**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' room measured at least 80 square (sq) feet (ft) per resident in 16 (Rooms 101 - 104 and Rooms 110 - 121) of 29 resident rooms in the facility. Findings included: The Client Accommodations Analysis, dated 01/13/2025, revealed the following measurements: - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 77 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 71 sq ft for each resident. - In room [ROOM NUMBER], there was 73 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 77 sq ft for each resident. During the initial tour of the facility on 01/13/2025 at 10:38 AM, no residents voiced any concerns regarding the size of their room. During the Resident Council meeting on 01/15/2025 at 10:30 AM, Resident #44 stated the room sizes were small, but it did not affect the care they received. Resident #11 stated it was tight in their room, but the staff made it work. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2024, revealed Resident #344 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 11/04/2024, revealed Resident #11 had a BIMS score of 13, which indicated the resident had intact cognition. During an interview on 01/15/2025 at 12:25 PM, Certified Nurse Aide (CNA) #1 stated room size did not affect the care she provided to the residents. During an interview on 01/15/2025 at 2:30 PM, CNA #2 stated resident rooms were not the size they were supposed to be, but she could provide the care the residents needed without any issue. During an interview on 01/15/2025 at 2:34 PM, the Assistant Administrator stated the facility did not have policy for room size. During an interview on 01/15/2025 at 2:36 PM, Housekeeping Service Worker #3 stated there had been no issues with the room sizes affecting care and the room measurements were all accurate. During an interview on 01/16/2024 at 8:57 AM, the Director of Nursing stated no one had ever had issues with the room size affecting care. Recommend waiver continue in effect. Don [NAME], HFEIIS 1/27/25 ---------------------------------------------------------- Health Facilities Evaluator Supervisor Date Request waiver continue in effect. ----------------------------------------------------------- Administrator Signature Date

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse for one of five sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 hit Resident 1 in the shoulder during transfer from the bed to the wheelchair. This failure violated Resident 1's right to be free from abuse. Findings: During a review of Resident 1's admission Record (a document containing demographic information), indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Diagnosis Report (a document listing resident's diagnoses) dated 4/8/24, indicated Resident 1 was admitted to the skilled nursing facility with diagnoses which included, .Dementia (progressive or persistent loss of intellectual functioning) .Parkinson (a brain disorder that causes unintended or uncontrollable movements) .Type 2 Diabetes Mellitus (high blood sugar) . During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 8 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderate impairment, and 00-07 indicates sever impairment) which indicated Resident 1 had moderate cognitive impairment. During a concurrent interview and record review on 4/29/24 at 8:45 am., with the Administrator (ADM), Resident 1's Facility Reported Event dated 4/8/24, was reviewed. The ADM stated CNA 1 was providing care to Resident 1. The ADM stated Resident 1 became combative with staff while care was being provided and bit CNA 1. The ADM stated CNA 1 hit Resident 1 on the back. The ADM stated CNA 1 should have not hit Resident 1. The ADM stated it was a staff to resident abuse. During a telephone interview on 4/29/24 at 9:05 am., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/8/24 CNA 4 notified me Resident 1 was uncooperative during care and CNA 1 hit Resident 1 in the back. LVN 1 stated it was an abuse to resident and should have never happened. During a telephone interview on 4/29/24 at 9:17 am., with CNA 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 was uncooperative with care and verbally aggressive. CNA 1 stated she was helping another CNA transfer Resident 1 from the bed to the wheelchair and Resident 1 bit her. CNA 1 stated she reacted and hit Resident 1 on her back. CNA 1 stated it was not appropriate to hit residents. CNA 1 stated what she did was physical abuse to Resident 1. During an interview on 4/29/24 at 11:35 am., with Director of Staff Development (DSD), the DSD stated she was made aware of the incident on 4/8/24 by the ADM. The DSD stated it was reported CNA 1 hit Resident 1 while providing care. The DSD stated when Resident 1 became agitated, nursing staff should have stopped the care immediately. The DSD stated CNA 1 abused Resident 1 by hitting her on the back. The DSD stated residents have the right to be free from any types of abuse. During a telephone interview on 5/1/24 at 10:05 am., with CNA 4, CNA 