apple juice and administered through the nasogastric tube into the stomach, then flush tube with additional apple juice. Do not mix with other liquids. On 5/16/23 at 1428 hours, an interview was conducted with LVN 8. LVN acknowledged that lansoprazole was mixed/dissolved in water instead of mixing with apple juice or apple sauce as ordered by physician. 2. On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 and concurrent review of the medical record was conducted with LVN 8. Review of the Order Summary Report showed a physician's order dated 6/29/22, to administer Lactulose Solution 20 gm/30 ml 30 ml via GT one time a day for bowel management and to hold for loose stools. However, LVN 8 did not administer the Lactulose as ordered to Resident 22 during the medication administration observation. On 5/16/23 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 stated she did not administer the Lactulose because it was not available in the facility during the medication administration. 3. On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 was conducted with LVN 8, LVN 8 administered a crushed Oyster Shell Calcium 500 mg with Vitamin D 5 mg via GT. However, review of the Order Summary Report showed a physician's order dated 6/30/22, to administer Oscal with vitamin D3 tablet 500/200 MG-UNIT one tablet via GT two times a day for supplement. On 5/16/23 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 acknowledged vitamin D 200 IU should have been given to Resident 22. 4. On 5/16/23 at 0931 hours, a medication administration observation for Resident 422 was conducted with LVN 7. LVN 7 crushed diltiazem (drug that can treat high blood pressure and chest pain) 300 mg ER (extended release tablet, medication designed to make it last longer in the body) and KCl ER tablet (potassium chloride extended release, this medication is a mineral supplement used to treat or prevent low amounts of potassium in the blood) and administered to Resident 422. Review of the Order Summary Report showed a physician's order dated 5/8/23, to administer diltiazem HCL ER 24 Hour 300 mg one tablet by mouth one time a day, HOLD IF SBP less than 100 mmHg, and another physician's order dated 5/8/23, to administer potassium chloride ER tablet 40 mEq by mouth one time a day for supplement. On 5/16/23 at 1242 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 was asked if the dializem HCL ER and Potassium Chloride ER should have been crushed. LVN 7 stated it should not have been crushed; however, she crushed the medications because Resident 422 requested for the medications to be crushed. 5. On 5/16/23 at 0931 hours, a medication administration observation for Resident 422 was conducted with LVN 7. LVN 7 had crushed Xifaxan (brand name for rifaximin- antibiotics that can treat traveler's diarrhea and intestinal infection) 550 mg as per the resident's request, mixed it with apple sauce, and placed in a plastic medicine cup. After administering Xifaxan, it was observed moderate amount of residue was left inside the medication cup. Resident 422 did not receive a full dose of the medication as ordered. Review of the Order Summary Report for Resident 422 showed a physician's order dated 5/8/23, to administer rifaximin 550 mg one tablet by mouth two times a day for SIBO-Small Bowel intestinal Bacterial Overgrowth. On 5/16/23 at 1242 hours, an interview was conducted with LVN 7. LVN 7 acknowledged and verified Resident 422 did not receive the full dose as ordered. 6. On 5/16/23 at 0931 hours, a medication administration observation and concurrent medical review for Resident 422 was conducted with LVN 7. Review of the Order Summary Report for Resident 422 showed a physician's order dated 5/8/23, to administer diclofenac sodium External Gel 1% 4 gm to both BLE joints topically two times a day for pain management. During the medication administration observation, LVN 7 did not apply diclofenac to the resident's BLE joints. However, review of Resident 422's MAR showed diclofenac was documented as administered to the resident On 5/16/23 at 1242 hours, an interview was conducted with LVN 7. LVN 7 verified the medication was signed for in the MAR as administered; however the medication was not administered to Resident 422.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications were removed from Treatment Cart A and Medication Room B. * The facility failed to ensure Resident 45's medication requiring refrigeration was stored in the medication refrigerator. * The facility failed to ensure the discontinued eye drop medication was removed from Refrigerator A. * The facility failed to ensure the opened insulin pens and medication vial labeled with open date more than 30 days for Residents 25, 56, and 100) were removed from stock or Medication Cart A. * Two bottles of pain-relieving oil were observed on Resident 53's bedside table. These failures had the potential to negatively impact the residents' well-being; had the potential for the medications to lose the stability and effectiveness; and had the potential for residents, staff, and visitors to have an access to the medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility: Storage of Medications dated 4/2008 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if current order exists. Further review of the facility's P&P showed medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Review of the Drug Pharmacology Information from Lexicomp (drug reference developed to provide drug reference solutions for hospital wide or community pharmacist ) for Insulin Lispro, under Storage/Stability section showed store unopened vials, cartridges and prefilled pens under refrigeration between 2 and 8 degrees C (36 degrees F and 46 degrees F) until the expiration date or at room temperature < 30 degrees C (<86 degrees F) for 28 days; do not freeze; keep away from the heat and light. Store in in-use vials under refrigeration between 2 degrees C and 8 degrees C (36 degrees F and 46 degrees F) or at room temperature <30 degrees C (<86 degrees F) and use within 28 days. Store in-use cartridges and prefilled pens at room temp <30 degrees C (<86 degrees F) and use within 28 days; do not freeze. 1. On 5/17/23 at 0900 hours, an inspection of Medication Room B and concurrent interview was conducted with the DSD. One bottle of Earwax Softener drop was found with an expiration date of 4/2023. The DSD verified and acknowledged the finding. On 5/17/23 at 1043 hours, an inspection of Treatment Cart A and concurrent interview was conducted with LVN 6. A Pluro Gel Wound and Burn Dressing (no specific resident name) was found with an expiration date of 3/2023. LVN 6 verified the finding. 2. On 5/17/23 at 1057 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 5. Resident 45's arformoterol (medication to treat breathing problems caused by chronic obstructive pulonary disease) 15 mcg/2 ml solution/nebulizer labeled as REFRIGERATE was found inside Medication Cart B. LVN 5 acknowledged and verified the finding and stated the medication should have been kept in the refrigerator. 3. On 5/17/23 at 0830 hours, an inspection of Refrigerator A and concurrent interview was conducted with RN 4. A bottle of latanoprost .005% (medication to treat glaucoma, an eye condition which can cause blindness) with a refilled date of 7/1/22, was discontinued on 8/2/22; however, the medication was still inside Refrigerator A. RN 4 verified the finding and stated the medication should have been removed from Refrigerator A. 4. On 5/16/23 at 1447 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 4. The following medications were observed inside Medication Cart A: - Insulin (hormones which regulates the amount of sugar in the blood. Lack of insulin causes a form of diabetes) Lispropen 100 u/ml, with an open date of 4/8/23, for Resident 56 - Insulin Lispro pen 100 u/ml, with an open date of 4/2/23, for Resident 26 - Regular insulin -Humulin 100 u/ml vial, with an open date of 3/30/23, for Resident 100 The insulin vials were opened for more than 30 days at room temperature and stored inside Medication Cart A. When LVN 4 was asked how long should the insulin should be kept at room temperature and used once opened, LVN 4 stated for 28 days. 5. Review of the facility's P&P titled Medication Storage in the Facility dated April 2008 showed the medications and biologicals are stored safely, and properly, following manufacturer's recommendation or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized. Review of the facility's P&P titled Self-Administration of Medication dated April 2008 showed bedside medication storage is permitted only when it does not present a risk to confused residents who wander into rooms of, or room with, residents who self-administer, the manner of storage prevents access by other residents, and all nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage and to give unauthorized medications to the change nurse for return to the family or responsible party. On 5/16/23 at 0924 hours, an observation of Resident 53's room was conducted. Two bottles of [NAME] pain relieving oil was observed on top of Resident 53's bedside table. Review of Resident 53's medical record was initiated on 5/16/23. Resident 53 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 53's Order Summary Report did not show an order for the pain reliving oil. Review of Resident 53's Care Plan showed a care plan problem dated 8/27/21, to address the resident's risk for pain secondary to arthritis. Review of Resident 53's Self-Administration of Medication assessment dated [DATE], showed Resident 53 was not capable of the following: - storing medications in a secure location, - opening/closing the medication containers, - administering medication by various routes, - correctly state/read name of medication and its prescribed use, - identify common side effects of medication(s), - correctly state what time medication(s) are to be taken, - correctly state and dispense the proper dosage for medication(s), - accurately document self-administration of medication(s), and - safe self-administration of medications. The [NAME] Loong pail relieving medication was labeled with, but not limited to the following: - Active Ingredients: Methyl Salicylate 35% external analgesic (pain medication) and Menthol 16% external analgesic (pain medication), - Warnings: for external use only, use only as directed, avoid contact with eye and mucous membranes, do not apply on open wounds, damaged or irritated skin, do not bandage or cover with any type of wrap except clothing, do not use with heating pad or apply with external heat and do not use one hour prior to bathing or within 30 minutes of bathing. - Stop use and ask a doctor if: condition worsens, pain persist for more than seven days, pain clears up then recurs few days later and sever skin irritation occurs. - Keep out of reach of children, if swallowed get medical help or contact a Poison Control Center immediately. - Directions: adults and children [AGE] years of age or older, apply to the affected areas no more than 3-4 times daily - Other information: This product may cause allergic reaction on some individuals. Test on small areas before use. On 5/16/23 at 1649 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified Resident 53 had two bottles of [NAME] Loong pain relieving oil on the bedside table. When asked, LVN 3 stated Resident 53 was not supposed to have [NAME] Loong pain relieving oil medication at the bedside. On 5/17/23 at 1529 hours, an interview was conducted with Resident 53. When asked where Resident 53 used the [NAME] Loong pain relieving oil, Resident 53 pointed at his fingers and knees and Resident 53 stated, arthritis. On 5/18/23 at 1044 hours, a follow-up interview with a Vietnamese translator was conducted with Resident 53. When asked if Resident 53 used the [NAME] Loong pain relieving oil, Resident 53 stated he had the medication at the bedside and used the medication as needed when achy. On 5/22/23 at 1410 hours, an interview and concurrent record review was conducted with the DON. The DON verified Resident 53 was not capable of safe self-administration and storing medication in a secure location. When asked if Resident 53 was supposed to have [NAME] Loong pain relieving oil at bedside, the DON acknowledged Resident 53 was not supposed to have the medication at the bedside. When asked regarding the facility's process to ensure the resident's rooms did not have unauthorized medications for bedside storage, the DON stated the facility conducted weekly Guardian Angel Rounds to check each resident's room and the reports were submitted to the Administrator. Review of the facility's form titled Guardian Angel - Action Rounds dated 3/2022, showed to observe the following and correct if needed that includes no medication/creams on the bedside/over-bed table. On 5/22/23 at 1513 hours, an interview and concurrent review of the facility document was conducted with the Administrator. When asked to review the facility's weekly Guardian Angel records, the Administrator was unable to show the weekly reports of Guardian Angel-Action Rounds for Resident 53's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 24 final sampled residents (Resident 51) was provided with food prepared in a form to meet the resident's individual need. * The facility failed to ensure Resident 51 was provided with pureed dessert as per the resident's diet order. This failure posed the risk for Resident 51 to develop complications like aspiration (accidental breathing in food or fluid into the lungs) and choking. Findings: Medical record review for Resident 51 was initiated on 5/16/23. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 51's MDS assessment dated [DATE], showed Resident 51 was edentulous (lacking teeth). Review of Resident 51's H&P examination dated 2/23/23, showed Resident 51 had diagnoses of Parkinson's disease, dementia, and dysphagia. Review of Resident 51's Order Summary Report as of 5/18/23, showed a physician's order dated 4/27/23, to provide a regular pureed texture diet. Review of the facility's Daily Spreadsheet for lunch on 5/16/23, showed to serve citrus streusel bar for dessert. The Daily Spreadsheet for lunch on 5/16/23, showed a pureed citrus streusel bar will be provided for the residents on puree diet. On 5/16/23 at 1218 hours, a dining observation was conducted in Resident 51's room. Resident 51 was served with pureed food. However, a slice of citrus streusel was observed on Resident 51's meal tray. On 5/16/23 at 1224 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 51 was on a puree diet and should not be served with a slice of citrus streusel. Review of Resident 51's Meal Ticket for lunch on 5/16/23, showed Resident 51 was on a regular pureed diet. On 5/17/23 at 1539 hours, an interview with LVN 5 was conducted. When asked what type of dessert that the residents on puree diet should have, LVN 5 stated it should be baby food, apple sauce, pudding or yogurt consistency or ice cream. LVN 5 acknowledged Resident 51 was not provided with the appropriate dessert based on her diet order during the lunch meal.

Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' family members and visitors were trained on safe food handling practices of food brought to the residents by the family members and other visitors. This failure posed the risk for the residents to have foodborne illness. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors (undated) showed prepared food must be consumed by the resident with three days. If not consumed in three days, the food will be thrown away by the facility staff. However, the P&P did not address educating family members on safe food handling practices. On 5/17/23 at 0832 hours, an observation of the resident's food storage refrigerator was conducted. The posted instructions on the refrigerator door showed food will be disposed after 72 hours. On 5/17/23 at 1005 hours, an interview with RN 1 was conducted. When asked about their process on how the family or visitors were educated on safe food handling when food was brought from outside, RN 1 stated they would tell the family or visitors that they would keep the food in the resident's designated refrigerator, heat it up in the microwave located in the admission area, and would discard the food after 72 hours, if not consumed. On 5/17/23 at 1015 hours, an interview with the DON was conducted. When asked about their process on how the family or visitors were educated on safe food handling when food was brought from outside, the DON stated the RD would talk with the family or visitors. On 5/17/23 at 1457 hours, an interview with the RD was conducted. When asked about their process on how the family or visitors were educated on safe food handling when food was brought from outside, the RD stated they encouraged the family members to bring food for appropriate residents. The RD further stated the facility would store it for three days in the resident's designated refrigerator and they could heat it up in the microwave. The RD stated only verbal education was provided to the family members or visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate and complete medical records of one of three final closed record sampled residents (Resident 121). * The facility failed to the POLST was voided as per the facility's P&P when Resident 121's family member requested to change the treatment options and failed to ensure one of three copies of Resident 121's POLSTs was in the medical record. This failure has the potential to put the resident at risk for a delay in necessary care and treatment. Findings: Review of the facility's P&P titled Physician Orders for Life Sustaining Treatment (POLST) revised [DATE], showed to void a POLST, a draw line through the entire section A and D and write VOID on large letters across the document, then sign and date it. All voided POLST documents are to be retained in the resident's medical record. Closed medical record review for Resident 121 was initiated on [DATE]. Resident 121 was readmitted in the facility on [DATE], and had expired on [DATE]. Review of Resident 121's POLST dated [DATE], showed the following items were checked. - Do Not Attempt Resuscitation/DNR (Allow Natural Death) - Selective Treatment with request transfer to hospital only if comfort needs cannot be met in current location - Long-term artificial nutrition, including feeding tubes - No Advance Directive Review of Resident 121's Nurses Progress Note dated [DATE] at 1906 hours, showed the nurse received a call from Resident 121's PA and informed the facility that he had conversations with Resident 121's son and the responsible representative requesting to change Resident 121's POLST to full code, full treatment, and continue with no enteral feeding tubes. However, there was no POLST reflecting the full code, full treatment, and no enteral feeding tubes as per the above progress note. Review of Resident 121's POLST dated [DATE], showed the following items were checked. - Do Not Attempt Resuscitation/DNR (Allow Natural Death) - Selective Treatment with request transfer to hospital only if comfort needs cannot be met in current location - No artificial means of nutrition, including feeding tubes - No Advance Directive Further review of Resident 121's physical or electronic chart failed to show a copy of Resident 121's POLST dated [DATE], was voided. The POLST dated [DATE], did not show a line in Section A through D, the written word void, the date, and signature when the POLST was voided as per the facility's P&P. On [DATE] at 1131 hours, a telephone interview was conducted with the PA. The PA stated he spoke to Resident 121's responsible representative a couple days after Resident 121 had expired. The PA stated the family member told him that some of Resident 121's family members from Vietnam visited the facility the day before Resident 121 had expired. On that same day, Resident 121's responsible representative decided to change the POLST again on Saturday, [DATE], to DNR status. On [DATE] at 1352 hours, a telephone interview was conducted with RN 2. RN 2 verified she received the call from the PA with Resident 121's responsible representative who wished to change the POLST of Resident 121 on [DATE], from DNR to full code/full treatment. RN 2 stated she filled out the POLST form with the changes and flagged the POLST form in Resident 121's medical record for the Resident 121's responsible representative to sign when he comes to the facility. On [DATE] at 1355 hours, an interview was conducted with the DON. The DON verified the above findings and stated she could not find the hard copy of the POLST for Resident 121 dated [DATE], in the medical record. The DON stated the copy of the resident's POLST should be in the medical record. On [DATE] at 1358 hours, an interview was conducted with the Medical Records Director. The Medical Records Director stated she did not find a hard copy of POLST dated [DATE], in Resident 121's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper infection control practices were followed for two of 24 final sample residents (Residents 72 and 106). * The facility failed to ensure RN 1 performed handwashing during the preparation of parenteral medication. This failure had the potential for Resident 72 getting infected and posed the risk of spreading infection to another resident. * The facility failed to ensure CNA 3 followed the contact precautions when providing care for Resident 106 who was on enhanced standard precaution. This posed the risk for the transmission of disease-causing microorganisms Findings: 1. Review of the facility's P&P titled Preparation and General Guidelines, IIA2 Medication Administration - General Guidelines dated 10/2017 showed hands are washed before and after administration of topical, ophthalmic, otic, parenteral , enteral, rectal, and vaginal medications. On 5/17/23 at 0831 hours, RN 1 was observed during the preparation of IV medication for Resident 72. The following was observed: - RN 1 was observed performing handwashing at the office sink near the IV medication cart in Station 3. RN 1 opened the computer, opened the medication room, and went inside, came out and closed the medication room carrying the IV antibiotic bag, opened the IV medication cart, pulled out the IV tubing, then completed the preparation of IV medication. However, RN 1 was observed not performing handwashing during the preparation of the IV medication. Review of Resident 72's Order Summary Report order dated 5/12/23, showed to administer ceftriaxone sodium (antibiotic) Intravenous Solution reconstituted 1 gm intravenously one time a day for sepsis/UTI for 12 days. 2. Review of the facility's document titled The Six Moments of Enhanced Standard Precautions (undated) showed for these six groups of care activities, use hand hygiene, gloves and gowns: morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatment, cleaning the environment, wound care, and mobility assistance and preparing to leave room. Review of the CDPH AFL 22-21 titled Enhanced Standard Precautions for Skilled Nursing Facilities dated 10/5/22, showed Title 42 CFR section 483.80 requires that nursing facilities must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Enhanced Standard Precautions for Skilled Nursing Facilities, 2022 provides a practical, resident-centered and activity-based approach to implement measures to prevent MDRO transmission that are less restrictive than Contact Precautions. Recommendations for the use of gowns and gloves by health care providers are based on assessments of a resident's risk for being colonized and likelihood of transmitting MDRO, whether or not the resident is known to be MDRO colonized or infected. On 5/16/23 at 0948 hours, the Six Moments of Enhanced Standard Precautions sign was observed posted outside Resident 106's room alerting anyone entering the room to perform hand hygiene and don gloves and gown when providing the six groups of care activities. A cart containing gowns was observed below the posted enhanced standard precautions sign. CNA 3 was observed in the room wearing a gown and a mask. CNA 3 was not wearing gloves. CNA 3 was observed picking up the soiled bed sheet from the resident's bed, then placed it in the soiled linen cart. CNA 3 was observed pulling the Hoyer lift (medical devices that are used to transfer patients with limited mobility) out of the room. CNA 3 was observed touching the isolation cart, then pushing the soiled linen cart away. CNA 3 was observed touching another linen cart, then went out to the patio exit with her linen cart. CNA 3 was observed not performing hand hygiene between these tasks. On 5/16/23 at 0952 hours, an interview was conducted with CNA 3. When asked what isolation Resident 106 was, CNA 3 stated Resident 106 was on contact isolation for infection in the urine. CNA 3 acknowledged Resident 106 was on enhanced standard precaution. CNA 3 stated she should have worn gown and gloves while changing the linen. Medical record review for Resident 106 was initiated on 5/16/23. Resident 106 was admitted to the facility on [DATE]. Review of Resident 106's Order Summary Report showed a physician's order dated 1/24/23, for enhanced standard precautions for Candida Auris (aka C. Auris, is a yeast or a type of fungus that causes severe infections and can spread in healthcare setting). On 5/18/23 at 1503 hours, an interview was conducted with the IP. The IP verified Resident 106 was on enhanced standard precautions. The IP stated CNA 3 should have worn gloves and gowns while changing the linens, then performed hand hygiene before donning and after taking off gloves.

Based on observation, interview, and facility document review, the facility failed to ensure the essential kitchen equipment was maintained in safe operating condition when: 1. The walk-in ceiling fan cover had a brown residue resembling rust. 2. The reach-in freezer had ice build-up. 3. The manual dish machine draining table was not properly attached to the adjoining dish machine draining table. Failure to maintain necessary kitchen equipment in proper working order may result in compromised food safety. Findings: According to the USDA Food Code Section 4-501.11 Good Repair and Proper Adjustment, proper maintenance of equipment to manufacturer's specifications helps ensure it will continue to operate as designed. Review of the facility document titled Maintenance Job Request, undated, showed no entries from 2/18/22 to 5/16/23. Review of the facility document titled Sanitation Audit Report (SAR) completed by the RD on 2/10 and 3/30/23, showed major equipment was in working order. The SAR completed by the RD on 4/28/23, showed the oven was not working. 1. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the walk-in refrigerator was conducted. The ceiling fan cover had a brown residue which resembled rust. The DSS acknowledged the findings. 2. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the reach-in freezer was conducted. There was ice build-up on the fan cover and the top of the freezer. The DSS acknowledged the findings. 3. On 5/17/23 at 1124 hours, an observation of the manual dish washing sink and concurrent interview was conducted with the DSS. Cracked, discolored white caulk was attached to the manual dish washing sink drain table. The white caulk had a paper-like substance imbedded in the caulk. The DSS stated he did not know what the substance was. When asked how he communicated maintenance issues to the maintenance, the DSS stated he called or texted the maintenance supervisor or documented in the maintenance log located in the kitchen. An interview was conducted with the RD on 5/17/23 at 1454 hours. The RD was asked if she included the maintenance problems in her monthly Sanitation Audit Report (SAR). The RD stated she did include maintenance problems in her SAR but she communicated verbally to the DSS if there were any issues. She stated the DSS handled maintenance problems. On 5/17/23 at 1610 hours, an interview was conducted with the ESD. The ESD was asked how he was notified of maintenance problems in the kitchen. The ESD stated he checked the maintenance log located in the kitchen daily. When asked regarding the cracked white caulking on the manual dish washing sink in the kitchen, the ESD stated the DSS had informed him today and he was working on fixing it. On 5/18/23 at 1514 hours, an interview was conducted with the ESD. The ESD was asked if the maintenance department was responsible for routine maintenance of kitchen equipment. The ESD stated the maintenance department was not responsible for routine maintenance of any kitchen equipment. On 5/18/23 at 1520 hours, an interview was conducted with the DSS. The DSS confirmed there was no routine maintenance completed of kitchen equipment. The DSS added the outside vendors were contacted if the kitchen equipment was not functioning properly. On 5/19/23 at 1014 hours, an interview was conducted with the RD. The RD confirmed the ice build-up in a freezer was not normal. The RD stated she was aware of the ice build up in the reach-in freezer two months ago and spoke to the DSS about it, but stated she was not sure if she addressed the ice build-up in the reach in freezer on her report, the SAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure seven of 24 final sampled residents (Residents 52, 54, 60, 67, 85, 99, and 422) were provided with the appropriate respiratory care when: * The facility failed to administer the oxygen therapy as ordered and failed to ensure the titration oxygen order included the parameters as to how to titrate the oxygen flow rate. * The facility failed to ensure Residents 85 and 422 were provided with continuous oxygen therapy per the physician's order. In addition, the facility failed to ensure Resident 422's nebulizer mask was changed weekly and stored properly per the facility's P&P. * The facility failed to ensure Resident 60's oxygen therapy tubing was changed weekly per the facility's P&P. * The facility failed to ensure Resident 52's nebulizer mask was changed weekly per the facility's P&P. * The facility failed to ensure Residents 67 and 99's suction set-up bag showed the date when it was changed. These failures had the potential to effect the respiratory health and well being of the residents in the facility. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 9/2/22, showed the oxygen therapy must be administered under the orders of a physician, and the staff must document the ongoing assessment of a resident's condition warranting the oxygen administration and the response to oxygen therapy. Medical record review for Resident 54 was initiated on 5/16/23. Resident 54 was initially admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 5/23/23, to administer oxygen via T-Mask at 2 L/minute and may titrate oxygen to maintain SpO2 (oxygen saturation level) greater or equal to 92%. * However, the order did not include the parameter as to how to titrate the oxygen flow rate. Review of the Weights and Vitals Summary dated 5/23/23, showed the following documentation of Resident 54's SpO2 levels: - On 5/17/23, Resident 54's SpO2 level was 97% at 0409 hours, 96% at 1700 hours, and 100% at 2028 hours. - On 5/19/23 at 2109 hours, Resident 54's SpO2 level was at 96%. - On 5/23/23, Resident 54's SpO2 level was 99% at 0048 hours, and 96% at 1530 hours. Review of the rounding reports was initiated on 5/16/23. The following was identified: - On 5/17/23 at 1051 hours, Resident 54 received oxygen at 7 L/minute. - On 5/19/23 at 1548 hours, Resident 54 received oxygen at 6 L/minute. - On 5/23/23 at 1026 hours, Resident 54 received oxygen at 4 L/minute. On 5/23/23 at 1028 hours, an interview was conducted with LVN 5 in Resident 54's room. LVN 5 verified that Resident 54 received 4 L/minute of oxygen. When asked when Resident 54's oxygen flow rate (amount being administered) and SpO2 level were last checked, LVN 5 stated the resident's oxygen flow rate should be checked once for every shift; however, at this time, she had not checked for her shift yet. On 5/23/23 at 1043 hours, LVN 5 was observed checking the Resident 54's oxygen flow rate and SPO2 level. LVN 5 stated Resident 54's SpO2 level was at 100% and LVN 5 proceeded to decrease Resident 54's oxygen flow rate from 4 to 2 L/minute. On 5/23/23 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. When asked, the DON stated the oxygen therapy orders should have a titration parameters. Upon review of Resident 54's oxygen therapy order, the DON verified Resident 54's oxygen therapy order did not have a titration parameters to guide the staff as to the appropriate flow rate of oxygen the resident should be receiving. When asked how often the nurses should reassess the resident after titrating up on a resident's oxygen flow rate, the DON stated the staff should reassess a resident five minutes after increasing a resident's oxygen flow rate. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were notified and acknowledged the above findings. 6. Review of the facility's P&P titled Changing the Yankauer undated showed to minimize the risk of infection to the resident and the resident's Yankauer shall be changed on a regular schedule and as needed. Under the section for procedure showed to gather the Yankauer, and label with the date and resident's initials. On 5/16/23 at 1606 hours, an observation of Resident 99 was conducted in the resident's room. Resident 99's Yankauer with a label dated 5/12/23, and a suction tubing dated 5/14/23, were noted inside the suction set-up bag in the bedside table's drawer. However, Resident 99's suction set-up bag was dated 5/2023. On 5/16/23 at 1622 hours, an observation and concurrent interview was conducted with RT 1. RT 1 verified Resident 99's Yankauer was dated 5/12/23, and the suction tubing was dated 5/14/23. However, the suction set-up bag was dated 5/2023 and RT 1 verified he could not tell the date when it was changed. Review of Resident 99's medical record was initiated on 5/16/23. Resident 99 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 99's Care Plan initiated on 9/19/22, showed a care plan problem addressing Resident 99's dependence on tracheostomy related to impaired breathing mechanics with interventions to assess tracheostomy for excessive tracheal and/or oral secretions frequently and as needed for suction and suctioning as necessary. Review of Resident 99's Tracheostomy Daily Notes dated 5/16/23, showed Resident 99 was suctioned at 0720, 0920, and 1320 hours. On 5/22/23 at 1410 hours, an interview was conducted with the DON. When asked how often the facility staff should change the suction supplies, the DON stated Resident 99's suction supplies including the suction set-up bag should be dated and changed once a week. 7. On 5/16/23 at 1559 hours, an observation of Resident 67 was conducted in the resident's room. Resident 67's Yankauer was dated 5/12/23 and the suction tubing dated 5/14/23 were noted to be inside the suction set-up bag. However, the suction set-up bag was dated May 2023. On 5/16/23 at 1623 hours, an observation and concurrent interview was conducted with RT 1. RT 1 verified Resident 67's Yankauer was dated 5/12/23, and the suction tubing was dated 5/14/23. However, the suction set-up bag was dated 5/2023 and RT 1 verified he could not tell the date when it was changed. Review of Resident 67's medical record was initiated on 5/16/23. Resident 67 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 67's Care Plan revised on 4/26/23, showed a care plan problem addressing Resident 67's dependence on the tracheostomy related to impaired breathing mechanics with an intervention to assess tracheostomy for excessive tracheal and/or oral secretions frequently and as needed for suctioning and suction as necessary. Review of Resident 67's Continuous Ventilator Flow Sheet dated 5/16/23, showed Resident 67 was suctioned at 0830, 1230, and 1430 hours. On 5/22/23 at 1410 hours, an interview was conducted with the DON. When asked how often the facility staff should change the suction supplies, the DON stated Resident 67's suction supplies including the suction set-up bag should be dated and changed once a week. 2. Review of the facility's P&P titled Oxygen Administration revised 9/2/22, showed to change the oxygen tubing and mask weekly and as needed if it becomes soiled or contaminated. If applicable, change the nebulizer tubing and delivery devices every 72 hours, per manufacturer's recommendation or per facility policy and as needed if they become soiled or contaminated. Keep the delivery devices covered in plastic bag when not in use. On 5/16/23 at 0920 hours, Resident 422 was observed seated in a wheelchair in her room. Resident 422 was noted to be on room air. An oxygen concentrator was placed near Resident 422's bed, and the oxygen tubing was in a set-up bag dated 5/15/23. A nebulizer machine was also observed on top of Resident 422's bedside table. The nebulizer tubing was attached to the nebulizer and an undated nebulizer mask without a set-up bag was kept inside the bed side table's drawer. When Resident 422 was asked if she was using her nebulizer mask, Resident 422 stated she had started using her nebulizer twice a day. On 5/16/23 at 0939 hours, an observation of Resident 422 and concurrent interview was conducted with LVN 7. LVN 7 verified the nebulizer mask did not have a label with its start used date and was not stored in a set-up bag. Medical record review was initiated on 5/16/23. Resident 422 was readmitted to the facility on [DATE]. Review of Resident 422's Order Summary Report showed the following physician's orders: - dated 5/8/23, to administer oxygen at three liters per minute via nasal cannula continuous to maintain oxygen saturation above 90% every shift; and - dated 5/9/23, to administer albuterol sulfate (bronchodilator) inhalation nebulization solution 0.83 mg/3 ml via nebulizer every six hours for shortness of breath. Review of Resident 422's MAR for May 2023 showed Resident 422's SpO2 level was monitored from 5/8 to 5/18/23, with checkmarks and staff's initials; and it was ranging from 94-98%. Further review of the MAR showed Resident 422 was administered albuterol sulfate via nebulizer on 5/9 at 1200 and 1800 hours; 5/10 to 5/17/23 at 0000, 0600, 1200 and 1800 hours; and 5/18/23 at 0000, 0600, 1200 hours. On 5/17/23 at 1621 hours, Resident 422 was observed inside her room. Resident 422 was noted to be on room air. On 5/18/23 at 0800 hours, Resident 422 was observed in the hallway. Resident 422 was noted to be on room air. On 5/18/23 at 0831 hours, Resident 422 was observed seated in a wheelchair in her room. Resident 422 was noted to be on room air. A nebulizer mask without a set-up bag dated 5/16/23, was seen on top of the bedside table. When Resident 244 was asked if she was being administered with her oxygen, Resident 422 stated she only used the oxygen as needed for an extra boost. On 5/18/23 at 0932 hours, an observation for Resident 422 and concurrent interview and medical record review was conducted with RN 1. RN 1 verified Resident 422's nebulizer mask was not stored in set-up bag and that Resident 422 had a physician's order for administration of oxygen continuously. RN 1 stated Resident 422 was on room air and not receiving her oxygen therapy as per the physician's order. RN 1 checked Resident 422's SpO2 level, and it was 93% on room air. 3. Observation of Resident 85 was initiated on 5/16/23. The following was identified: - On 5/16/23 at 1213 hours, Resident 85 was noted to be in bed at room air. - On 5/17/23 at 1540 hours, Resident 85 was noted to be in bed at room air. - On 5/18/23 at 0808 and 0822 hours, Resident 85 was noted to be in bed at room air. In addition, there was no oxygen concentrator and oxygen tubing seen in Resident 85's room. Medical record review was initiated on 5/16/23. Resident 85 was readmitted to the facility on [DATE]. Review of Resident 85's Order Summary Report showed a physician's order dated 1/5/23, to administer oxygen via nasal cannula at 2 L/minute and may titrate the oxygen dose to maintain the SpO2 level greater or equal to 92% every shift. Review of Resident 85's MAR showed Resident 85's SpO2 level was monitored from 5/1 to 5/17/23, with checkmarks and staff initials and they were ranged from 96-97%. On 5/18/23 at 0930 hours, an observation for Resident 85 and concurrent interview and medical record review was conducted with RN 1. RN 1 verified Resident 85 had a physician's order for the administration of oxygen continuously; however, Resident 85 was on room air and did not receive the oxygen therapy as per physician's order. RN 1 checked Resident 85's SpO2 level that was 97% on room air. 4. On 5/16/23 at 1430 hours, Resident 60 was observed in bed receiving oxygen at 2 L/minute via nasal cannula. An oxygen set-up bag with a label dated 4/24/23, was noted at the bedside. Medical record review for Resident 60 was initiated on 5/16/23. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's Order Summary Report showed a physician's order dated 4/4/23, to administer oxygen at 2-5 L/minute via nasal cannula to maintain an SpO2 level above 90%. Review of Resident 60's MAR for May 2023 showed Resident 60's SpO2 level was monitored from 5/1 to 5/18/23. On 5/16/23 at 1445 hours, an observation for Resident 60 and concurrent interview and medical record review was conducted with RN 3. RN 3 was informed of Resident 60's oxygen set-up bag with a label dated 4/24/23, at the bedside, RN 3 stated the oxygen set-up bag should be changed weekly by the morning shift nursing staff or the central supply staff. 5. On 5/16/23 at 0908 hours, Resident 52 was observed in the wheelchair. A nebulizer set-up bag with a label dated 5/8/23, was seen on top of the bedside table. Medical record review for Resident 52 was initiated on 5/16/23. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Order Summary Report showed a physician's order dated 3/2/23, to administer ipratropium-albuterol (medication used to treat and prevent symptoms such as wheezing and shortness of breath caused by ongoing lung disease) inhalation solution 0.5 - 2.5 mg/3 ml every four hours. Review of Resident 52's MAR for May 2023 showed the ipratropium-albuterol medication was administered to Resident 52 from 5/1 to 5/18/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours; and 5/19/23 at 0000, 0400, and 0600 hours. On 5/16/23 at 1247 hours, an observation for Resident 52 and concurrent interview was conducted with LVN 8. LVN 8 was informed of Resident 52's oxygen set-up bag noted at bedside with a label dated 5/8/23. LVN 8 stated the nebulizer set-up bag was usually changed weekly, every Monday. On 5/18/23 at 1437 hours, an interview was conducted with the Central Supply staff. The Central Supply staff stated he was responsible for changing the oxygen tubing and nebulizer mask weekly, every Monday morning. The Central Supply staff stated if a resident came after Monday, then it would be the responsibility of the nurses to set-up the oxygen tubing, nebulizer mask, and equipment. The Central Supply staff stated the oxygen tubing and nebulizer mask should be in a set-up bag with date. The Central Supply staff stated in the subacute unit, the RTs and nurses should change the oxygen tubing and nebulizer masks; however, he was not sure if these were being changed weekly.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure an adequate oversight of the kitchen was provided when multiple issues were identified in regard to the kitchen safety and sanitation, following the facility's recipes, and monitoring of the kitchen staff' competency. This failure had the potential to result in food not being served in a safe and sanitary manner which could lead to foodborne illness and resident nutritional needs not being met for the 115 facility residents who received food prepared in the kitchen. Findings: According to the USDA Food Code 2022 Annex 4 Management of Food Practices-Achieving Active Managerial Control of Foodborne Illness Risk Factors showed under section G. Assess Active Managerial Control of Foodborne Illness Risk Factors and Implementation of Food Code Interventions, the Demonstration of Knowledge: it is the responsibility of the person in charge to ensure compliance with the Code. The knowledge and application of Food Code provisions are vital to preventing foodborne illness and injury. The data collected by FDA suggest that having a certified food manager on-site has a positive effect on the occurrence of certain foodborne illness risk factors in the industry. Review of the facility's Director of Food Services job description signed and dated by the DSS on 1/22/20, showed the primary purpose of this job position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Service Department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. Review of the facility document titled Employee Performance Appraisal signed and dated by the DSS on 2/16/21, showed the DSS was excellent in knowledge and quality of work. During the multiple observations at the kitchen and facility conducted from 5/16 to 5/23/23 at various times, the following was identified related to food safety and sanitation: 1. The Potential for cross contamination during food preparation, Time Temperature Control for Safety Foods were not handled safely, lack of proper hand hygiene, food preparation equipment was not sanitized when washed manually, kitchen surfaces were not sanitized, refrigerated and frozen foods were not stored properly, hair restraints were not worn appropriately, food preparation equipment was not clean, non-food contact surfaces in the kitchen were not clean, an ice storage chest with soiled wheels was stored on a food preparation counter, and employee's food was not stored appropriately. On 5/17/23 at 1454 hours, an interview was conducted with the RD. The RD was asked how she had communicated her concerns from the Sanitation Audit Report (SAR) she completed monthly. The RD stated she discussed her concerns from the SAR verbally to the DSS. The RD added the DSS handled most of the issues in the SAR. When asked how the RD knew her concerns had been resolved, the RD stated she addressed any concerns on the spot or reminded the DSS if she had sanitation concerns. On 5/18/23 at 1448 hours, an interview was conducted with the DSS. The DSS was asked how the RD communicated the findings from the monthly SAR. The DSS stated the RD emailed a copy of the SAR to him, the RD verbally explained the SAR to the DSS, then the DSS would talk to his staff regarding the findings. The DSS acknowledged he did not have documented evidence to show when he had spoken to the kitchen staff regarding the RD's SAR. The DSS was asked if he performed an audit of the kitchen. The DSS stated he conducted a kitchen walk through but did not document the findings. The DSS was asked how he confirmed the kitchen staff completed the required cleaning or sanitation of the kitchen. The DSS stated the kitchen staff were assigned cleaning schedules. The DSS acknowledged that oftentimes, he did not have the opportunity to check the cleaning schedule being completed. The DSS added he was not involved with Quality Assurance and Performance Improvement for the Food and Nutrition Department. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she was not involved with the kitchen cleaning schedules but expected the cleaning schedules to be completed and the kitchen was kept clean. Cross reference to F812. 2. The facility's recipes were not followed for the American and Vietnamese menu puree vegetable, puree meats, and puree dessert; and the Vietnamese puree starch were not followed. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents nutritional needs were met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food, then adding an unmeasured quantity of stabilizer was not ideal. Cross reference to F803. 3. The kitchen staff were not competent in completing and implementation of the daily kitchen tasks, including prevention of cross contamination, proper hand hygiene, sanitization of food preparation equipment and food preparation surfaces, following recipes, knowledge of final cooking temperature for poultry, and manual dishwashing procedures. On 5/17/23 at 1454 hours, an interview was conducted with the RD regarding employee training. The RD stated she was available to do in-service training but the DSS handled in-service training of the kitchen employees. The RD stated if she saw something as a problem she would provide the in-service training on the spot, but it was a verbal without documentation. The RD stated she was not involved in assessing the kitchen employees' competency. The RD added she was not involved in assessing the DSS's competency either as they were coworkers. During an interview conducted with the DSS regarding the kitchen employees' competency and employees' in-service training on 5/18/23 at 1448 hours, the DSS stated he assessed his employees' competency with an annual competency evaluation that was based on knowledge and demonstration. Review of the facility documents titled Verification of Job Competency Demonstration for Cooks 1, 4, and Diet Aide 1 failed to show documentation from the DSS that these employees' competency had been verified. The DSS was asked regarding the kitchen employees in-service training, the DSS stated he tried to have a monthly in-service training. The DSS stated he decided on the topic/subject for the training based on findings he observed and mandatory for all the kitchen staff. The DSS was asked how he determined the employee's comprehension of the in-service, the DSS stated he provided a question and answer about the in-service topic. A request was made for in-service training related to the following topics: cross contamination, sanitization of food preparation equipment and food preparation surfaces, following resident recipes, knowledge of final cooking temperature for poultry, and manual dishwashing procedures. However, the DSS was not able to provide any documented evidence for the above in-services training topics provided to the kitchen staff. During an interview conducted with the DSS on 5/19/23 at 0950 hours, the DSS was asked regarding the new employee training, the DSS confirmed DA 2 was newly hired on 3/31/23, and stated the new employees were trained for one to two weeks by the senior employees who did the same job, then the DSS allowed the new employee to work alone. The DSS stated DA 2's first day alone was on 5/18/23. The DSS was asked how did he ensure the new employee would be competent prior to working alone. The DSS stated there was a competency form that he filled out but had not completed the competency form for DA 2. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed any new employee should be deemed competent prior to working alone. The RD stated she would do a walk through with new employees but had not completed a walk through with DA 2 because she was too busy. Cross reference to F802. On 5/18/23 at 1034 hours, an interview was conducted with the Administrator. The Administrator was asked how he did ensure that his managers were competent in running their departments. The Administrator stated he is over all the department managers. The managers were evaluated annually. The DSS's last annual evaluation was completed by the previous Administrator. The Administrator stated he ensured the managers had dealt with compliance issues. The Administrator added the RD did a sanitation report and the DSS received a copy. The DSS attended quarterly corporate in-service training. The Administrator provided an email dated 5/18/23, from the Corporate [NAME] President of nutrition showing the DSS had attended all the training.

Based on observation, interview, facility document and P&P review, the facility failed to ensure the resident menu was followed as evidenced by: 1. Puree vegetable recipes were not followed for the American and Vietnamese menus. 2. Puree meat recipes were not followed for the American and Vietnamese menus. 3. Puree cake recipe was not followed for all menus. 4. Puree rice recipe was not followed for the Vietnamese menu. These failures posed the risk for an inconsistent product and to not meet the nutritional needs of the 23 residents who received puree diets. Findings: Review of the facility's P&P titled Cycle Menus revised 9/14/18, menus must be followed as written. Review of the facility's Diet Count by Diet dated 5/17/23, showed there were 23 regular pureed servings. However, the Diet Count sheet did not distinguish between American and Vietnamese menus. Review of the facility's Diet Count by Diet dated 5/18/23, showed there were 24 regular pureed servings. However, the Diet Count sheet did not distinguish between American and Vietnamese menus. 1. Review of the facility's Recipe: Pureed Vegetables (undated) showed options for six, 12, 24, and 48 servings. For 24 servings, use 24 servings of regular vegetables. Warm fluid such as milk, or low sodium broth ½ cup to 1 ½ cups. If needed: stabilizer: instant potatoes ¾ cup to 1 ½ cup. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm liquid (low sodium broth or milk) if needed. - See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. - Puree on low speed, adding stabilizer where needed. See above for amounts. a. Review of the facility's Daily Spreadsheet dated 5/17/23, showed spring blend vegetables serving size was four ounces. On 5/17/23 at 1026 hours, an observation of the vegetable puree preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1 with the DSS as a translator. [NAME] 1 stated he was preparing 20 puree portions. Using a four-ounce scoop, [NAME] 1 placed ten scoops of vegetables that included water the vegetables were cooked in, into the RC. [NAME] 1 stated he wanted honey consistency for the pureed vegetables. [NAME] 1 then, added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. [NAME] 1 added an unmeasured quantity of instant mashed potatoes to the RC with a total of four additional times; and blended the mixture after adding each quantity of instant mashed potatoes. [NAME] 1 was asked if he added a certain amount of instant mashed potatoes to the vegetables. [NAME] 1 stated it depended on the type of vegetable. The DSS confirmed a consistency of mashed potatoes was the goal for pureed foods. [NAME] 1 did not refer to any recipe during the vegetable puree preparation for the American lunch menu. b. Review of the facility document titled Garlic [NAME] Beans (undated) showed the portion size was four ounces. On 5/18/23 at 0905 hours, an observation of the vegetable puree preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. It was noted [NAME] 4 prepared green peas instead of garlic green beans. [NAME] 4 stated she substituted green peas for green beans for lunch today. [NAME] 4 stated she was preparing about 18 puree servings. [NAME] 4 stated she used 2.5 pounds (equivalent to 10 four-ounce servings) of frozen peas cooked in water. [NAME] 4 stated she substituted peas for green beans for lunch today. [NAME] 4 placed an unmeasured quantity of the peas and water mixture into the RC and added one four-ounce cup of instant mashed potatoes. The mixture was blended. [NAME] 4 added another unmeasured quantity of the pea and water mixture to the RC. The peas and water mixture was blended again. The final product had a liquid consistency. [NAME] 4 stated the mixture would thicken over time and placed the pureed peas on top of the steam table. [NAME] 4 did not refer to any recipe during the vegetable puree preparation for the Vietnamese lunch menu. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents' nutritional needs were met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food, then adding an unmeasured quantity of stabilizer was not ideal. 2.a. Review of the facility's Recipe: Puree Meats dated 4/1, showed options for six, 12, 24 and 48 servings. For six servings, use six serving of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, ¾ to 1 ½ cups of liquid. Stabilizer: instant potato 0-6 Tablespoons. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. - Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. - Add stabilizer to increase the density of the pureed food if needed. On 5/17/23 at 1133 hours, an observation of the puree meat preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing five puree meat portions, three ounces each. Using the three-ounce scoop, [NAME] 1 measured five meat portions into the RC. [NAME] 1 then added an unmeasured quantity of chicken broth to the RC. The meat and broth mixture was blended. After blending, the meat and broth mixture had a liquid consistency. [NAME] 1 then added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. The meat and broth mixture was too thick so [NAME] 1 added an additional three 3-ounce scoops of chicken broth to the RC to achieve mashed potato consistency. b. Review of the facility document titled Chicken Curry and Sweet Potatoes (undated) showed ingredients for 50 servings included 6 2/3 pounds of boneless, skinless chicken thigh meat, fresh yellow onion, fresh garlic clove peeled, fresh ginger root, fresh herb lemon grass, fresh carrots, fresh sweet potato, fresh red chili pepper paste, Thai curry paste, light brown sugar, coconut milk, fish sauce, hot water, and chicken soup base. Review of the facility's Recipe: Puree Meats dated 4/17 showed options for six, 12, 24 and 48 serving options. For 24 servings, use 24 servings of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, three cups to 1 ½ quarts of liquid. Stabilizer: instant potato ¾- 1 ½ cups. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. - Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. - Add stabilizer to increase the density of the pureed food if needed. On 5/18/23 at 0821 hours, an observation of the puree meat preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. [NAME] 4 stated she was preparing about 18 servings of chicken curry for the puree diet. After cutting an unmeasured quantity of raw chicken and onion, [NAME] 4 added the chicken, onion and unmeasured quantities, packages of curry powder, turmeric powder and white mushroom seasoning salt directly to a cooking pot. [NAME] 4 then, added unmeasured quantities of coconut milk and water to the chicken mixture; and boiled it on the stove. [NAME] 4 did not refer to any recipe during the preparation of the chicken curry. On 5/18/23 at 0925 hours, [NAME] 4 poured the chicken mixture from the pot into the RC and blended the mixture. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents' nutritional needs were met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food then adding an unmeasured quantity of stabilizer was not ideal. 3. Review of the facility's Recipe: Puree Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 3/17, showed for 24 servings, add warm milk or cold milk three cups to 1 ½ quarts, thickener ¾- 1 ½ cups. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed adding milk gradually. See above for recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve desired consistency. - Puree should reach a consistency of applesauce. - Add stabilizer to increase density of the pureed food if needed. Review of the facility's Daily Spreadsheet dated 5/17/23, showed the residents on puree diet will be served a #10 scoop (3 to 4 ounces) of pureed strawberry shortcake. On 5/17/23 at 1054 hours, an observation of the puree strawberry shortcake preparation for the lunch meal was conducted with [NAME] 1. [NAME] 1 stated he was preparing 20 portions of puree cake. [NAME] 1 added 12 pieces of strawberry shortcake to the RC. [NAME] 1 then poured an unmeasured quantity of milk directly from the milk carton into the RC. The cake and milk mixture was blended. [NAME] 1 added four more pieces of strawberry shortcake and added an unmeasured quantity of milk directly from the milk carton to the RC, blended the mixture again. [NAME] 1 added two more pieces (total of 18 pieces) of strawberry shortcake to the RC and blended the mixture. [NAME] 1 added a #16 scoop (two ounces) of thickener to the RC and blended the mixture. The pureed cake was placed in a pan. [NAME] 1 did not refer to any recipe during the strawberry shortcake puree preparation. On 5/17/23 at 1059 hours, an observation of the portioning of the puree cake for all puree diets was conducted with DA 2. DA 2 stated he was preparing 23 portions of puree cake. DA 2 stated he used a #12 scoop (2 1/2 to 3 ounces) to serve the puree strawberry shortcake. When finished, DA 2 had portioned out 28 servings of puree strawberry shortcake. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure resident nutritional needs are met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food then adding an unmeasured quantity of stabilizer was not ideal. 4. Review of the facility document titled pureed starch (undated) showed options for six, 12, 24, and 48 servings. For 24 servings, prepare 24 starch servings, warm milk 3 cups to 1 ½ quarts, if needed: stabilizer instant potato ¾ - 1 ½ cups. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm milk. See above for recommended amounts of liquids, starting with the smaller amount and adding in more as needed to achieve consistency. If starch is already moist after being pureed, you may not need much added milk. - Puree should reach a consistency slight softer than whipped topping. May add more liquid if needed to reach this consistency. - Add stabilizer to increase the density of the pureed food if needed. On 5/18/23 at 0830 hours an observation of the puree rice preparation for the Vietnamese lunch menu was conducted with [NAME] 4 with the DSS present. [NAME] 4 stated she was pureeing about 18 servings. When asked how she measured the 18 servings she stated she used the scoop located in the rice bin. [NAME] 4 asked the DSS how big the scoop was that was stored in the rice bin. The DSS replied it was a large scoop. [NAME] 4 added an unmeasured quantity of cooked rice to the RC followed by an unmeasured quantity of water. The mixture was blended. When asked how much water she added, [NAME] 4 stated she just watched the mixture and added more water as needed. [NAME] 4 then added more unmeasured quantity of water to the rice mixture and blended the mixture. [NAME] 4 stated the product was too runny and added an unmeasured quantity of instant mashed potatoes. [NAME] 4 did not refer to any recipe during the puree rice preparation. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure resident nutritional needs are met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food then adding an unmeasured quantity of stabilizer was not ideal. Review of the facility document titled Sanitation Audit Report (SAR) completed by the RD on 2/10 and 4/28/23 showed the recipes were available and being followed. However, the SAR completed by the RD on 3/30/23, showed inappropriate textures were served.

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the kitchen staff were competent in the position related duties when: 1. Two of four cooks (Cooks 1 and 4) failed to perform the following: a. Failed to prevent cross contamination, b. Failed to perform proper hand hygiene during food preparation, c. Failed to sanitize food preparation equipment when washed manually, d. Failed to sanitize food preparation surfaces, and e. Failed to follow the recipes. 2. One of four cooks (Cook 1) failed to know the final cooking temperature of chicken. 3. One of seven DA (DA 1) failed to know the manual dish washing procedure. 4. One of seven DA (DA 2) failed to follow the resident menu. These failures had the potential to cause food borne illness and not meet the resident's nutritional needs for the 115 residents who received food prepared in the kitchen. Findings: 1.a. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Dry Storage 7. Any opened products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated .8. Remove food stored in bins from their original packaging. Label and date all storage containers or bins. Keep free of scoops. Lids need to be tight fitting and in good condition .Clean and sanitize insides of food bins when product is changed out or is outdated. On 5/17/23 at 1026 hours, an observation of the puree meal preparation and concurrent interview was conducted with [NAME] 1 with the DSS as an interpreter . An unlabeled, undated white plastic container with a cracked red plastic lid was used to store instant mashed potatoes. A metal four-ounce measuring cup covered with old, dried instant mashed potatoes was observed stored inside the white plastic container. The white plastic container was almost empty. [NAME] 1 filled the white plastic container with instant mashed potatoes from a new instant mashed potato plastic container, put the scoop inside, and placed the red cracked lid on top. The DSS confirmed the scoop should not be stored inside the plastic container. On 5/18/23 at 0905 hours, an observation of the Vietnamese menu puree preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 obtained the white plastic container with a cracked red plastic lid containing the instant mashed potatoes. The DSS was asked if the original plastic food containers with a cracked lid was appropriate for storage, the DSS stated, No. The DSS asked [NAME] 4 to change the storage container for the instant mashed potatoes. [NAME] 4 obtained a clear plastic container, labeled and dated the container, then transferred the instant mashed potatoes into the container. Once the Vietnamese menu puree preparation was completed, [NAME] 4 stored the metal four-ounce measuring cup used for the instant mashed potatoes inside the clear plastic container containing the instant mashed potatoes. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed the original plastic food containers should be discarded and not used for food storage. The scoops should not be stored inside the bins. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Raw Meat . 3. Wash and sanitize all the surfaces, equipment, and utensils that have come in contact with raw meats before using for any other food to prevent cross-contamination. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed in part, under number 10, cutting boards need to be washed and sanitized between each use . Color-coded cutting boards are desirable designating boards for raw products versus cooked products. On 5/18/23 at 0821 hours, an observation of the Vietnamese menu lunch meal preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 prepared chicken curry for the Vietnamese menu lunch meal. Wearing gloves, [NAME] 4 cut raw chicken on a brown cutting board. The DSS confirmed a brown cutting board was to be used for cooked meats only. The DSS added [NAME] 4 should use a yellow cutting board which was for raw chicken. [NAME] 4 obtained a yellow cutting board and transferred the raw chicken to the yellow cutting board. [NAME] 4 completed cutting the raw chicken on the yellow cutting board. [NAME] 4 went to the refrigerator walk in, opened the door with the same gloved hands she touched the raw chicken with, and obtained a raw onion. [NAME] 4 placed the raw onion on the yellow cutting board and proceeded to cut the raw onion. The DSS stated [NAME] 4 should have used a green cutting board to cut the onion, which was designated for fruits and vegetables only. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed using different colored cutting boards avoided the potential for cross contamination. The RD confirmed using the same cutting board for the raw chicken and raw vegetables posed the risk for cross contamination and could lead to food borne illness. The DSS was unable to provide in-service education training regarding cross contamination for the kitchen employees. Cross reference to F812, example #1. b. Review of the facility's P&P titled Personal Hygiene/Safety/Food Handling/Infection Control revised 11/30/22, showed in part, under number 2, Clean hands, fingernails, and Gloves b. Hands must always be washed after . handling any unsanitary items. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Raw Meat .2. Wash hands before and after handling raw meat to prevent the transmission of bacteria to food from the hands and from objects that have been touched by hands. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed appropriate hand washing and glove use. On 5/17/23 at 1020 hours, an observation was conducted of [NAME] 1 in the kitchen. [NAME] 1 put soiled dishes in the dish machine, then proceeded to put plastic wrap on the residents' food bowls without washing his hands. On 5/17/23 at 1037 hours, [NAME] 1 was observed to wash the soiled Robot Coupe (RC, a machine used to puree food) in the dish machine, placed prepared vegetables on the steam table, obtained a pen from his pocket and labeled the instant mashed potato container, then began to puree sweet potatoes without washing his hands. On 5/17/23 at 1200 hours, [NAME] 1 was observed to touch his cell phone from his pocket then proceeded to prepare the resident food for lunch tray line without washing his hands. On 5/18/23 at 0821 hours during the Vietnamese food preparation, an observation of [NAME] 4 was conducted. [NAME] 4 obtained spices from the storage without wearing gloves. [NAME] 4 donned gloves without washing her hands, then proceeded to touch multiple unclean surfaces: the water faucet handle, counter, knife handle, then [NAME] 4 touched raw chicken. [NAME] 4 opened the walk-in door using the same gloved hands she touched the raw chicken, then proceeded to touch a raw onion without changing gloves or washing her hands. On 5/18/23 at 0830 hours, an observation was conducted of [NAME] 4. [NAME] 4 changed her gloves to puree the resident food but failed to wash her hands between glove change. On 5/18/23 at 0844 hours, an observation of [NAME] 4 was continued . [NAME] 4 changed her gloves prior to cutting raw chicken for mechanically altered diets but failed to wash her hands between glove change. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD was asked when hand washing was necessary. The RD stated hand washing was necessary to prevent cross contamination between dirty and clean tasks and between glove changes. Review of the facility's document titled Lesson Plan: Infection Prevention dated 7/25/22, showed [NAME] 1 was in attendance, but [NAME] 4 was not in attendance. Cross reference to F812, example #3. c. Review of the facility's P&P titled Pots and Pans- Sanitizing Solution revised 8/31/18 showed in part, .2. Fill all tanks 2/3 full. a. Fill first tank with water and an effective concentration of detergent. b. Fill second tank with clean rinse water. c. Fill third tank with tepid water for sanitizing to fill line. If third sink is not available or is not used, pots and pans are run through the dish machine to sanitize as an alternate method. 3. Add sanitizing agent to third tank according to EPA-registered label use directions. a .200 ppm or 150-400 ppm (depending on which kind you use) is the required concentration of sanitizer-to-water ratio using a quaternary ammonia-base sanitizer .5. Scrub pots and pans in first tank using a scouring pad or appropriate cleaning tool, 6. Rinse pots and pans free of detergent in second tank. 7. Sanitize pots and pans in third tank by immersing in water with sanitizing agent for at least two minutes or per manufacturer guidelines. On 5/18/23 at 0841 hours, an observation of [NAME] 1 was conducted in the kitchen. [NAME] 1 manually washed the steam table pans by scrubbing the pans with water, then rinsed the pans off with water. The DSS confirmed all the items washed manually should be washed and sanitized. On 5/18/23 at 0902 hours, an observation of [NAME] 4 was conducted in the kitchen. [NAME] 4 manually washed the Robot Coupe (RC). [NAME] 4 sprayed soap on the RC through the soap dispenser, scrubbed the top and bottom of the RC, rinsed the RC with water, then placed the RC to drain at the side of sink. On 5/18/23 at 0921 hours, an interview was conducted with the DSS. The DSS confirmed all pots and pans should be sanitized in the dish machine or the three-sink method could be utilized to wash, rinse, and sanitize the pots and pans. The DSS further stated the cook was in a rush to wash the RC, therefore, the cook did not sanitize the RC in the dish machine and should have given the RC to the dishwasher to sanitize it. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she believed the pots and pans were washed and sanitized in the dish machine. The RD added all the food preparation equipment and utensils must be sanitized. The DSS was unable to provide documentation of in-service education training regarding manual dish washing for the kitchen employees. Cross reference to F812, example #4. d. Review of the facility's P&P titled Sanitizer Use Concentrations for Food Services and Food Production Facilities revised 4/30/20 showed in part, c. A quaternary ammonium compound solution shall have a minimum temperature and contact time based on the concentration as listed in the following chart: Concentration Range: 200 ppm (part per million) or 150-400 ppm .3. All surfaces and equipment should be washed with a sanitizing solution. On 5/18/23 at 0844 hours, an observation of [NAME] 4 in the kitchen was conducted. [NAME] 4 was preparing the chicken curry for the lunch meal. [NAME] 4 picked up a large, soiled spoon from the food preparation counter. [NAME] 4 wiped the food preparation counter with a paper towel then continued food preparation activities for the lunch meal. On 5/18/23 at 0905 hours, an observation of [NAME] 1 in the kitchen was conducted. [NAME] 1 obtained a cleaning cloth from the sanitation bucket. [NAME] 1 rinsed and wrung the cleaning cloth out three times with water in the food preparation sink. [NAME] 1 proceeded to wipe the stove top with the cleaning cloth. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed that all kitchen surfaces should be cleaned with a cleaning cloth stored in the sanitizing solution. The RD confirmed cleaning the food production surfaces with a paper towel or cleaning cloth that had been rinsed out with water was not appropriate. The DSS was unable to provide documentation of in-service education training regarding sanitation of food production surfaces for the kitchen employees. Cross reference to F812, example #5. e. Review of the facility's document titled Recipe: Pureed Vegetables, undated, showed six, 12, 24, and 48 serving options. For 24 servings, use 24 servings of regular vegetables. Warm fluid such as milk, or low sodium broth ½ cup to 1 ½ cups. If needed: Stabilizer: instant potatoes ¾ cup to 1 ½ cup. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk) if needed. See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree on low speed, adding stabilizer where needed. See above for amounts. Review of the facility's document titled Daily Spreadsheet dated 5/17/23, showed the spring blend vegetables serving size was four ounces. On 5/17/23 at 1026 hours, an observation of the spring blend vegetable puree preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1 with the DSS as a translator. [NAME] 1 stated he was preparing 20 puree portions. Using a four-ounce scoop, [NAME] 1 placed ten scoops of vegetables that included water the vegetables were cooked in, into the Robot Coupe (RC, an equipment used to puree foods). [NAME] 1 stated he wanted honey consistency for the pureed vegetables. [NAME] 1 then added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. [NAME] 1 added an unmeasured quantity of instant mashed potatoes to the RC, a total of four additional times; and blended the mixture after adding each quantity of instant mashed potatoes. [NAME] 1 was asked if he added a certain amount of instant mashed potatoes to the vegetables. [NAME] 1 stated it depended on the type of vegetable. The DSS confirmed a consistency of mashed potatoes was the goal for pureed foods. No recipe was referred to during the vegetable puree preparation for the American lunch menu. Review of the facility's document titled Garlic [NAME] Beans undated showed the portion size was four ounces. On 5/18/23 at 0905 hours, an observation of the vegetable puree preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. It was noted [NAME] 4 prepared green peas rather than garlic green beans. [NAME] 4 stated she substituted green peas for green beans for lunch today. [NAME] 4 stated she was preparing about 18 puree servings. [NAME] 4 stated she used 2.5 pounds (equivalent to 10 four-ounce servings) of frozen peas cooked in water. [NAME] 4 placed an unmeasured quantity of the pea and water mixture into the RC and added one-four ounce of instant mashed potatoes. The mixture was blended. [NAME] 4 added another unmeasured quantity of the pea and water mixture to the RC. The pea and water mixture was blended again. The final product had a liquid consistency. [NAME] 4 stated the mixture would thicken over time and placed the pureed peas on top of the steam table. No recipe was referred to during the vegetable puree preparation for the Vietnamese lunch menu. Review of the facility's document titled Recipe: Puree Meats dated 4/17, showed six, 12, 24, and 48 serving options. For six servings, use six serving of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, ¾ to 1 ½ cups of liquid. Stabilizer: instant potato 0-6 Tablespoons. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. 5. Add stabilizer to increase the density of the pureed food if needed. On 5/17/23 at 1133 hours, an observation of the puree meat preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing five puree meat portions, three ounces each. Using the three-ounce scoop, [NAME] 1 measured five meat portions into the RC. [NAME] 1 then added an unmeasured quantity of chicken broth to the RC. The meat and broth mixture was blended. After blending, the meat and broth mixture had a liquid consistency. [NAME] 1 then added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. The meat and broth mixture was too thick so [NAME] 1 added an additional three 3-ounce scoops of chicken broth to the RC to achieve mashed potato consistency. Review of the facility's document titled Chicken Curry and Sweet Potatoes undated showed Ingredients: for 50 servings included 6 2/3 pounds of boneless, skinless chicken thigh meat, fresh yellow onion, fresh garlic clove peeled, fresh ginger root, fresh herb lemon grass, fresh carrots, fresh sweet potato, fresh red chili pepper paste, Thai curry paste, light brown sugar, coconut milk, fish sauce, hot water, and chicken soup base. Review of the facility's document titled Recipe: Puree Meats dated 4/17 showed six, 12, 24, and 48 serving options. For 24 servings, use 24 serving of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, three cups to 1 ½ quarts of liquid. Stabilizer: instant potato ¾- 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. 5. Add stabilizer to increase the density of the pureed food if needed. On 5/18/23 at 0821 hours, an observation of the puree meat preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. [NAME] 4 stated she was preparing about 18 servings of chicken curry for the puree diet. After cutting an unmeasured quantity of raw chicken and onion, [NAME] 4 added the chicken, onion and unmeasured quantities directly from the packages of curry powder, turmeric powder, and white mushroom seasoning salt to a cooking pot. [NAME] 4 then added unmeasured quantities of coconut milk and water to the chicken mixture and boiled it on the stove. No recipe was referred to during the preparation of the chicken curry. On 5/18/23 at 0925 hours, [NAME] 4 poured the chicken mixture from the pot into the RC and blended the mixture. Review of the facility's document titled Recipe: Puree Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 3/17 showed for 24 servings to add warm milk or cold milk three cups to 1 ½ quarts, thickener ¾- 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed adding milk gradually. See above for recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve desired consistency. 3. Puree should reach a consistency of applesauce. 4. Add stabilizer to increase density of the pureed food if needed. Review of the facility's document titled Daily Spreadsheet dated 5/17/23, showed puree diets received a #10 scoop of pureed strawberry shortcake. On 5/17/23 at 1054 hours, an observation of the puree strawberry shortcake preparation for the lunch meal was conducted with [NAME] 1. [NAME] 1 stated he was preparing 20 portions of puree cake. [NAME] 1 added 12 pieces of strawberry shortcake to the RC. [NAME] 1 then poured an unmeasured quantity of milk directly from the milk carton into the RC. The cake and milk mixture was blended. [NAME] 1 added four more pieces of strawberry shortcake and added an unmeasured quantity of milk directly from the milk carton to the RC, blended the mixture again. [NAME] 1 added two more pieces (total of 18 pieces) of strawberry shortcake to the RC and blended the mixture. [NAME] 1 added a #16 scoop (two ounces) of thickener to the RC and blended the mixture. The puree cake was placed in a pan. No recipes were referred to during the strawberry shortcake puree preparation. Review of the facility's document titled pureed starch undated showed six, 12, 24, and 48 serving options. For 24 servings, prepare 24 starch servings, warm milk 3 cups to 1 ½ quarts, if needed: stabilizer instant potato ¾ - 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm milk. See above for recommended amounts of liquids, starting with the smaller amount and adding in more as needed to achieve consistency. If starch is already moist after being pureed, you may not need much added milk. 4. Puree should reach a consistency slight softer than whipped topping. May add more liquid if needed to reach this consistency. 5. Add stabilizer to increase the density of the pureed food if needed. On 5/18/23 at 0830 hours, an observation of the puree rice preparation for the Vietnamese lunch menu was conducted with [NAME] 4 and the DSS present. [NAME] 4 stated she was pureeing about 18 servings. When asked how she measured the 18 servings she stated she used the scoop located in the rice bin. [NAME] 4 asked the DSS how big the scoop was that was stored in the rice bin. The DSS replied it was a large scoop. [NAME] 4 added an unmeasured quantity of cooked rice to the RC followed by an unmeasured quantity of water. The mixture was blended. When asked how much water she added, [NAME] 4 stated she just watched the mixture and added more water as needed. [NAME] 4 then added more unmeasured quantity of water to the rice mixture and blended the mixture. [NAME] 4 stated the product was too runny and added an unmeasured quantity of instant mashed potatoes. No recipe was referred to during the puree rice preparation. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents' nutritional needs are met. The RD acknowledged adding unmeasured quantities of liquid to the puree foods prior to blending the food then adding an unmeasured quantity of stabilizer is not ideal. The DSS was unable to provide documentation of in-service education training regarding following resident menus for the kitchen employees. Cross reference to F803, examples #1, #2, #3, and #4. 2. Review of the professional reference FoodSafety.gov titled Safe Minimum Cooking Temperatures Charts revised 4/12/19, showed the minimum internal temperature for poultry should be 165 degrees Fahrenheit (F). An interview was conducted with [NAME] 1 with the DSS as a translator on 5/17/23 at 1138 hours, in the kitchen. [NAME] 1 was asked if he took the final cooking temperatures of meats. [NAME] 1 stated he did take the final cooking temperatures of meats but did not record the temperatures. During the lunch meal tray line observation and concurrent interview with [NAME] 1 using the DSS as an interpreter, on 5/17/23 at 1203 hours, [NAME] 1 took the tray line temperature of the BBQ chicken. The temperature of the BBQ chicken was 140 degrees F using the surveyor's thermometer. [NAME] 1 was asked if 140 degrees F was ok for chicken. [NAME] 1 did not answer. [NAME] 1 was then asked what the final cooking temperature of chicken should be. [NAME] 1 stated 135-140 degrees F. The DSS agreed that the final cooking temperature of chicken should be 135-140 degrees F. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed the facility took final cooking temperatures of meats but did not record the final cooking temperatures. The RD acknowledged the cooks should know the appropriate final cooking temperatures of meats. The DSS was unable to provide documentation of in-service education training regarding appropriate final cooking temperatures of food for the kitchen employees. 3. Review of the facility's P&P titled Pots and Pans- Sanitizing Solution revised 8/31/18 showed in part, .2. Fill all tanks 2/3 full. a. Fill first tank with water and an effective concentration of detergent. b. Fill second tank with clean rinse water. c. Fill third tank with tepid water for sanitizing to fill line. If third sink is not available or is not used, pots and pans are run through the dish machine to sanitize as an alternate method. 3. Add sanitizing agent to third tank according to EPA-registered label use directions. a .200 ppm or 150-400 ppm (depending on which kind you use) is the required concentration of sanitizer-to-water ratio using a quaternary ammonia-base sanitizer .5. Scrub pots and pans in first tank using a scouring pad or appropriate cleaning tool, 6. Rinse pots and pans free of detergent in second tank. 7. Sanitize pots and pans in third tank by immersing in water with sanitizing agent for at least two minutes or per manufacturer guidelines. On 5/18/23 at 0817 hours, an interview was conducted with Diet Aide (DA) 1 regarding the manual dishwashing procedure with the DSS present. DA 1 stated the pots and pans were washed manually with hot water and soap, then sanitized and air dried. The DA stated manual dishwashing was a two step process. The DSS confirmed DA forgot to state the pots and pans were rinsed before being sanitized. The DSS was unable to provide documentation of in-service education training regarding manual dishwashing for the kitchen employees. 4. Review of the facility's document titled Recipe: Puree Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 3/17 showed, for 24 servings to add warm milk or cold milk three ups to 1 ½ quarts, thickener ¾- 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed adding milk gradually. See above for recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve desired consistency. 3. Puree should reach a consistency of applesauce. 4. Add stabilizer to increase density of the pureed food if needed. Review of the facility's document titled Daily Spreadsheet dated 5/17/23 showed the puree diets received a #10 scoop of pureed strawberry shortcake. On 5/17/23 at 1059 hours, an observation of the portioning of the puree cake for all puree diets was conducted with DA 2. DA 2 stated he was preparing 23 portions of the puree cake. DA 2 stated he used a #12 scoop to serve the puree strawberry shortcake. When finished, DA 2 had portioned out 28 servings of puree strawberry shortcake. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all portion sizes must be followed to ensure resident nutritional needs are met. The DSS was unable to provide documentation of in-service education training regarding following the resident menu for the kitchen employees. Cross reference to F803, example #3. An interview regarding kitchen employee competency was conducted with the DSS on 5/18/23 at 1448 hours. The DSS stated he assessed his employees' competency with an annual competency evaluation that was based on knowledge and demonstration. Review of the facility's document titled Employee Performance Appraisal signed by DA 1 on 5/3/23, showed DA 1's knowledge and quality of work was good. Review of the facility's document titled Verification of Job Competency Demonstration - Diet Aides for DA 1 dated 2022 showed DA 1's initials for emergency dish washing procedure and when to use it. The column titled Verified by was blank. There was no documentation from the DSS showing DA 1 was competent in emergency dish washing procedures. Review of the facility's document titled Employee Performance Appraisal signed by [NAME] 1 on 5/11/22 showed [NAME] 1's knowledge and quality of work was excellent. Review of the facility's document titled Verification of Job Competency Demonstration - Cooks for [NAME] 1 dated 2022 showed [NAME] 1's initials for use of recipes, glove use and food preparation, hand washing procedure, how to clean and sanitize equipment, counter tops and food storage procedures for dry storage. The column titled Verified by was blank. There was no documentation from the DSS showing [NAME] 1 was competent in use of recipes, glove use and food preparation, hand washing procedure, how to clean and sanitize equipment counter tops and food storage procedures for dry storage. Review of the facility's document titled Employee Performance Appraisal signed by [NAME] 4 on 3/23/23, showed [NAME] 4's knowledge and quality of work was excellent. Review of the facility's document titled Verification of Job Competency Demonstration - Cooks for [NAME] 4 dated 2022 showed [NAME] 4's initials for use of recipes, cutting board use, glove use in food preparation, hand washing procedure, how to clean and sanitize equipment, counter tops, food storage procedures for dry storage. The column titled Verified by was blank. There was no documentation from the DSS showing [NAME] 4 was competent in the use of recipes; cutting board use; glove use in food preparation; hand washing procedure; how to clean and sanitize equipment and counter tops; and food storage procedures for dry storage. An interview regarding new employee training was conducted with the DSS on 5/19/23 at 0950 hours. The DSS confirmed DA 2 was newly hired on 3/31/23. The DSS was asked how the new employees were trained. The DSS stated the new employees were trained by other employees who did the same job for 1-2 weeks then he let the new employee work alone. The DSS stated DA 2's first day alone was on 5/18/23. The DSS was asked how he ensured the new employee were competent prior to working alone. The DSS stated there was a competency form that he filled out but had not completed the competency form for DA 2. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed any new employee should be deemed competent prior to working alone. The RD stated she did a walk through with new employees but had not completed a walk through with DA 2 because she was too busy.

Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when: 1. Potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) was not prevented. A scoop was stored in the instant mash potato container and the kitchen staff did not use proper color coded cutting board when cutting raw chicken and vegetable. 2. Time Temperature Control for Safety (TCS) Foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not handled safely as no cooling down log for the leftover chicken and turkey cooked on the previous day. 3. Proper hand hygiene was not performed by the kitchen staff. 4. Food preparation equipment was not sanitized when washed manually. 5. Kitchen surfaces were not sanitized. 6. Refrigerated and frozen foods were not stored safely. 7. Hair restraints were not worn appropriately by the kitchen staff. 8. Food preparation equipment and ice machine were not clean. 9. Non-food contact surfaces in the kitchen were not clean. 10. A rolling ice chest with soiled wheels was stored on a food preparation table. 11. Employee food was not stored appropriately. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 115 residents who received food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/16/23, showed 115 of 115 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Dry Storage 7. Any opened products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated .8. Remove food stored in bins from their original packaging. Label and date all storage containers or bins. Keep free of scoops. Lids need to be tight fitting and in good condition .Clean and sanitize insides of food bins when product is changed out or is outdated. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed no concerns with the scoops stored inside the bulk storage. a. On 5/17/23 at 1026 hours, an observation of the puree meal preparation and concurrent interview was conducted with [NAME] 1 with the DSS as an interpreter . An unlabeled, undated white plastic container with a cracked red plastic lid was used to store instant mashed potatoes. A metal four-ounce measuring cup covered with dried instant mashed potatoes was observed stored inside the white plastic container. The white plastic container was almost empty. [NAME] 1 filled the white plastic container with instant mashed potatoes from a new instant mashed potato plastic container, put the four-ounce measuring scoop inside covered with dried instant mashed potatoes inside and placed the red cracked lid on top. The DSS confirmed the scoop should not be store inside the plastic container. The four-ounce measuring scoop covered with dried instant mashed potatoes was placed on top of the white plastic container. On 5/18/23 at 0905 hours, an observation of the Vietnamese menu puree preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 obtained the white plastic container with a cracked red plastic lid containing the instant mashed potatoes. The DSS was asked if original plastic food containers with a cracked lid was appropriate for storage, the DSS stated, No. The DSS asked [NAME] 4 to change the storage container for the instant mashed potatoes. [NAME] 4 obtained a clear plastic container, labeled and dated the container, then transferred the instant mashed potatoes into the container. Once the Vietnamese menu puree preparation was completed, [NAME] 4 stored the metal four-ounce measuring cup covered in dried instant mashed potatoes used inside the clear plastic container which contained instant mashed potatoes. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed the original plastic food containers should be discarded and not used for food storage. Scoops should be clean and not be stored inside bins. b. According to the USDA Food Code 2022 Annex 4. Management of Food Safety Practices - Achieving Active Managerial Control of Foodborne Illness Risk Factors, F. Facility-wide Considerations: In order to have active managerial control over personal hygiene and cross-contamination, certain control measures must be implemented in all phases of the operation. All of the following control measures should be implemented regardless of the food preparation process used .Prevention of cross-contamination of ready-to-eat food or clean and sanitized food-contact surfaces with soiled cutting boards, utensils, aprons, etc., or raw animal foods. Review of the facility's P&P titled Food Storage revised 4/6/23, showed for Raw Meat, under Number 2. Wash hands before and after handling raw meat to prevent the transmission of bacteria to food from the hands and from objects that have been touched by hands. 3. Wash and sanitize all surfaces, equipment, and utensils that have come in contact with raw meats before using for any other food to prevent cross-contamination. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed in part, 10. Cutting boards need to be washed and sanitized between each use . Color-coded cutting boards are desirable designating boards for raw products versus cooked products. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed potential cross contamination of raw animal foods was not monitored by the RD. On 5/18/23 at 0821 hours, an observation of the Vietnamese menu lunch meal preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 prepared chicken curry for the Vietnamese menu lunch meal. Wearing gloves, [NAME] 4 cut raw chicken on a brown cutting board. The DSS confirmed a brown cutting board was to be used for cooked meats only. The DSS added [NAME] 4 should use a yellow cutting board which was for raw chicken. [NAME] 4 obtained a yellow cutting board and transferred the raw chicken to the yellow cutting board. [NAME] 4 completed cutting the raw chicken on the yellow cutting board. [NAME] 4 went to the refrigerator walk in, opened the door with the same gloved hands she touched the raw chicken and obtained a raw onion. [NAME] 4 placed the raw onion on the yellow cutting board and proceeded to cut the raw onion. The DSS stated [NAME] 4 should have used a green cutting board to cut the onion, which was designated for the fruits and vegetables only. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed using a different colored cutting boards avoided the potential for cross contamination. The RD confirmed using the same cutting board for the raw chicken and raw vegetables posed the risk for cross contamination and could lead to food borne illness. 2. According the USDA Food Code 2022 Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57º Celsius (C) [135º Fahrenheit (F)] to 21ºC (70°F); and (2) Within a total of six hours from 57ºC (135ºF) to 5ºC (41°F) or less. Review of the facility's P&P titled Refrigerated Leftover Storage revised 8/31/23, showed in part, the leftover foods should not be saved and re-used for human consumption if there is any doubt of wholesome quality . Do Not Save: .Meats- precooked or cooked day before and chilled. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed TCS food was not monitored by the RD. During the initial kitchen tour with the DSS on 5/16/23 at 0800 hours, a pan of cooked turkey dated 5/15/23, was observed in the walk-in refrigerator. The DSS stated the turkey was cooked the day before and would be used as an alternative for the residents today. On 5/17/23 at 1022 hours, an interview was conducted with the DSS regarding the leftover chicken seen in the walk-in refrigerator on 5/16/23. The DSS stated the leftover chicken had been discarded. On 5/18/23 at 0830 hours, an interview was conducted regarding proper cooling of TCS foods with [NAME] 4 and the DSS. [NAME] 4 stated the kitchen never saved leftover food. [NAME] 4 stated if the leftover food was kept, the kitchen staff could eat it. When asked if [NAME] 4 was familiar with a cooling log, [NAME] 4 did not respond. The DSS stated the facility did not use a cooling log because they did not save leftover food. A telephone interview was conducted with the RD on 5/19/23 at 1014 hours. The RD stated leftover food should be properly cooled down, but the facility tried not to save the leftover food. The RD stated the facility used a cooling log if the leftover food was saved. 3. According the USDA Food Code 2022, Section 2-301.14 When to Wash Food, employees shall clean their hands and exposed portions of their arms . immediately before engaging in food preparation and .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. (G) When switching between working with raw food and working with ready- to-eat-food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Review of the facility's P&P titled Personal Hygiene/Safety/Food Handling/Infection Control revised 11/30/22, showed in part, 2. Clean hands, fingernails, and Gloves b. Hands must always be washed after . handling any unsanitary items. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Raw Meat .2. Wash hands before and after handling raw meat to prevent the transmission of bacteria to food from the hands and from objects that have been touched by hands. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed appropriate hand washing and glove use. On 5/17/23 at 1020 hours, an observation of [NAME] 1 was conducted in the kitchen. [NAME] 1 put the soiled dishes in the dish machine, then proceeded to put plastic wrap on the resident food bowls without washing his hands. On 5/17/23 at 1037 hours, [NAME] 1 was observed to wash the soiled Robot Coupe (RC, a machine used to puree food) in the dish machine, placed prepared vegetables on the steam table, obtained a pen from his pocket and labeled the instant mashed potato container then began to puree sweet potatoes without washing his hands. On 5/17/23 at 1200 hours, [NAME] 1 was observed to touch his cell phone from his pocket, then proceeded to prepare the resident food for lunch tray line without washing his hands. On 5/18/23 at 0821 hours, during the Vietnamese food preparation, an observation of [NAME] 4 was conducted. [NAME] 4 obtained spices from the storage without wearing gloves. [NAME] 4 donned gloves without washing her hands then proceeded to touch multiple unclean surfaces: the water faucet handle, the counter, and the knife handle; then [NAME] 4 touched raw chicken. Without changing gloves and washing her hands, [NAME] 4 opened the walk-in door and obtained a raw onion. On 5/18/23 at 0830 hours, an observation was conducted of [NAME] 4. [NAME] 4 changed her gloves to puree the resident food but failed to wash her hands between glove change. On 5/18/23 at 0844 hours, an observation continued of [NAME] 4. [NAME] 4 changed her gloves prior to cutting the raw chicken for mechanically altered diets but failed to wash her hands between glove change. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD was asked when hand washing was necessary. The RD stated hand washing was necessary to prevent cross contamination between dirty and clean tasks and between glove changes. 4. Review of the facility's P&P titled Pots and Pans- Sanitizing Solution revised 8/31/18, showed in part, .2. Fill all tanks 2/3 full. a. Fill first tank with water and an effective concentration of detergent. b. Fill second tank with clean rinse water. c. Fill third tank with tepid water for sanitizing to fill line. If third sink is not available or is not used, pots and pans are run through the dish machine to sanitize as an alternate method. 3. Add sanitizing agent to third tank according to EPA-registered label use directions. a .200 ppm or 150-400 ppm (depending on which kind you use) is the required concentration of sanitizer-to-water ratio using a quaternary ammonia-base sanitizer .5. Scrub pots and pans in first tank using a scouring pad or appropriate cleaning tool, 6. Rinse pots and pans free of detergent in second tank. 7. Sanitize pots and pans in third tank by immersing in water with sanitizing agent for at least two minutes or per manufacturer guidelines. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed no concerns with the three-compartment sink (manual dishwashing sink) chemical concentration used for sanitizing. On 5/18/23 at 0841 hours, an observation of [NAME] 1 was conducted in the kitchen. [NAME] 1 manually washed steam table pans by scrubbing the pans with water, then rinsed the pans off with water. The DSS confirmed all the items washed manually should be washed and sanitized. On 5/18/23 at 0902 hours, an observation of [NAME] 4 was conducted in the kitchen. [NAME] 4 manually washed the Robot Coupe (RC). [NAME] 4 sprayed soap on the RC through the soap dispenser, scrubbed the top and bottom of the RC, rinsed the RC with water, then placed the RC to drain at the side of sink. On 5/18/23 at 0921 hours, an interview was conducted with the DSS. The DSS confirmed all pots and pans should be sanitized in the dish machine or the three-sink method could be utilized to wash, rinse, and sanitize the pots and pans. The DSS further stated the cook was in a rush to wash the RC, therefore, the cook did not sanitize the RC in the dish machine but should have given the RC to the dishwasher to sanitize it. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she believed the pots and pans were washed and sanitized in the dish machine. The RD added all food preparation equipment and utensils must be sanitized. 5. Review of the facility's P&P titled Sanitizer Use Concentrations for Food Services and Food Production Facilities revised 4/30/20 showed in part, c. A quaternary ammonium compound solution shall have a minimum temperature and contact time based on the concentration as listed in the following chart: Concentration Range: 200 ppm (part per million) or 150-400 ppm .3. All surfaces and equipment should be washed with a sanitizing solution. On 5/18/23 at 0844 hours, an observation of [NAME] 4 in the kitchen was conducted. [NAME] 4 was preparing the chicken curry for the lunch meal. [NAME] 4 picked up a large, soiled spoon from the food preparation counter. [NAME] 4 wiped the food preparation counter with a paper towel, then continued food preparation activities for the lunch meal. On 5/18/23 at 0905 hours, an observation of [NAME] 1 in the kitchen was conducted. [NAME] 1 obtained a cleaning cloth from the sanitation bucket. [NAME] 1 rinsed and wrung the cleaning cloth three times with water in the food preparation sink. [NAME] 1 proceeded to wipe the stove top with the cleaning cloth. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all kitchen surfaces should be sanitized with a cleaning cloth stored in the sanitizing solution. The RD confirmed cleaning food production surfaces with a paper towel or cleaning cloth that had been rinsed out with water was not appropriate. 6. Review of the facility's P&P titled Food storage revised 4/6/23, showed Eggs, Milk, and Cheese. Eggs should be checked for cracks, and any damaged one should be disposed of. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed food was stored labeled, dated and sealed. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the walk-in refrigerator was conducted. Two broken eggs were observed with raw egg contents touching unbroken eggs. The DSS confirmed the broken eggs must be removed. a. Review of the facility's P&P titled Food Storage revised 4/6/23 showed in part, Frozen Meat/Poultry and Foods 3. Storage: .Food to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated paper. Label and date all food items. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed food was stored labeled, dated, and sealed. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the reach-in freezer was conducted. An open, unlabeled, and undated bag of frozen ground beef was observed. The ground beef showed signs of freezer burn, a condition of discoloration or other damage caused to frozen food by evaporation. The DSS confirmed all foods in the freezer should be sealed, labeled, and dated. 7. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness (A), Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils . Review of the facility's P&P titled Personal Hygiene/Safety/Food Handling/Infection Control revised 11/30/22, showed in part, 3. Head Covering Worn a .Hair must be appropriately restrained or completely covered. c. Beards or any body hair that may be exposed . must be covered. Review of the facility document titled Sanitation Audit Report completed by the RD on 2/10 and 4/28/23, showed no concerns with hair restraints. The SAR completed by the RD on 3/30/23, showed one employee was not wearing a hair net. During the initial tour of the kitchen on 5/16/23 at 0800 hours, [NAME] 1 and the DSS were observed with facial hair not covered with a hair restraint. During the lunch meal tray line observation on 5/16/23 at 1209 hours, Cooks 1 and 2 were serving lunch with facial hair not covered with a hair restraint. During the lunch meal observation on 5/16/23 at 1225 hours, the DSS was observed inside the kitchen with facial hair not covered with a hair restraint. During the puree meal preparation with [NAME] 1 and the DSS on 5/17/23 at 1026 hours, both [NAME] 1 and the DSS had facial hair not covered with a hair restraint. On 05/17/23 at 1122 hours, an observation of [NAME] 3 was conducted. [NAME] 3's hair was not completely covered with the hair restraint while cooking. On 05/17/23 at 1200 hours, an observation of the lunch meal tray line was conducted. [NAME] 2 with facial hair not covered with a hair restraint was observed serving food. On 5/18/23 at 0804 hours, during a kitchen observation, the DSS and Cooks 1 and 2 were observed with facial hair not covered with a hair restraint. On 5/18/23 at 0830 hours, an observation of the Vietnamese lunch meal preparation was conducted with [NAME] 4. [NAME] 4's hair net did not cover all her hair. On 5/19/23 at 1014 hours, a telephone interview with the RD was conducted. The RD confirmed anyone in the kitchen must wear a hair restraint. The RD added full scalp coverage was preferred. 8. According to the USDA Food Code 2022 Section 4-602.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10/23, showed the minor equipment was not clean, blender and RC with debris. Review of the facility's document titled Sanitation Audit Report completed by the RD on 3/30/23, showed the minor equipment was clean. Review of the facility's document titled Dining- Sanitation Audit completed by the RD on 4/28/23, showed the minor equipment was not clean. The comments section showed cleaning schedule to ensure cleaner equipment. a. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, the following items were observed: -The bowl scraper of the RC was chipped and had a brown residue. -More than five sheet pans had a hard black residue. -Four muffin pans had a hard brown residue. -Four frying pans had a hard black residue. -One stock pot had a black residue. -One dome drying rack had food crumbs and a white residue. The DSS confirmed all of the food preparation equipment should be clean. On 5/17/23 at 1454 hours, an interview was conducted with the RD. The RD was asked how she communicated her concerns from the Sanitation Audit Report (SAR) that she completed monthly. The RD stated she communicated her concerns from the SAR verbally to the DSS. She added the DSS handled most things. When asked how the RD knew her concerns had been resolved, the RD stated she addressed any concerns on the spot or reminded the DSS if she had sanitation concerns. On 5/18/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed food preparation equipment should be clean. The RD was asked if she inspected food preparation equipment as part of the monthly SAR she conducted, the RD stated she performed a general look through of the food preparation equipment in the kitchen. b. On 5/16/23 at 1110 hours, an observation of the facility's ice machine and concurrent interview was conducted with the ESD. The ESD stated the ice machine was just purchased on 3/28/23. The ESD stated the ice machine contract company would clean the internal components of the ice machine twice a year and the ESD would clean the internal components of the ice machine quarterly. The ESD stated he had not completed the first quarterly cleaning of the ice machine yet. The internal components of the ice machine were observed with a black residue on the inside of the evaporator cover. The ESD confirmed the black residue was not normal and should not be there. On 5/17/23 at 1158 hours, an interview was conducted with the Administrator regarding the black residue found on the ice machine evaporator cover. The Administrator stated the ice machine contract company confirmed the black residue was not due to a mechanical issue with the ice machine. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated as part of her SAR, she checked the ice machine cleaning log and filters but did not inspect the inside of the ice machine. 9. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Review of the facility's P&P titled Cleaning Schedules revised 8/31/23, showed the Food and Nutrition Services staff shall maintain the sanitation of the food and nutrition services department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, the kitchen floors, dry storeroom, walk-in refrigerator and chemical closet were observed to be dirty with food debris and sticky with a black residue. The DSS stated the walk-in floor was cleaned one to two times a week. The DSS stated the dry storeroom floor should be mopped nightly and could attract pests. The DSS confirmed the floor in the chemical closet was not clean. The DSS stated the kitchen floors were not deep cleaned, only swept and mopped. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, the ceiling vent in the dish room was observed with a gray fuzzy residue. The DSS confirmed the ceiling vent in the dish room was not clean and stated it was cleaned monthly. In addition the following was observed: - The ceiling fan cover had a brown residue which resembled rust. The ceiling next to the fan cover in the walk-in refrigerator was observed with a gray and black residue. The DSS confirmed the ceiling fan cover and ceiling in the walk-in refrigerator were not clean. - A large fan was observed in the dish room with a gray residue. The DSS confirmed the large fan was not clean. - The shelves used to store food preparation equipment had peeling paint and a brown residue which resembled rust. The DSS acknowledged the above findings and stated all kitchen equipment should be clean. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM cook for the bottom shelves for eight of 14 opportunities. Out of the 14 of opportunities, none was signed off by the DSS for cleaning of the bottom shelves. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM cook for the refrigerator for one of 14 opportunities. Out of the 14 opportunities, zero was signed off by the DSS for cleaning of the refrigerator. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the AM dietary aid for the bottom shelves and floor for zero of 14 opportunities. Out of the 14 opportunities, zero was signed off by the DSS for cleaning of the bottom shelves and floor. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the AM dietary aide for the refrigerators and all shelves for 14 of 14 opportunities. Out of the 14 opportunities, one of 14 opportunities was signed off by the DSS for cleaning of the refrigerator and all shelves. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM dietary aide for the refrigerator shelves, sweeping and moping the floors in the walk-in for two of 14 opportunities. Out of the 14 opportunities, zero of 14 opportunities was signed off by the DSS for cleaning of the refrigerator shelves, sweeping and moping the floor in the walk-in. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM dietary aides for preparation area floors and floor corners for two of 14 opportunities. Out of the 14 opportunities, one of 14 opportunities was signed off by the DSS for cleaning of the preparation area floor and floor corners. Review of the facility's document titled Dietary Cleaning Schedule showed the fan located in the dish room, ceiling vent in the dish washing area, ceiling fan in the walk-in refrigerator, and reach-in freezer were not included in the facility's Dietary Cleaning Schedule. Review of the facility's document titled Sanitation Audit Report (SAR) completed by the RD on 2/10 and 4/28/23, showed the floors, walls, and ceiling were not clean. The SAR completed by the RD on 3/30/23, showed no concerns with the cleanliness of the kitchen floors, walls, or ceilings. On 5/18/23 at 1448 hours, an interview was conducted with the DSS. The DSS was asked how the RD communicated the findings from the SAR. The DSS stated the RD emailed a copy to him. The RD verbally explained the SAR to the DSS, then he would talk to his staff regarding the findings. The DSS acknowledged he did not document when he spoke with his staff regarding the RD's SAR. The DSS was asked if he performed an audit of the kitchen. The DSS stated he did a kitchen walk through but did not document the findings. The DSS was asked how he confirmed the kitchen staff completed the required cleaning. The DSS stated the kitchen staff were assigned cleaning schedules. The DSS acknowledged that often times, he did not have the opportunity to check if the cleaning schedule was completed. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she was not involved with the kitchen cleaning schedules but expected the cleaning schedules to be completed and the kitchen was clean. 10. According to the USDA Food Code 2022, Section 4-602.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. On 5/17/23 at 1047 hours, a large rolling ice chest with soiled wheels designed to be rolled on the ground was observed on a food preparation table. The DSS was asked why a rolling ice chest that was rolled on the ground was stored on a food preparation table. The DSS stated the facility bought ice since the ice machine was not clean and he did not want to store the rolling ice chest on the floor. The DSS acknowledged he had other ice chests that were not the rolling type but did not use them to store the ice. The DSS stated he would remove the rolling ice chest from the food preparation table. 11. Review of the facility's P&P titled Nourishment Refrigerator/Freezer Storage Guide dated 5/23 showed in part, 10. Associate's food should not be stored in resident's refrigerator refrigerator/freezer or other cold storage units where resident food is stored. Review of the facility document titled Sanitation Audit Report completed by the RD on 3/30 and 4/28/23, showed storage of employee food was a concern. During the initial kitchen tour on 5/16/23 at 0800 hours, a concurrent observation and interview with the DSS was conducted. Employee food was observed stored in the kitchen freezer. The DSS verified the finding and stated it should be stored in the employee refrigerator. On 05/19/23 at 1014 hours, a telephone interview with the RD was conducted. The RD stated employees must store their food in the designated employee's refrigerator only.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one of two sampled residents (Resident 1) was complete and accurately documented. * The facility failed to ensure Resident 1's seizure episodes on 12/8/22 were documented. This had the potential for the resident's care needs not being met as their medical information was incomplete and inaccurate. Findings: On 12/21/22 at 1218 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she visited Resident 1 on 12/8/22 around 1930 hours, Resident 1 had a seizure. Family Member 1 stated she was informed by one of the nurses that Resident 1 also had another seizure earlier in the day. Medical record review for Resident 1 was initiated on 12/21/22. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's medical record failed to show documentation of Resident 1's seizure episodes on 12/8/22. On 12/23/22 at 0635 hours, a telephone interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated Resident 1 had a seizure on 12/8/22 at approximately 1930 hours, which lasted about 57 seconds. LVN 1 stated she timed the seizure, made sure Resident 1 was safe, and notified the physician of the resident's seizure episode and verified there was no documentation showing any of Resident 1's seizure episodes that had occurred during her shift on 12/8/22. On 12/23/22 at 0916 hours, a telephone interview and concurrent medical record review was conducted with RN 1. RN 1 stated she was the RN Supervisor on 12/8/22 during the 0700 to 1930 hours shift. RN 1 stated Resident 1's assigned nurse informed her that Resident 1 experienced a seizure that afternoon. RN 1 verified there was no documentation showing any of Resident 1's seizure episodes on 12/8/22, and stated both seizure episodes should have been documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/20/21 at 0919 hours, an observation was conducted of Resident 58 in bed watching television with the call light on the floor and not within reach. On 4/20/21 at 0931 hours, CNA 2 entered the room and spoke to Resident 58. CNA 2 exited Resident 58's room with the call light still on the floor not within reach. On 4/20/21 at 0933 hours, an interview and concurrent observation was conducted with CNA 2. CNA 2 stated Resident 58 used the call light when she needed assistance. CNA 2 acknowledged the call was on the floor and not within the resident's reach. CNA 2 stated the call light should have been placed within reach of Resident 58. Based on observation, interview, and facility P&P review, the facility failed to ensure the call light system was within reach for one of 23 final sampled residents (Resident 18) and one nonsampled resident (Resident 58). This failure had the potential for the residents to not receive timely care and assistance from the staff. Findings: Review of the facility's P&P titled Answering the Call Light dated 10/21 showed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. On 4/20/21 at 0745 and 0830 hours, during the initial tour of the facility, Resident 18 was observed lying in bed with her call light not within reach. Resident 18's call light was observed hanging on the wall behind the head of bed. Medical record review for Resident 18 was initiated on 4/20/21. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's plan of care showed a care plan problem dated 1/21/21, addressing Resident 18's risk for falls and injuries. The approach plan included to keep the call light within Resident 18's reach. On 4/20/21 at 0920 hours, a concurrent observation and interview was conducted with CNA 2. CNA 2 verified Resident 18's call light was hanging on the wall behind the head of the bed. CNA 2 acknowledged Resident 18's call light was out of reach and should be clipped onto the sheet to ensure timely care and assistance was provided when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain a copy of the resident's advance directive in the medical record for one nonsampled resident (Resident 34). This had the potential for the resident's decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 9/23/20, showed when there is an advance directive about a resident's care and treatment, the facility will require that a copy of such directives be included in the medical record. Once the advance directive is received by the facility, it will notify the resident's primary care physician of the resident's advance directive decisions so, if necessary, appropriate orders can be written. Medical record review for Resident 34 was initiated on 4/21/21. Resident 34 was admitted to the facility on [DATE]. Review of Resident 34's MDS dated [DATE], showed Resident 34 had no cognitive impairment. Review of the POLST dated 2/1/21, showed Resident 34 had an advance directive, but it was not available. Review of the Advance Directive Acknowledgment form dated 2/5/21, showed Resident 34 had executed an advance directive, but it was not available at that time. Review of the Social Services Assessment form dated 2/5/21, showed Resident 34 had an advance directive and the document would be dropped off at the facility by a family member. Further review of the medical record did not show a copy of Resident 34's advance directives. On 4/23/21 at 0843 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 34's medical record did not contain a copy of the advance directive. The SSD stated Resident 34 had the capacity to make his own decisions and since a current POLST was in Resident 34's medical record, the follow up on obtaining a copy of the advance directive would not have occurred until the next quarterly social services assessment in May 2021. On 4/23/21 at 1101 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 34's advance directive was not in the medical record. The DON stated it was necessary for the staff to follow up on obtaining a copy of Resident 34's advance directive and to include it in his medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to implement the plan of care to reflect the individual care needs for one of 23 final sampled residents (Resident 79) and two nonsampled residents (Residents 44 and 60). * The facility failed to ensure Resident 79 had bilateral floor mats and foot cradle in place. * The facility failed to ensure Residents 44 and 60 were provided with two-person assist with their ADLs. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents to attain or maintain their highest practicable physical well-being. Findings: 1a. Medical record review for Resident 79 was initiated on 4/20/21. Resident 79 was readmitted to the facility on [DATE]. Review of the History and Physical examination dated 1/22/21, showed Resident 79 had the necrotizing (death of part of the body's soft tissues) toes. Review of Resident 79's plan of care showed a care plan problem dated 3/24/21, addressing Resident 79's pressure ulcers. The approach plan included placing a foot cradle in bed. b. Review of the Interdisciplinary Resident Safety Investigation and Intervention dated 11/19/20, showed Resident 79 had a fall incident. The form showed to continue the use of bilateral floor mats as part of the intervention. Review of Resident 79's plan of care showed a care plan problem revised on 11/23/20, addressing Resident 79's risk for falls. The approach plans included to place bilateral floor mats to both sides of the bed. On 4/22/21 at 0905, 0941, and 1047 hours, Resident 79 was observed lying on his left side, with a pillow under his right arm. There were no foot cradle in place and bilateral floor mats observed on either side of the bed. On 4/22/21 at 1120 hours, an observation, interview, and concurrent medical record review was conducted with RN 6. RN 6 verified the above findings. RN 6 stated Resident 79 should have had the foot cradle in place as a precaution due to the resident's skin issues including diabetic ulcers. RN 6 stated she did not know why Resident 79 did not have the bilateral floor mats in place. 2. Medical record review for Resident 44 was conducted on 4/20/21. Resident 44 was readmitted to the facility on [DATE]. Review of the Resident admission assessment dated [DATE], under Fall Risk Factors, showed Resident 44 was non-ambulatory, had poor safety judgement, and required two person assist for ADLs and mobility. Review of the plan of care showed a care plan problem dated 8/25/20, addressing Resident 44's ADL deficits. The care plan showed Resident 44 required total assistance from two people for bed mobility, dressing, personal hygiene, and bathing. The approach plans included to assist Resident 44 with ADLs to the extent needed. Review of the MDS dated [DATE], showed Resident 44 was totally dependent and required two or more persons for assistance with bed mobility, dressing, and personal hygiene. On 4/21/21 at 0845 hours and 4/22/21 at 0815 hours, CNA 9 was observed bathing and dressing Resident 44 without any assistance. 3. Medical record review for Resident 60 was conducted on 4/20/21. Resident 60 was admitted to the facility on [DATE]. Review of the plan of care showed a care plan problem dated 2/23/21, to address Resident 60's ADL deficits. The care plan showed Resident 60 required total assistance from two people for bed mobility, dressing, personal hygiene, and bathing. The approach plans included to assist Resident 60 with ADLs to the extent needed. Review of the MDS dated [DATE], showed Resident 60 was totally dependent and required two or more persons for assistance with bed mobility, dressing, and personal hygiene. On 4/21/21 at 0900 hours and 4/22/21 at 0826 hours, CNA 9 was observed changing and cleaning Resident 60 without any assistance from other staff. On 4/22/21 at 0842 hours, an interview was conducted with CNA 9. CNA 9 verified he provided ADL care for both Residents 44 and 60 by himself. CNA 9 stated he normally cleaned the residents on his own and would only ask for help if he needed assistance pulling the residents up in bed. CNA 9 stated he was not aware of the residents requiring more than one staff to provide ADL care. On 4/22/21 at 1530 hours, an interview and concurrent medical record review was conducted with RN 6. RN 6 verified the CNAs changed and cleaned the residents on their own. RN 6 verified the residents should be assisted with the appropriate numbers of staff based on the residents' needs to avoid accidents. RN 6 stated most of the staff were busy and did not always have time to help the CNAs during ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure two of 23 final sampled residents (Residents 16 and 79) attained and maintained their highest practicable physical well-being. * The facility failed to ensure the insulin injection sites for Residents 16 and 79 were rotated. This failure posed the risk of damaging or causing tissue injuries due to repeated injection sites. * Resident 79 was administered fludrocortisone acetate (medication used to help control the amount of sodium and fluids in the body) when the resident's SBP (systolic blood pressure, the top number of blood pressure that measures the amount of pressure exerted on the vessels when the heart is contracting) was above the parameter prescribed by the physician. This failure had the potential for Resident 79 to receive unnecessary medication and develop significant side effects. Findings: 1a. Medical record review for Resident 79 was initiated on 4/20/21. Resident 79 was readmitted to the facility on [DATE]. Review of Resident 79's History and Physical examination dated 1/22/21, showed Resident 79's diagnoses included chronic renal failure, hypertension, and renal insufficiency. Review of Resident 79's Order Summary Report showed a physician's order dated 6/1/20, to administer fludrocortisone acetate 0.1 mg via GT every 12 hours for COPD and hold if the SBP was greater than 130 mmHg. Review of Resident 79's Medication Administration Record for April 2021 showed the licensed nurses administered fludrocortisone acetate to Resident 79 even though the resident's SBP was 133 mmHg on 4/18/21 at 2100 hours, and 134 mmHg on 4/21/21 at 0900 hours. Further review of the medical record showed no documented evidence the licensed nurses held the medication as ordered on 4/18/21 at 2100 hours and on 4/21/21 at 0900 hours. In addition, there was no documentation showing the physician was notified the medication was given outside of the parameter. On 4/26/21 at 1355 hours, an interview and concurrent medical record review for Resident 79 was conducted with RN 2. RN 2 reviewed the medical record and verified the above findings. RN 2 verified the medication should have been held because the resident's SBP was greater than 130 mmHg. RN 2 acknowledged there was no documentation the physician was notified. b. Review of the facility's P&P titled Insulin Administration revised October 2010 showed the injection sites should be rotated preferably within the same general area (abdomen, thigh, upper arm). Review of Resident 79's Order Summary Report, showed the physician orders dated 6/1/20, to administer the following: - Humalog (fast acting insulin) subcutaneously (under the skin) every 12 hours as per sliding scale (the dose of insulin based on the resident's blood sugar level). The order showed to rotate the injection sites. - Lantus (long acting insulin) 10 units subcutaneously one time a day. The order also showed to rotate the injection sites. Review of Resident 79's Medication Administration Record for February 2021 showed multiple dates when the licensed nurses administered the insulin injections at the same site. For example, on 2/3/21 at 0600 and 1800 hours, Resident 79 received the Humalog injections at site 2. In addition, on 2/3/21 at 0900 hours, Resident 79 also received the Lantus injection at site 2. 2. Medical record review for Resident 16 was initiated on 4/20/21. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 16's Order Summary Report showed a physician's order dated 1/16/21, to administer Admelog solution (fast acting insulin) subcutaneously every six hours as per the sliding scale. Review of Resident 16's Medication Administration Record for February 2021 showed multiple dates when the licensed nurses administered the insulin injections on the same site. For example, on 2/18/21 at 0600, 1200, and 1800 hours, Resident 16 received the insulin injections at site 10. On 2/21/21 at 0600, 1200, and 1800 hours, Resident 16 received the insulin injections at site 3. On 4/26/21 at 1345 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings and stated the insulin injection sites should have been rotated for Residents 16 and 79.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record for Resident 6 was initiated on 4/20/21. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's MDS dated [DATE], showed Resident 6 was severely cognitively impaired and required physical assistance from two persons for bed mobility. Review of Resident 6's plan of care showed a care plan problem dated 2/18/21, addressing Resident 6's risk for skin breakdown, further skin breakdown, and recurrent skin breakdown with existing deep tissue pressure injury on his left lateral heel. The approach plan included repositioning every two hours. On 4/21/21 at 0748, 0915, 1100, and 1200 hours, Resident 6 was observed lying on his left side with a pillow supporting his back. On 4/21/21 at 0910 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 6 was totally dependent on staff for turning and repositioning. On 4/22/21 at 1535 hours, an interview was conducted with RN 6. RN 6 verified the findings. RN 6 stated the CNA should have repositioned Resident 6 every two hours to prevent pressure injuries. RN 6 stated the CNAs were busy with their assigned tasks, so they might have missed repositioning the residents. 3. Medical record for Resident 53 was initiated on 4/20/21. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's MDS dated [DATE], showed Resident 53 was totally dependent and required physical assistance from two persons for bed mobility. Review of Resident 53's plan of care showed a care plan problem dated 4/12/21, addressing Resident 53's risk for skin breakdown and further skin breakdown. The care plan problem was updated on 4/13/21, to address Resident 53's skin condition of unstageable pressure injury on the Sacrococcygeal area. The approach plans included repositioning the resident every two hours. Further review of Resident 53's plan of care showed a care plan problem dated 4/14/21, addressing Resident 53's risk for sensory deprivation. The approach plan included repositioning and checking the resident at least every two hours and as needed. On 4/22/21 at 0851, 1025, 1100, and 1200 hours, Resident 53 was observed lying in bed on his left side. On 4/22/21 at 1020 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 53 was totally dependent on staff for turning and repositioning. On 4/22/21 at 1535 hours, an interview was conducted with RN 6. RN 6 verified the findings. RN 6 stated the CNA should have repositioned Resident 53 every two hours to prevent pressure injuries. RN 6 stated the CNAs were busy with their assigned tasks so they might have missed repositioning the residents. 4. Medical record for Resident 77 was initiated on 4/20/21. Resident 77 was readmitted to the facility on [DATE]. Review of Resident 77's History and Physical examination dated 3/15/21, showed Resident 77 was in a persistent vegetative state. Review of Resident 77's MDS dated [DATE], showed Resident 77 was totally dependent and required physical assistance from two persons for bed mobility. Review of Resident 77's plan of care showed a care plan problem dated 3/12/21, addressing Resident 53's risk for skin breakdown and further skin breakdown. The care plan problem was updated on 3/13/21, to address Resident 77's skin condition of pressure injuries on his left and right upper buttocks. The approach plan included repositioning the resident every two hours. On 4/22/21 at 0901, 1000, and 1200 hours, Resident 77 was observed lying in bed on her left side. On 4/22/21 at 1430 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 77 was totally dependent on staff for turning and repositioning. CNA 8 stated she repositioned Resident 77 after a bed bath or during incontinence care. On 4/22/21 at 1535 hours, an interview was conducted with RN 6. RN 6 verified the findings. RN 6 stated the CNA should have repositioned Resident 77 every two hours to prevent pressure injuries. RN 6 stated the CNAs were busy with their assigned tasks so they might have missed repositioning the residents. Based on observation, interview, and medical record review, the facility failed to ensure four of 23 final sampled residents (Residents 6, 53, 77, and 79) received appropriate care and treatment to prevent and promote the healing of pressure injuries. The facility failed to turn and reposition Residents 6, 53, 77, and 79 every two hours to meet their care needs. This failure had the potential to worsen or prevent the healing of the residents' pressure injuries. Findings: In 2016, the NPUAP (National Pressure Ulcer Advisory Panel) defined a pressure injury (same as ulcer) as a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The NPUAP also defined Stage 3 pressure injury as full-thickness skin loss in which fat tissue is visible in the ulcer; slough (yellow, tan or dead tissue) and/or eschar (a dry dark dead tissue); may be visible. Stage 4 pressure injury is defined as a full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, ligament, or bone in the ulcer; slough and/or eschar may be visible. An unstageable pressure injury is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; if slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Review of the facility's P&P titled Repositioning (undated), showed to reposition residents every two hours utilizing the side-back-side rotation. Residents with pressure ulcers will be turned in accordance with the plan of care. 1. Medical record review for Resident 79 was initiated on 4/20/21. Resident 79 was readmitted to the facility on [DATE]. Review of Resident 79's plan of care showed the following: - A care plan problem dated 11/16/19, addressing Resident 79's risk for skin breakdown, further skin breakdown, and recurrent skin breakdown. The approach plans included repositioning every two hours. - A care plan problem dated 11/18/19, addressing Resident 79's risk for sensory deprivation. The approach plans included repositioning and checking at least every two hours and as needed. Review of the MDS dated [DATE], showed Resident 79 required total assistance from two or more persons for bed mobility. Review of Resident 79's Weekly Wound assessment dated [DATE], showed Resident 79 had the Stage 4 sacrococcyx (tail bone) pressure injury. On 4/22/21 at 0905, 0941, 1047, 1140, 1149, and 1200 hours, Resident 79 was observed lying on his left side with a pillow under his right arm. On 4/22/21 at 1355 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 79 was unable to turn in bed on his own and was totally dependent on staff for turning and repositioning. When asked who was responsible for ensuring the residents were turned and repositioned, CNA 7 stated the CNAs and licensed nurses were responsible. CNA 7 stated the residents were supposed to be turned and repositioned every two hours; however, the CNAs did not usually finish cleaning and changing all of their assigned residents until around 1100 hours, and did not have time to go back and reposition the residents in between. CNA 7 verified Resident 79 was not turned and repositioned since he was cleaned in the morning. On 4/22/21 at 1415 hours, an interview was conducted with RN 7. RN 7 stated Resident 79 was unable to turn and reposition in bed on his own and required assistance from staff. Resident 79 had the sacrococcyx pressure injury and needed to be turned and repositioned every two hours to prevent worsening of the wound. When asked who was responsible for ensuring Resident 79 was turned and repositioned every two hours, RN 7 stated the CNAs were responsible and the licensed nurses would assist the CNAs if needed. RN 7 verified she did not assist in turning and repositioning Resident 79 in the morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the restorative device was applied to one of 23 final sampled residents (Resident 77). The facility failed to apply the splint on Resident 77's left arm. This posed the risk for Resident 77's left wrist and hand contracture to worsen. Findings: Medical record for Resident 77 was initiated on 4/21/21, Resident 77 was readmitted to the facility on [DATE]. Review of Resident 77's History and Physical examination dated 3/15/21, showed Resident 77 was in a persistent vegetative state. Review of Resident 77's MDS dated [DATE], showed Resident 77 was totally dependent on the staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS showed Resident 77 had bilateral impairment to the upper and lower extremities. Review of Resident 77's plan of care showed a care plan problem dated 3/26/21, addressing an existing contracture. The approaches included to apply the left wrist and hand splint for one hour per day, or as tolerated. Review of Resident 77's Medication Review Report showed a physician's order dated 3/26/21, for the restorative nursing program to apply the WHFO (wrist hand finger orthosis) splint to the resident every day shift for one hour five times a week or as tolerated. On 4/21/21 at 1615 hours, an observation was conducted in Resident 77's room. Resident 77 was observed lying on her left side without the splint on the left extremity. On 4/22/21 at 0901, 1000, 1200, and 1415 hours, Resident 77 was observed lying in bed without the splint on the left extremity. Review of the Restorative Administration Record dated April 2021 failed to show documentation Resident 77's WHFO splint for the left extremity was applied every day as ordered by the physician. On 4/22/21 at 1430 hours, an interview and concurrent medical record review was conducted with CNA 8. CNA 8 stated Resident 77 was totally dependent and on the restorative nursing program. CNA 8 stated Resident 77's left arm was contracted, but the resident did not need a splint. Resident 77's Restorative Administration Record for the month of April was reviewed with CNA 8. CNA 8 verified there was no documentation to show the WHFO splint was applied to Resident 77. CNA 8 stated the WHFO splint was not applied to Resident 77 for the month of April. On 4/23/21 at 0904 hours, an interview was conducted with the Physical Therapist. The Physical Therapist stated Resident 77 was on the restorative nursing program and the CNAs were trained to apply the splint. The Physical Therapist stated the WHFO splint for Resident 77 should have been applied to her left extremity as ordered to prevent deformity of her left extremity. The Physical Therapist stated there was no restriction preventing Resident 77 to have the WHFO splint applied to her left extremity. On 4/23/21 at 1000 hours, an interview and concurrent medical record review was conducted with RN 6. RN 6 stated the CNA should have applied Resident 77's WHFO splint as ordered. RN 6 verified Resident 77's medical record failed to show any documentation as to why the splint was not applied. RN 6 stated the licensed nurses should have checked on the task to ensure it was done to prevent Resident 77 from developing further contractures or deformity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/20/21 at 0730 hours, during the initial tour of the facility, a black box fan was observed plugged into the wall and placed on top of multiple towels on the wheelchair seat in Resident 22's room. Resident 22 stated she had the fan because her room was warm in the afternoon. On 4/20/21 at 1004 hours, a concurrent observation and interview was conducted with CNA 5. CNA 5 verified the black box fan was placed on top of the linens on the wheelchair seat and was moving when turned on. CNA 5 stated she had placed the black box fan on the wheelchair seat because it needed to be elevated to reach Resident 22. CNA 5 stated Resident 22 wanted the room to be cool most specially in the afternoon. On 4/20/21 at 1006 hours, an interview and concurrent observation was conducted with the Maintenance Director. The Maintenance Director verified the box fan in Resident 22's room should not be placed on top of the linens on the wheelchair. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safety measures were provided to prevent accident hazards for two of 23 final sampled residents (Residents 53 and 310) and one nonsampled resident (Resident 22). * The facility failed to implement the fall intervention for Resident 53 to be provided with two-person assistance for bed mobility after Resident 53 had sustained a fall by slipping out of bed during ADL care. * The facility failed to ensure Resident 310 was thoroughly assessed to determine if she was able to safely keep her smoking materials and ensure an environment free was from potential accident hazards. In addition, there were no individualized care plan problems developed to address safe storage and use of the smoking materials. * The facility failed to ensure a black box fan in Resident 22's room was adequately secured to prevent accident hazards. Findings: 1. Medical record review for Resident 53 was initiated on 4/20/21. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's MDS dated [DATE], showed Resident 53 required extensive assistance with two persons' physical assistance for bed mobility. Review of the Interdisciplinary Resident Safety Investigation and Intervention dated 4/17/21, showed on 4/17/21 at 1010 hours, Resident 53 slipped from the bed during care provided by a CNA. The documentation further showed Resident 53 was lying on a low air loss mattress that was described as slippery. On 4/22/21 at 1010 hours, an observation was conducted of Resident 53's. CNA 7 was observed providing incontinence care to Resident 53 by herself. Resident 53 needed to be turned from side to side in order to be changed. On 4/22/21 at 1025 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 53 was able to move in bed and sometimes he would become resistive to the care by pushing the staff away. On 4/22/21 at 1535 hours, an interview was conducted with RN 6. RN 6 verified the above findings and stated Resident 53 required two-persons physical assistance for bed mobility to prevent falls. On 4/27/21 at 0840 hours, an interview was conducted with the DON. The DON stated there was sufficient staffing for the CNAs to ask for help. The DON verified CNA 7 should have asked for help when providing care to Resident 53. 2. Review of the facility's P&P titled Smoking revised 8/2017 showed the resident will be assessed by the IDT initially when they verbalize the desire/interest to smoke. The assessment is to determine if the resident is able to smoke safely and not harm themselves or others. The resident's care plan will be updated to address smoking and to include smoking activity and any restrictions, special equipment or instructions required, if any. Residents will not be permitted to keep smoking materials in their possessions unless the interdisciplinary team determines they can manage them safely. Medical record review for Resident 310 was initiated on 4/20/21. Resident 310 was admitted on [DATE]. Review of Resident 310's History and Physical examination dated 4/14/21, showed Resident 310 had the capacity to understand and make decisions. Review of Resident 310's physician's orders dated 4/12/21 at 2029 hours, showed Resident 310 was able to smoke independently in the designated smoking patio. Review of Resident 310's Resident Care Conference Review dated 4/19/21, failed to show Resident 310 was assessed to determine if Resident 310 was able to manage her smoking materials safely. Review of Resident 310's IDT Smoking assessment dated [DATE], showed the resident was able to smoke independently and informed of the smoking policy, the designated smoking areas and smoking schedule, and the risks and benefits of smoking. Review of Resident 310's plan of care showed a care plan dated 4/12/21, addressing Resident 310's high risk for injury related to smoking. The approach interventions included visual checks on the resident's whereabouts daily, provide supervision when the resident is smoking, monitor the resident's compliance with the facility's smoking policy, continue to remind the resident of safety precautions when smoking, and encourage activity participation. On 4/20/21 at 1042 hours, an interview was conducted with Resident 310. Resident 310 stated she was able to smoke whenever she wanted to, and stated sometimes she kept her own smoking materials, and sometimes the facility staff took it from her. On 4/23/21 at 0747 hours, Resident 310 was observed smoking with another resident in the designated smoking area. On 4/23/21 at 0810 hours, Resident 310 was observed in the hallway wheeling herself independently in the hallway to her room. Resident 310 did not stop to return the smoking materials to the charge nurse. On 4/23/21 at 0825 hours, an interview was conducted with LVN 3. LVN 3 verified Resident 310's smoking supplies were with Resident 310. LVN 3 stated Resident 310 had been wanting to keep her smoking materials with her and they were looking for a better option to keep her smoking supplies safe. On 4/23/2021 at 0832 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 310's Smoking Assessment, Resident Care Conference Review, and smoking care plans failed to show Resident 310 was assessed to determine if she was able to manage and keep her smoking materials safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services for the use of GT for one of 23 final sampled residents (Resident 15). * The facility failed to dispose the outdated tube feeding bag and administration kit for Resident 15. This failure posed a risk for complications related to enteral feedings. Findings: On 4/20/21 at 0950 hours, during the initial tour of the facility, a bag of Isosource formula (enteral nutrition) with a tubing was observed connecting to the enteral feeding pump next to Resident 15's bed. Resident 15's enteral administration tubing was tied in a knot and left exposed to air. Resident 15's Isosource formula and tubing were dated 4/14/21. Medical record review for Resident 15 was initiated on 4/20/21. Resident 15 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 15 needed extensive assistance with her ADL care. Resident 15 was on tube feeding. Review of Resident 15's Order Summary Report showed a physician's order dated 1/19/21, for Isosource enteral feeding via JT at 60 ml per hour to start at 1600 hours until 1100 hours or until 1,200 ml infused every shift. Review of the Medication Administration Record for April 2021 showed Resident 15 was administered Isosource at 60 ml per hour starting at 1600 hours from 4/14 to 4/18/21, and was withheld starting 4/19/21. Review of the manufacturer's Directions for Use for Isosource 1.5 cal (feeding formula), showed maximum use of 48 hours after connection when proper technique is followed. Review of the manufacturer's directions for the enteral administration kit (as displayed on the packaging), showed to discard the administration set and transition connector when delivery was complete within a maximum of 48 hours. On 4/20/21 at 1032 hours, an interview and concurrent observation was conducted with the IP. The IP verified the used Isosource formula and tubing were connected to the enteral food pump next to Resident 15's bed were dated 4/14/21. The IP acknowledged the formula was opened six days ago and should have been discarded immediately when the administration was completed. When asked how long can the Isosource formula be used once opened, the IP stated she did not know. The IP stated she did not know how often the administration tubing had to be changed. On 4/27/21 at 1335 hours, an interview was conducted with the DON. The DON verified the findings and stated the Isosource formula and tubing should have been discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary services for respiratory care needs were provided for one of 23 final sampled residents (Resident 20) and one nonsampled resident (Resident 22). * The facility failed to obtain a physician's order for continuous oxygen therapy for Resident 22. Resident 22's continuous oxygen use was not documented in her medical record. * The facility failed to label and date the nasal cannula (thin flexible tube with small prongs inserted into the nostrils) used for oxygen administration for Residents 20 and 22. These failures posed the risk for complications related to respiratory treatment. Findings: According to the facility's P&P titled Oxygen Therapy revised 7/30/18, under the Policy section, showed oxygen will be administered as ordered by the physician. Oxygen is a drug and should be administered only by the licensed nurse/respiratory therapist. Under the Documentation section, showed the following information should be recorded: date and time of oxygen therapy, oxygen flow rate or oxygen percentage, and device. According to the facility's P&P titled Oxygen Therapy revised 7/30/18, under the Infection Control Protocol and Safety section, the oxygen tubing should be changed according to the manufacturer's recommendations. 1a. Review of Resident 22's medical record was initiated on 4/20/21. Resident 22 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 22 was cognitively intact. Resident 22 needed extensive assistance with her ADL's. Resident 22 was on oxygen therapy. Review of Resident 22's plan of care showed a care plan problem 1/29/21, addressing Resident 22's chronic respiratory failure. The approach interventions included to administer oxygen inhalation to Resident 22 as ordered. Review of Resident 22's Order Summary Report showed a physician's order dated 1/26/21, for oxygen at two to three liters per minute via nasal cannula as needed for shortness of breath or low oxygen saturation level. Review of the Medication Administration Record for April 2021 did not show any documentation that Resident 22 received continuous oxygen. On 4/20/21 at 0730 hours, Resident 22 was observed receiving oxygen via a nasal cannula at five liters per minute. On 4/21/21 at 1516 hours, Resident 22 was observed receiving oxygen via a nasal cannula. On 4/23/21 at 1407 hours, Resident 22 was observed receiving oxygen via a nasal cannula. On 4/27/21 at 1105 hours, an interview was conducted with Resident 22. Resident 22 was observed receiving oxygen via a nasal cannula at four liters per minute. Resident 22 stated she received oxygen every day, all day and night. On 4/27/21 at 1115 hours, an interview was conducted with CNA 5. CNA 5 stated she has been taking care of Resident 22 for a while and had observed the resident using her oxygen at all times. CNA 5 stated Resident 22 needed extensive assistance with her ADLs. CNA 5 stated Resident 22 tired easily during ADL care and had to be on oxygen at all times. On 4/27/21 at 1137 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she was not aware of Resident 22 receiving oxygen therapy continuously. LVN 2 acknowledged Resident 22's physician's order for oxygen therapy was for as needed. LVN 2 verified there was no documentation in the Medication Administration Record showing Resident 20 received oxygen continuously. On 4/27/21 at 1335 hours, an interview was conducted with the DON. The DON stated Resident 22 had been on continuous oxygen therapy. The DON acknowledged there was no physician's order for Resident 22's continuous oxygen use. The DON stated she was not aware Resident 22's oxygen order was only as needed. When asked about the documentation of Resident 22's oxygen use in the medical record, the DON stated it had to be recorded in the Medication Administration Record. b. On 4/20/21 at 0730 hours, during the initial tour of the facility, Resident 22 was observed receiving oxygen therapy via nasal cannula. The nasal cannula was not dated. 2. On 4/20/21 at 0725 hours, during the initial tour of the facility, Resident 20 was observed receiving oxygen therapy via a nasal cannula. Resident 20's nasal cannula was not dated. Review of Resident 20's medical record was initiated on 4/20/21. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Order Summary Report showed a physician's order dated 1/25/21, for continuous oxygen at two to three liters per minute via nasal cannula for asthma. On 4/20/21 at 1027 hours, an interview and concurrent observation was conducted with the IP. The IP stated the nasal cannula should be dated and changed weekly. The IP verified Residents 20 and 22's nasal cannula were not dated. On 4/27/21 at 1335 hours, an interview was conducted with the DON. When asked when the oxygen tubing were changed for the residents, the DON stated all oxygen had to be changed on Mondays. The DON verified the oxygen tubing had to be labeled to ensure it was changed weekly in order prevent complications from oxygen therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to one of 23 final sampled residents (Resident 84) and one nonsampled resident (Resident 3). * The facility failed to clarify with the physician when there were two different orders for pain scale for Residents 3 and 84. This failure posed the risk of the residents' pain not being managed appropriately. Findings: Review of the facility's P&P titled Pain Management revised October 2017, under the Procedure section, showed all pain scales will be converted to a 0-10 numeric scale for the purpose of documenting pain. Under the Management section, the licensed nurse will administer pharmacological interventions as ordered . based on the highest pain level that occurred on that shift. 1. Review of Resident 3's medical record was initiated on 4/21/21. Resident 3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 3 had severe cognitive impairment. Review of the medical record showed the facility utilized two different pain rating scales in assessing Resident 3's level of pain. Review of the Order Summary Report showed a physician's order dated 1/6/21, to monitor the resident's pain intensity before, during, and after the treatment with the following pain scale: 0 = no pain, 1 to 4 = mild, 5 to 7 = moderate, 8 to 9 = severe, and 10 = very severe, every 24 hours as needed. Another order dated 1/5/21, to administer hydrocodone/acetaminophen (narcotic pain medication) 10-325 mg one tablet every four hours as needed for severe pain (7-10), and administer hydrocodone/acetaminophen tablet 5-325 mg one tablet for moderate pain (5-6). Resident 3's pain scale rating for moderate and severe pain used for the as needed order for hydrocodone was different from the pain rating scale ordered by the physician on 1/6/21. 2. Review of Resident 84's medical record was initiated on 4/21/21. Resident 84 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 84 had severe cognitive impairment. Review of the medical record showed the facility utilized two different pain rating scales to assess Resident 84's level of pain. Review of Resident 84's Order Summary Report showed a physician's order dated 3/14/21, to monitor the resident's pain intensity before, during, and after the treatment with the following pain scale: 0 = no pain, 1 to 4 = mild, 5 to 7 = moderate, 8 to 9 = severe, and 10 = very severe. Another physician's order dated 3/12/21, showed to administer hydrocodone/acetaminophen 10-325 mg one tablet every four hours as needed for severe pain (7 to 10). Resident 84's pain scale rating for severe pain used for the as needed hydrocodone was different from the pain rating scale ordered by the physician on 3/14/21. On 4/26/21 at 1328 hours, a concurrent interview and medical record review was conducted with RN 2 for Residents 3 and 84. When asked about the two different pain rating scales used for Residents 3 and 84, RN 2 stated one pain scale was used for the residents' medication while another pain scale was used for skin treatment. RN 2 stated the use of two sets of pain scale were confusing and may lead to poor pain management for Residents 3 and 84. On 4/27/21 at 0945 hours, an interview was conducted with the DON. The DON verified the above findings and stated the pain scales had to match to avoid confusion on which pain medication to administer and may lead to poor pain management for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility's P&P titled Pain Management revised October 2017, under the Policy section, showed it is the policy of the facility to alleviate the residents' pain to a level acceptable to the resident. Under the Management section, the licensed nurse will administer pharmacological interventions as ordered. Review of Resident 20's medical record was initiated on 4/20/21. Resident 20 was admitted to the facility on [DATE]. Review of the physician's History and Physical examination dated 1/26/21, showed Resident 20 had chronic pain. Review of the MDS dated [DATE], showed Resident 20 was cognitively intact and had occasional episodes of moderate pain. Review of Resident 20's plan of care showed a care plan problem dated 1/25/21, addressing Resident 20's chronic pain. The interventions included to provide medication as ordered. Review of Resident 20's Order Summary Report showed an order dated 3/22/21, to administer oxycodone-acetaminophen (narcotic pain medication) 10-325 mg one tablet every 12 hours for moderate to severe pain at 0600 and 1800 hours. Another physician's order dated 1/25/21, showed to administer oxycodone-acetaminophen 5-325 mg every 6 hours PRN (as needed) for moderate to severe pain. Review of the Medication Administration Record for April 2021 showed Resident 20 received the oxycodone-acetaminophen 5-325 mg on 4/20/21 at 0815 hours, and the oxycodone-acetaminophen 10-325 mg scheduled for 0900 hours was not administered on 4/20/21. In addition, Resident 20's oxycodone-acetaminophen 10-325 mg one tablet every 12 hours prescribed to be given 0600 and 1800 hours, were administered at 0900 and 2100 hours. On 4/26/21 at 1115 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she administered the PRN dose of oxycodone-acetaminophen 5-325 mg to Resident 20 on 4/20/21 at 0815 hours, and held the oxycodone-acetaminophen 10-325 mg scheduled at 0900 hours due to the medication being unavailable. LVN 2 stated the C-II Continuation Letter for oxycodone-acetaminophen 10-325 mg for Resident 20 had not been signed by the physician; therefore, the medication was not available. LVN 2 acknowledged there was no physician's order to administer oxycodone 5-325 mg to substitute oxycodone 10-325 mg. On 4/27/21 at 0951 hours, an interview and concurrent medical record review was conducted with the DON. When asked about the process in managing Resident 20's oxycodone-acetaminophen 10-325 mg tablets, the DON stated the licensed staff had to order for a refill of Resident 20's oxycodone-acetaminophen tablets at least five days prior to the medications completely running out. The DON stated the licensed nurses had to transmit the C-II Continuation letter to the pharmacy for the physician's refill order. The DON stated it was the responsibility of the licensed nurses to follow up Resident 20's oxycodone-acetaminophen medication with the pharmacy to ensure the tablets was always available. The DON acknowledged Resident 20 needed the oxycodone-acetaminophen medication to address her chronic pain problems. When asked about the substitution of the as needed oxycodone-acetaminophen 5-325 mg on 4/20/21 at 0815 hours, instead of the oxycodone-acetaminophen 10-325 mg scheduled at 0900 hours, the DON stated the scheduled oxycodone-acetaminophen should have been given. The DON verified the routine oxycodone-acetaminophen 10-325 mg and the oxycodone-acetaminophen 5-325 mg were two different medication since they did not have the same dose. The DON acknowledged there was no physician's order to substitute Resident 20's routine oxycodone-acetaminophen 10-325 mg medication with the prn oxycodone-acetaminophen 5-325 mg tablet. When asked why Resident 20's oxycodone-acetaminophen 10-325 mg ordered for 0600 and 1800 hours was changed to 0900 and 2100 hours, the DON stated it should not have been changed without a physician's order. Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to develop and implement the procedures for the provision of pharmaceutical services to meet the needs of the residents as evidenced by: * The facility failed to ensure the controlled medications for Residents 3, 56, and 84 were accurately documented and reconciled in the Medication Administration Record. This posed the risk for diversion of controlled medications and medication administration errors. * The facility failed to replace the facility's emergency kit within 72 hours of opening as per the facility's P&P. This deficient practice posed the potential of an unavailable emergency medication supply. * The facility failed to administer Resident 20's scheduled pain medication as ordered by the physician due to the medication being not available. In addition, Resident 20's prescribed pain medication administration time was changed without clarifying the order with the physician. Findings: Review of the facility's P&P titled Pharmacy Services for Nursing Facilities Preparation and General Guidelines dated 10/2019 showed the individual who administers the medication dose shall record the administration on the resident's Medication Administration Record (MAR) immediately after the medication is given. Entering information on the accountability record does not replace recording medication administration on the MAR. 1. Review of Resident 3's medical records was initiated on 4/21/21. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed a physician's order dated 1/5/21, to administer hydrocodone/acetaminophen (narcotic pain medication) 10-325 mg tablet one tablet every four hours as needed for severe pain level of 7 to 10 (on a pain scale of 0 to 10 with 0 = no pain to 10 = severe pain), and/or to administer hydrocodone/acetaminophen 5-325 mg one tablet for moderate pain level of 5 to 6. Review of the Resident 510's Controlled Medication Count Sheets for hydrocodone/acetaminophen 5-325 mg and hydrocodone/acetaminophen 10-325 mg showed the following: - On 4/8 and 4/15/21, two doses of hydrocodone 5-325 mg tablets were removed at 0200 and 0600 hours. However, these doses were not documented in Resident 3's Medication Administration Record and Pain Flow Assessment Sheet. - A total of 27 doses of hydrocodone/acetaminophen 10 mg-325 mg tablets were removed from 3/18 to 4/19/21, as follows: - 3/18/21 at 1900 hours; - 3/19/21 at 0600 hours; - 3/20/21 at 2055 hours; - 3/21/21 at 0515 and 2110 hours; - 3/22/21 at 0540 hours; - 3/24/21 at 2105 hours; - 3/25/21 at 0510 and 2030 hours; - 3/29/21 at 0550 hours; - 4/1/21 at 2145 hours; - 4/2/21 at 0605 hours; - 4/3/21 at 2030 hours; - 4/4/21 at 0555 and 2200 hours; - 4/5/21 at 0605 hours; - 4/10/21 at 2215 hours; - 4/11/21 at 0515, 1800, and 2230 hours; - 4/12/21 at 0550 hours; - 4/15/21 at 2145 hours; - 4/16/21 at 0510 hours; - 4/17/21 at 2015 hours; - 4/18/21 at 0600 and 2200 hours; and - 4/19/21 at 0500 hours. However, only two of 27 doses were documented in Resident 3's Medication Administration Record and Pain Assessment Flow Sheet. The Controlled Medication Count Sheet showed 25 of the 27 tablets of hydrocodone/acetaminophen 10-325 mg tablets removed from Resident 3's medication bubble pack (a card where medications are placed in individual clear sealed bubbles) were not accounted for or recorded in the Medication Administration Record and Pain Assessment Flow Sheet. On 4/21/21 at 0835 hours, a concurrent observation and interview was conducted with RNs 2 and 3. RNs 2 and 3 verified no doses were documented as administered in the Medication Administration Record for hydrocodone/acetaminophen 5-325 mg tablets. In addition, RNs 2 and 3 verified only two of 27 doses of hydrocodone/acetaminophen 10-325 mg tablets were documented as administered to Resident 3 in the Medication Administration Record. On 4/21/21 at 1000 hours, the DON and Administrator were shown the documents by RN 2. The DON and Administrator verified the findings and stated this was not an acceptable practice. On 4/21/21 at 1608 hours, RN 8 verified the missing entries and acknowledged fault for most of the missing entries for Resident 3. RN 8 stated he understood the gravity of not documenting the narcotics, because if it was not documented, then it was not given. 2. Review of Resident 56's medical records was initiated on 4/21/21. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's Order Summary Report showed two physician's orders dated 4/2/21, as follows: - to administer one tablet of oxycodone extended release (narcotic pain medication) 30 mg every 12 hours for pain management, and - to administer one tablet of oxycodone immediate release 30 mg every four hours as needed for severe pain. Review of the Resident 56's Controlled Medication Count Sheet for Oxycontin continuous release (brand name for oxycodone) 30 mg showed the following dated: - 4/20/21, two doses of Oxycontin 30 mg tablets (0900 hours and 2100 hours) were documented as administered in Resident 56's Medication Administration Record. However, only one dose was documented as removed from Resident 56's medication bubble packs. - From 4/17 to 4/21/21, a total of 22 doses of oxycodone were removed from the medication bubble pack as follows: - on 4/17/21 at 0000, 0600, 1200, and 1700 hours; - on 4/18/21 at 0000, 0400, 1047, and 1615 hours; - on 4/19/21 at 0000, 0400, 0800, 1445, 1845, and 2245 hours - on 4/20/21 at 0300, 0800, 1300, 1800, and 2200 hours - on 4/21/21 at 0200, 0600, and 1100 hours; However, only 13 of 22 doses were documented as administered in Resident 56's Medication Administration Record and Pain Assessment Flow Sheet. On 4/21/21 at 1629 hours, a concurrent observation and interview was conducted with LVN 3 and RN 1. LVN 3 and RN 1 verified 9 of 22 oxycodone doses removed from medication bubble pack were not documented as administered in Resident 56's Medication Administration Record. LVN 3 and RN 1 also verified only one dose on 4/20/21, was documented as removed from the resident's medication bubble pack. When asked about the oxycodone tablets not documented in the Medication Administration Record, LVN 3 and RN 1 stated Resident 56 was not appropriately assessed for pain. LVN 3 and RN 1 stated they were unsure why multiple Oxycodone doses were not documented in the Medication Administration Record, or why the oxycontin was documented as administered twice, when the Controlled Medication Count Sheet only showed a single dose was removed. LVN 3 and RN 1 acknowledged these narcotic medications should have been documented properly because if it was not documented, then it was not given. On 4/21/21 at 1645 hours, the Administrator was made aware and acknowledged the above findings. 3. Review of Resident 84's medical record was initiated on 4/21/21. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's Order Summary Report showed a physician's order dated 3/12/21, for hydrocodone/acetaminophen 5-325 mg tablet one tablet every four hours as needed for severe pain. Review of the Resident 84's Controlled Medication Count Sheet for hydrocodone/acetaminophen 5-325 mg tablets showed from 3/14/21 to 4/19/21, a total of 38 doses of hydrocodone/acetaminophen 5-325 mg tablets were removed from Resident 84's medication bubble pack. However, only seven doses were documented as administered in Resident 84's Medication Administration Record and Pain Flow Assessment Sheet. On 4/21/21 at 0835 hours, a concurrent observation and interview was conducted with RNs 2 and 3. RNs 2 and 3 verified the Medication Administration Record was missing multiple entries. RNs 2 and 3 verified only seven of 38 doses were documented in the Medication Administration Record for hydrocodone/APAP 5-325 mg tablets. When asked about the hydrocodone tablets not documented in the Medication Administration Record, RN 2 stated Resident 84 was not correctly assessed for pain and the narcotics were not properly documented in the Medication Administration Record. RNs 2 and 3 stated the Controlled Medication Count Sheet and Medication Administration Record must match per the facility's P&P. On 4/21/21 at 1000 hours, the DON and Administrator were shown the documents by RN 2. The DON and Administrator verified the above findings and stated this was not acceptable practice. On 4/21/21 at 1608 hours, an interview was conducted with RN 8. RN 8 verified the missing entries and acknowledged fault for most of the missing entries for Resident 84. RN 8 stated he understood the gravity of not documenting the narcotics, because if it was not documented, then it was not given. 4. Review of the facility's P&P titled Emergency Pharmacy Service and Emergency Kits dated 2/13 showed the e-kit will be replaced within 72 hours of opening or next scheduled delivery, or as required by state regulation. On 4/20/21 at 1141 hours, a concurrent interview and inspection of Medication Room B was conducted with LVN 1. An emergency kit labeled PO (by mouth) had an open date of 3/27/21. The emergency kit was not replaced since it was opened on 3/27/21. LVN 1 verified the findings. LVN 1 stated the pharmacy should be contacted so they could deliver a new emergency kit to replace the one that was opened. LVN 1 stated she did not know if the pharmacy had been contacted regarding this opened emergency kit. On 4/20/21 at 1540 hours, LVN 1 verified once the emergency kit was opened, the pharmacy must be contacted for a replacement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of six unnecessary medication sampled residents (Residents 41 and 23) were not receiving unnecessary medications. * The facility failed to ensure the behavior manifestation and adverse side effects were monitored for Resident 41 related to the use of lorazepam (antianxiety medication). * The facility failed to ensure the adverse side effects were monitored for Resident 23 related to the use of citalopram (antidepressant medication). These failures had the potential for these residents to have adverse complications from their medications. Findings: Review of the facility's P&P titled General Guidelines for the Use of Psychoactive Medications revised 10/17 showed the facility staff should document episodes of behavior, the impact of the medication on behavior and the presence or absence of side effects for residents on psychoactive medications. Unnecessary drugs include any drugs used without adequate monitoring and any drugs without adequate indications for its use. Justification for the use of such drugs must include documentation in the clinical record that the resident is being monitored for adverse complications. 1. Medical record review for Resident 41 was initiated on 4/22/21. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's physician's order dated 4/16/21, showed to administer lorazepam 0.5 mg tablet by mouth every six hours as needed for anxiety until 4/30/21. Review of the Medication Administration Record for April 2021 showed the lorazepam medication was administered to Resident 41 six times from 4/16 to 4/21/21. However, there was no documented evidence of monitoring for the manifestations of anxiety to justify the use of lorazepam, nor was there monitoring for the adverse side effects of lorazepam on the Medication Administration Record from 4/16 to 4/21/21. Review of the Medication Review Report for April 2021 showed the previous order dated 3/29/21, for lorazepam tablet 0.5 mg by mouth every four hours as needed for anxiety manifested by agitation for 14 days. However, the manifested by was not included in the current order dated 4/16/21. On 4/22/21 at 1100 hours, a concurrent interview and medical record review was conducted with LVN 8. LVN 8 verified there was no documentation of behavior monitoring and adverse side effects monitoring. LVN 8 acknowledged there should have been monitoring for both behavior and adverse side effects while Resident 41 was administered the lorazepam medication. On 4/22/21 at 1115 hours, the DON acknowledged there was no monitoring for the behavior and adverse side effects of lorazepam for Resident 41. The DON verified there should be monitoring for the behavior and side effects of lorazepam. The DON stated that the monitoring should be documented in the Medication Administration Record, and the physician's order needed to be clarified. 2. Medical record review for Resident 23 was initiated on 4/22/21. Resident 23 was admitted to the facility on [DATE]. Review of the Medication Review Report showed a physician's order dated 1/26/21, for citalopram hydrobromide 20 mg tablet by mouth one time a day for depression manifested by verbalization of hopelessness. Review of the Medication Administration Record for April 2021 showed there was monitoring for the manifestations of depression to justify the use of citalopram, but there was no monitoring for the side effects of citalopram. On 4/22/21 at 1400 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 verified the current order of citalopram had no adverse side effect monitoring in the Medication Administration Record. LVN 3 acknowledged there should have been monitoring for the adverse effects while Resident 23 was administered the citalopram medication. On 4/22/21 at 1430 hours, an interview was conducted with the DON. The DON verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.33%. Two of two licensed nurses (LVN 2 and RN 4) were found to make the medication errors during the medication administration observation. * LVN 2 failed to administer the correct form of vitamin C and multivitamin to Resident 57 as ordered by the physician. * LVN 2 failed to administer the correct dose of selexipag to Resident 20. In addition, LVN 2 failed to administer multivitamins to Resident 20 as ordered by the physician. * RN 4 administered the wrong calcium medication to Resident 78. In addition, RN 4 failed to administer vitamins D2 and D3 to Resident 78 as ordered by the physician. These failures created the risk for the residents to have reduced therapeutic benefits, potential side effects, or complications related to the medications. Findings: Review of the facility's P&P titled Medication Administration Times revised 5/1/10, showed the residents' medications should be administered in accordance with written orders of the attending physician. 1. On 4/20/21 at 0915 hours, a medication administration observation for Resident 57 was conducted with LVN 2. LVN 2 prepared and administered the following medications to Resident 57: - enoxaparin (blood thinner) 40 mg/0.4 ml subcutaneous (under the skin) injection - multi-vite liquid with antioxidants (supplement) 15 ml - vitamin c (supplement) 500 mg one tablet - valproic acid liquid (antiseizure medication) 2.5 ml Review of the Medication Review Report showed the physician's orders dated 2/25/21, for multivitamins with minerals one tablet via GT one time a day scheduled at 0900 hours; and vitamin C liquid 5 ml via GT every 12 hours for supplement. On 4/20/21 at 1623 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 acknowledged Resident 57's multivitamins with minerals was ordered in a tablet form and vitamin C was ordered in a liquid form. LVN 2 acknowledged she administered Resident 57's vitamin C in a tablet form and multivitamins in liquid form. LVN 2 verified the administered medications did not match the physician's orders for Resident 57. 2. On 4/20/21 at 0920 hours, a medication administration observation for Resident 20 was conducted with LVN 2. LVN 2 prepared and administered the following medications to Resident 20. - oxycodone (opioid medication for pain) 5/325 mg one tablet; - bumetanide (water pill) 3 mg one tablet; - potassium chloride (supplement) 20 mEq extended release tablet one tablet; - vitamin c (supplement) 500 mg one tablet; - docusate sodium (stool softener) 100 mg one tablet; - selexipag (medication for pulmonary hypertension) 200 mcg one tablet; - opsumit macitentan tablets (medication for pulmonary hypertension) 2 mg five tablets; - lidocaine patch 5% one patch, which Resident 20 refused; and - Asmanex HFA (mometasone furoate) inhalation aerosol (medication for asthma), which Resident 20 refused. Review of the Medication Review Report for April 2021 showed the physician's orders dated 1/25/21, for multivitamins one tablet by mouth one time a day scheduled to be administered at 0900 hours; and selexipag tablet 1200 mcg one tablet by mouth every 12 hours for pulmonary hypertension. On 4/22/21 at 0750 hours, an interview was conducted with the DON. The DON acknowledged Resident 20 should have received six tablets of the selexipag 200 mcg medication to ensure she received the full dose of 1200 mcg as prescribed by the physician. On 4/26/21 at 1017 hours, an interview was conducted with LVN 2. LVN 2 acknowledged she did not administer Resident 20's multivitamins. LVN 2 stated Resident 20 had an order for selexipag 1200 mcg one tablet twice a day. LVN 2 verified the selexipag medication available for Resident 20 was 200 mcg per tablet, and she administered one tablet only. LVN 2 stated in order to administer 1200 mcg of selexipag, she had to administer six 200 mcg selexipag tablets. LVN 2 stated the physician's order for Resident 20's selexipag medication needed clarification to ensure the correct dose was administered. 3. On 04/20/21 at 0935 hours, a medication administration observation for Resident 78 was conducted with RN 4. RN 4 prepared and administered the following medications to Resident 78: - iron (supplement) 325 mg one tablet; - folic acid (supplement) 1 mg one tablet; - hydrocortisone (anti-inflammatory medication) 5 mg one tablet; - linagliptin/Trajenta (blood sugar medication) 5 mg one tablet; - multivitamin with mineral (supplement) one tablet; - amlodipine (blood pressure medication) 5 mg one tablet; - metformin (blood sugar medication) 500 mg one tablet; - clearlax polyethylene glycol 3350 (laxative) one packet in one cup of water; - timolol 0.5% eye drops (medication to lower eye pressure) one drop on both eyes; - brimonidine 0.2% (medication to lower eye pressure) one drop on both eyes; - oyster shell calcium 500 mg plus vit D (supplement) one tablet; - sodium chloride (supplement) 1 gm one tablet; - lorazepam (antianxiety medication) 0.5 mg one tablet; and - hydrocodone-acetaminophen 10-325 mg (narcotic pain medication) one tablet. Review of the Medication Review Report for April 2021 showed the following physician's orders dated 3/12/21: - calcium carbonate tablet 500 mg by mouth every 12 hours for supplement, - vitamin D2 tablet (ergocalciferol) 2000 units by mouth one time a day for supplement, and - vitamin D3 tablet (cholecalciferol) 2000 units by mouth one time a day for supplement. On 4/20/21 at 1532 hours, an interview was conducted with RN 4. RN 4 acknowledged she administered Resident 78 oyster shell calcium instead of the calcium carbonate 500 mg as ordered by the physician. RN 4 verified she did not administer the vitamin D2 and vitamin D3 prescribed by the physician. On 4/22/21 at 0750 hours, an interview was conducted with the DON. The DON verified the above medication errors.

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the medications were stored as per the facility's P&P. * The opened Tuberculin PPD vial (purified protein derivative, a multi-dose injectable solution used to determine if a patient has tuberculosis) was not labeled with the open date and was stored in Medication Room A. * The opened Tuberculin PPD vial with an open date past 30 days was stored in Medication Room B. * An emergency kit containing multiple expired medications was stored in Medication Room A. These failures posed the risk of the test not showing an accurate result when determining if a resident had tuberculosis and the potential to result in unsafe administration of medications to the residents. Findings: Review of the facility's P&P titled Medication Storage in the Facility revised August 2019 showed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, and disposed of according to procedures. 1. On 4/20/21 at 1042 hours, an inspection of Medication Room A was conducted with LVN 1. An opened vial of Tuberculin PPD was observed in the refrigerator without an open date. The label on the Tuberculin PPD vial showed to discard opened product after 30 days. When asked when the PPD vial was opened, LVN 1 stated she did not know since the vial did not show a date when it was opened. LVN 1 stated it should have been labeled with the open date. LVN 1 stated it had to be discarded. 2. On 4/20/21 at 1151 hours, an inspection of Medication Room B was conducted with LVN 1. An opened vial of Tuberculin PPD was observed in the refrigerator with an open date of 3/12. The label on the tuberculin PPD vial showed to discard opened product after 30 days. When asked how long the PPD vial could be used from the time it was opened, LVN 1 stated the tuberculin vial had to be discarded since the open date had past the 30 days. On 4/21/21 at 0840 hours, an interview was conducted with the DON. The DON verified the above findings and stated the undated and outdated Tuberculin PPD vials had to be discarded. 3. On 4/20/21 at 1100 hours, an inspection of Medication Room A was conducted with LVN 1. An emergency kit labeled IM (intramuscular) contained the following expired medications: - one vial of diazepam (antianxiety medication) 5 mg/ml 10 ml, with the expiration date of 2/1/21; - one vial of bacteriostatic water (water for injection) 30 ml, with the expiration date of 3/1/21; - two vials of naloxone (medication to reverse opioid overdose) 0.4 mg/ml, with the expiration date of 11/2020; and - one vial of prochlorperazine (medication to treat nausea and vomiting) 10 mg/2ml, with the expiration date of 2/1/21 LVN 1 verified the findings and stated the expired medications had to be discarded. On 4/21/21 at 0840 hours, an interview was conducted with the DON. The DON verified the above findings and stated the emergency kit had to be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure coordination of hospice services for one of 23 final sampled residents (Resident 32). * The facility failed to show documentation of the current hospice plan of care and certification for Resident 32. In addition, the facility failed to maintain complete documentation of hospice staff visits and services provided for Resident 32. * The facility failed to ensure staff were aware of the individual designated as the facility's hospice coordinator for Resident 32. These failures had the potential to put the resident on hospice services at risk of uncoordinated medical care between the facility and hospice agency. Findings: Review of Hospice Provider A's Nursing Facility Services Agreement dated [DATE], showed the following: - The Responsibilities of Facility/Coordination of Care section showed the hospice and the facility shall communicate with one another regularly and each party is responsible for documenting such communications in its respective clinical record. The Responsibilities of Hospice/Provision of Information section showed the hospice is responsible for providing the most recent plan of care and physician certifications and recertifications of terminal illness. - The Responsibilities of Facility/Inpatient Clinical Records section showed the facility shall maintain an inpatient clinical record for each hospice patient that includes a record of all inpatient services furnished and events regarding care that occurred at the facility. - The Responsibilities of Facility/Designated Facility Member section showed the facility is responsible for designating a member of the facility's interdisciplinary team with a clinical background to coordinate care provided by the facility and the hospice. Medical record review for Resident 32 was initiated on [DATE]. Resident 32 was admitted to the facility on [DATE], under hospice care. Review of Resident 32's MDSs dated [DATE] and [DATE], showed Resident 32 was cognitively intact and received hospice care. Review of Resident 32's care plan problem dated [DATE], showed Resident 32 received hospice care. Review of Resident 32's Medication Review Report showed a physician's order dated [DATE], to admit Resident 32 to Hospice Provider A for cardiomyopathy. Review of Resident 32's Hospice Certification and Plan of Treatment, showed the hospice certification period from 10/20 to [DATE]. Review of Resident 32's Certification/Recertification of Terminal Illness & Physician Narrative showed the certification period to be from 10/20 to [DATE]. a. Review of the projected hospice visit calendars from January to [DATE] showed incomplete entries. Review of the hospice visit progress notes from January to [DATE], showed the incomplete entries. On [DATE] at 1523 hours and [DATE] at 0925 hours, an interview was conducted with Resident 32. Resident 32 stated the representative from Hospice Provider A visited him in the facility for wellness checks every week. Resident 32 stated the CNA from Hospice Provider A visited him in the facility on Mondays, Wednesdays, and Fridays at 0600 hours, to assist him with showers and dressing. Resident 32 stated the schedule had been the same since he was admitted to the facility. On [DATE] at 0803 hours, an interview was conducted with CNA 4. CNA 4 stated the hospice staff assisted Resident 32 with showers but was not aware of any other services provided. CNA 4 stated she did not know what days and how often the hospice staff came to the facility to see Resident 32. On [DATE] at 1338 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she was not familiar with the resident and was not sure what hospice services provided for Resident 32. LVN 1 verified the hospice projected visit calendar and visit progress notes were incomplete for Resident 32, therefore, the facility's staff would not know when and what services were provided for Resident 32. On [DATE] at 1410 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the facility's staff would not know what hospice services were provided for Resident 32 since the hospice projected visit calendar and visit progress notes for Resident 32 were incomplete. RN 1 verified the Hospice Certification and Plan of Treatment and Certification/Recertification of Terminal Illness & Physician Narrative in Resident 32's medical record had expired on [DATE]. On [DATE] at 1430 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the hospice projected visit calendar and visit progress notes for Resident 32 were incomplete. The DON acknowledged the facility's staff would not be aware of what hospice services being provided for Resident 32 due to lack of hospice documentation. The DON verified the Hospice Certification and Plan of Treatment and Certification/Recertification of Terminal Illness & Physician Narrative for Resident 32 had expired on [DATE], and was unable to show evidence of current documents. b. On [DATE] at 1523 hours, an interview was conducted with Resident 32. Resident 32 stated no one at the facility was a hospice designee or coordinator to his knowledge. Resident 32 stated he did not communicate with the facility's staff regarding hospice services. On [DATE] at 0810 hours, an interview was conducted with RN 1. RN 1 stated the social worker was the facility's hospice coordinator for Resident 32. On [DATE] at 0914 hours, an interview was conducted with the DON. The DON stated she was the facility's hospice coordinator for Resident 32 and the staff were aware. On [DATE] at 1338 hours, an interview was conducted with LVN 1. LVN 1 stated the charge nurse of the day or the RN supervisor was the facility's hospice coordinator for Resident 32. On [DATE] at 1400 hours, an interview was conducted with the Administrator. The Administrator stated he was the responsible facility representative for issues related to the written hospice agreement, but the DON was responsible for coordinating all clinical aspects of care related to Resident 32. The Administrator stated the DON was the facility's hospice coordinator and staff were aware of this designation. On [DATE] at 1335 hours, the Administrator and the DON acknowledged the findings. The DON stated the facility staff should have known the DON was the facility's hospice coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility's P&P titled Infection Control Manual for Coronavirus (COVID-19) revised 3/31/21, showed the facility should make efforts to allow for safe visitation for residents and loved ones. The facility should ensure screening of all who enter the facility for fever and COVID-19 symptoms and document the name and contact information of any visitors to assist with contract tracing if needed. On 4/23/21 at 1139 hours, an observation was conducted at the facility's entrance. There were three visitors observed entering the facility with a gurney passing through the front desk without being screened. The Receptionist who was observed talking on the phone stopped the visitors and instructed the three visitors to check their temperatures as she continued to answer the phone. The three visitors were observed checking their own temperatures. One of the three visitors was observed signing in the logbook, then all three of them proceeded to enter the facility. On 4/23/21 at 1145 hours, an interview and concurrent facility document review was conducted with the Receptionist. Review of the Visitor/Vendor Screening Log for COVID-19, showed on 4/23/21 at 1139 hours, three visitors' name were written in one box under the box for Vendor/Visitor's Name, N/A was written under the box for Visitor's Phone Number, and the word low with a number 96.6 were written under the box for Temperature Values. The Receptionist verified the findings and stated she should have made sure all of the visitors were screened and logged it accurately in order to contact trace them when in needed. On 4/23/21 at 1345 hours, an interview was conducted with the IP. The IP verified the above findings. The IP stated the three visitors were from an ambulance company and it was not an emergency call. The IP stated the Receptionist should have ensured each visitor was screened and logged in completely and accurately to prevent the spread of the COVID -19. Based on observation, interview, and medical record review, the facility failed to ensure the appropriate infection control practices designed to help prevent the development and transmission of infections were implemented for one of 23 final sampled residents (Resident 16) and for visitors entering the facility. * The facility failed to don the appropriate PPE prior to entering an isolation room and failed to don clean gloves during wound care treatment. * The facility failed to properly screen the visitors for signs and symptoms of COVID-19 prior to entering the facility. These failures posed the risk for transmission of COVID-19 and other disease-causing microorganisms in the facility. Findings: 1. In 2016, the NPUAP (National Pressure Ulcer Advisory Panel) defined a pressure injury (same as ulcer) as a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Stage 4 pressure injury is defined as a full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, ligament, or bone in the ulcer; slough and/or eschar may be visible. Medical record review for Resident 16 was initiated on 4/20/21. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 16's plan of care showed a care plan problem dated 4/18/21, addressing Resident 16's possible exposure to COVID-19. The approach plans included contact and droplet isolation precautions, proper handwashing, and donning gown, mask, and gloves when providing care. Review of the Weekly Wound assessment dated [DATE], showed Resident 16 had the Stage 4 sacrococcyx (tail bone) pressure ulcer. On 4/26/21 at 0815 hours, an observation of Resident 16's room was conducted. The transmission-based precaution sign was the posted outside of Resident 16's room with instructions to don PPEs prior to entering the room. There was an isolation cart placed outside of the room filled with gowns, gloves, and masks. On 4/26/21 at 0821 hours, a wound care observation was conducted with LVN 4. There were two staff members wearing the gown, mask, and faceshields already in the room to assist with turning Resident 16. LVN 4 wore the mask and faceshield prior to entering Resident 16's room; however, LVN 4 did not don a gown. LVN 4 performed hand hygiene, donned clean gloves, and then took off the wound dressing from the resident's sacroccocyx wound. After taking the old dressing off, LVN 4 performed hand hygiene, donned clean gloves, then cleaned the wound using the gauze soaked with normal saline. While cleaning the wound, Resident 16 started having a bowel movement. LVN 4 discarded the dirty gloves, washed her hands, and called another CNA to assist with cleaning Resident 16. LVN 4 was observed going outside of the room to don a gown. After Resident 16 was cleaned, LVN 4 washed her hands and donned clean gloves. LVN 4 used her right gloved hand to push the privacy curtain away from the bedside table. Without changing gloves, LVN 4 used her right gloved hand to soak the gauze in normal saline and proceeded to clean Resident 16's wound. On 4/26/21 at 0907 hours, an interview was conducted with LVN 4. LVN 4 verified she did not don a gown in the beginning of the wound treatment. LVN 4 stated Resident 16 was placed on isolation as a precaution because he was recently readmitted from the hospital. LVN 4 stated it was not necessary to wear a gown when providing wound treatment unless the resident's wound had excessive exudate. When asked how she would know whether the wound had exudate or not prior to taking the dressing off, LVN 4 stated she knew because she was familiar with all of the residents. LVN 4 was informed of the observations during wound treatment. LVN 4 verified she should have changed her gloves after touching the privacy curtain and before continuing with Resident 16's wound treatment. On 4/27/21 at 0824 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified Resident 16 was placed on isolation precautions because he was recently readmitted back from the hospital. The IP stated Resident 16 needed to be taken off isolation because he was fully vaccinated for COVID-19 and did not need to be on isolation anymore; however, she had not informed the staff. The IP stated because Resident 16 was still in an isolation room and had the roommate who was also on isolation, the staff was expected to wear full PPEs when entering the room and providing care. When asked about the practice for providing wound care treatment, the IP stated she expected the staff to perform hand hygiene thoroughly. The IP verified the staff needed to wash their hands and change the gloves after touching dirty surfaces and before proceeding with wound care treatment.

Based on observation and interview, the facility failed to provide a sanitary and comfortable homelike environment for the residents and staff. * Resident 20's bathroom was observed with orange brownish stains on the walls and brownish sediments on the floor. * Dead cockroaches and black-colored droppings were observed in Medication Room A. Findings: 1. On 4/20/21 at 0735 hours, during the initial tour of the facility, Resident 20's bathroom was observed to have orange brownish stains on the walls behind the toilet seat and on the sides of the wall; and brownish sediments were observed on the floor by the toilet. On 4/20/21 at 1006 hours, an interview and concurrent observation was conducted with Maintenance Director. The Maintenance Director acknowledged the orange stained walls and brownish sediment on the floor surrounding the toilet in Resident 20's restroom. 2. On 4/20/21 at 1042 hours, an inspection of Medication Room A was conducted with LVN 1. Two large dead cockroaches were found under the sink by the medication refrigerator. Another dead (third) cockroach was found under the residents' food refrigerator. LVN 1 stated she was not sure how often Medication Room A was cleaned. LVN 1 acknowledged Medication Room A had to be cleaned. On 4/26/21 at 1401 hours, a follow-up observation of Medication Room A was conducted with LVN 1. A dead cockroach and black colored droppings were observed under the residents' food refrigerator. LVN 1 verified the findings. On 4/26/21 at 1410 hours, the Administrator verified the cockroach and pest droppings found under the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the proper labeling and dating of foods in the kitchen and refrigerator used for the residents' food brought in by the visitors. * The facility failed to ensure the proper thawing of meats in the refrigerator. * The facility failed to ensure the proper hand hygiene performed by the kitchen's staff. * The facility failed to ensure the proper use of sanitizing solution. * The facility failed to ensure the kitchen equipment and utensils were cleaned. * The facility failed to air dry equipment. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/21/21, showed 69 of 109 residents in the facility received food prepared in the kitchen. Review of the facility's Sanitation Assessment Report dated 3/1/21, showed the following areas needed improvement: - Food storage shelves and containers - clean no chipped paint. - Food covered, dated, and labeled. No leftovers over 7 days. Review of the facility's document titled Sanitation Audit Report dated 3/5/19, showed the following were observed: - Food were labeled, dated, and sealed; no expired leftovers. - Thawing foods were labeled and dated when pulled from freezer. - Minor equipment were cleaned. - No cross-contamination when handling clean and dirty dishes. - Dishware and utensils were cleaned, sanitized, and store separately without wet nesting or food debris. - Surface cleaning/sanitizing buckets were in use. 1a. Review of the facility's P&P titled Labeling and Dating dated 2020 showed the newly opened food items will need to be closed and labeled with an open date and used by the date that follows the guidelines. In addition, all prepared foods need to covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal service. Left overs will be covered, labeled and dated. On 4/20/21 at 0721 hours, an initial tour of the kitchen was conducted with Dietary [NAME] 1. During the initial tour, the following items were observed in the walk-in refrigerator: - One bag of opened shredded carrots, with an expiration date 4/8/21; - One opened bag of salad was unlabeled and undated; - Two unopened packed bags of salad, with the use by date of 4/8 and 4/18/21; - Two prepared salad bowls in plastic wrap were unlabeled and undated; - Two bowls of prepared hard boiled eggs were unlabeled and undated; - One bin with four bags of thawing pork was undated; - One bin with two bags of thawing beef was undated; - One storage bin of cherry filling with the preparation date of 4/2, and use by 4/10; - One storage bin of apple sauce was unlabeled and undated; - One storage bin of jelly with the preparation date 4/2/21, and use by 4/13/21; - One storage bin of salad was unlabeled and undated; - An opened package of plastic wrapped cream cheese was undated and unlabeled; - One storage bin of shredded cheese was undated and unlabeled; - A large pitcher of juice was undated and unlabeled; Dietary [NAME] 1 and the Dietary Supervisor verified the findings and stated the food items should have been properly labeled, dated, and discarded. b. Review of the facility's P&P titled Food for Residents From Outside Sources dated 2018 showed prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator. If opened, the food must be sealed, dated to the date opened and disposed of in two days after opening. Review of the facility's P&P titled Bringing in Food for a Resident dated 2018 showed the food or beverage items without a manufacturer's expiration date will be dated upon arrival in the facility and thrown away two days after the date marked, or if frozen 30 days. Foods in unmarked or unlabeled containers will be marked with the current date and the resident's name. Prepared foods, beverages, or perishable foods that require refrigeration will be marked with the date food was opened and resident's name. On 4/20/21 at 1116 hours, an observation of the refrigerator in Medication Room A and concurrent interview was conducted with LVN 1. One plastic bag with the resident's name and room number, undated, contained the following: - one undated bottle of liquid fish sauce; - one undated bottle of [NAME] seasoning liquid; and - one jar of salted fish (bottle label showed fish sauce) with the expiration date of 12/30/20. LVN 1 was asked about the residents' food items. LVN 1 stated they were supposed to date the food items when they were placed in the refrigerator. When asked how long the food products were allowed in the refrigerator, LVN 1 stated food was kept until the food's expiration date and disposed of afterwards. On 4/20/21 at 1119 hours, an interview was conducted with LVN 4. LVN 4 was asked about foods brought from outside by visitors. LVN 2 stated when they received foods brought from visitors, they were required to label the foods with the resident's name, room, and date the food to be stored in the refrigerator. LVN 4 stated they kept the food in the refrigerator depending on the food's expiration date. On 4/20/21 at 1215 hours, an interview was conducted with RN 1. RN 1 stated the foods brought in by the visitors for the residents should be labeled with the resident's name, room number, and date when the food was placed in the refrigerator. 2. According to the USDA Food Code 2017, 2-301.14, When to Wash, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment, and utensils, and unwrapped single-service and single use articles; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. Review of the facility's P&P titled Hand Washing Procedure dated 2020 showed hands need to be washed after handling soiled dishes and before and after doing housekeeping procedures. Review of the facility's P&P titled Glove Use Policy dated 2020 showed gloves need to be changed before beginning a new task, and before handling all food. On 4/20/21 at 0807 hours, Dietary Aide 1 was observed handling dirty dishware, then continued to handle prepared foods. Dietary Aide 1 was then observed handling the dirty dishware, before proceeding to handle clean dishware. Dietary Aide 1 did not performed hand hygiene. The Dietary Supervisor stated Dietary Aide 1 should have washed her hands between tasks. 3. Review of the facility's P&P titled Thawing of Meats dated 2018 showed thawing meat can properly be done in a refrigerator at 41 degrees F or colder. Allow two to three days to defrost, depending on quantity and total weight of meal. Label defrosting meat with pull and use by date. On 4/20/21 at 0721 hours, an initial tour of the kitchen was conducted in the kitchen with the Dietary Cook. During the initial tour, four packages of thawing pork and two packages of thawing beef stew were observed in the separate storage bins in the walk in refrigerator. Dietary [NAME] 1 was asked about the thawing meats. Dietary [NAME] 1 stated the meat was pulled two days ago or yesterday, and stated they needed to label and date the thawing meats. On 4/21/2021 at 0742 hours, an observation and concurrent interview was conducted with the Dietary Supervisor. The same four packages of thawing pork and two bags of thawing beef stew were observed in the separate storage bins in the walk in refrigerator, with a label showing 4/20/21. When asked about the thawing meats in the refrigerator, the Dietary Supervisor stated they did not keep track of the date or time while thawing the meats in the refrigerator. The Dietary Supervisor stated they would discard the thawing meats. 4. According to the USDA Food Code 2017, 4-701.10, Food- Contact Surfaces and Utensils, effective sanitization procedures destroy organisms that may be present on wiping cloths, food equipment, or utensil after cleaning. It is important surfaces be clean before sanitized to allow sanitizer to achieve its maximum benefit. Review of the facility's P&P titled Manual Warewashing dated 9/2017, showed all dining staff will be knowledgeable in proper technique including chemical sanitizer testing and concentration. On 4/22/2021 at 1633 hours, an observation and interview was conducted with Dietary [NAME] 2. Dietary [NAME] 2 was observed wringing out a red towel under running water and cleaning her workstation. When Dietary [NAME] 2 was asked to demonstrate how to test the sanitizing buckets, Dietary [NAME] 2 stated she did not know how to test the sanitizing buckets and stated she used water, paper towels, or new towels to clean her work station. On 4/22/2021 at 1640 hours, an interview was conducted with the Dietary Supervisor. The Dietary Supervisor stated Dietary [NAME] 2 should be using the sanitizer in the red buckets to clean and sanitize all kitchen work stations. 5. According to the USDA Food Code 2017, 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils, the food- contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; Nonfood-contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Equipment dated 9/2017 showed all food contact equipment will be cleaned and sanitized after every use. In addition, all non-contact equipment will be clean and free of debris. Review of the facility's P&P titled Manual Warewashing dated 9/2017 showed the dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and all dishware will be air dried and properly stored. On 4/20/21 at 0800 hours and 4/22/21 at 1040 hours an observation and interview was conducted with the Dietary Supervisor. The following was identified: - Two wire racks with three shelves each appeared brown, sticky, with crusty like substance; - A table mounted can opener with a yellow, sticky surface near the blade; - Six scoops with dried food particles on the scoop; and - A rack used to store plate covers appeared with dried food debris; The Dietary Supervisor verified the above findings and stated they should have been properly cleaned, sanitized, or replaced. 6. According to the USDA Food Code 2017, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. Review of the facility's P&P titled Manual Ware washing dated 9/2017 showed all service ware and cookware will be air dried prior to storage. a. On 4/22/21 at 1017 hours, an observation and interview was conducted with the Dietary Supervisor. Five pellet undercovers were observed stacked on top of each other. When the pellet undercovers were lifted, they were observed to be wet. The Dietary Supervisor stated they needed to let the pellet undercovers dry longer. b. On 4/22/2021 at 1032 hours, an observation and concurrent interview was conducted with the Dietary Supervisor. Six water pitchers were observed standing up on a tray, and water was observed inside the water pitchers. When asked about the water pitchers, the Dietary Supervisor stated the pitchers should be dry before storing.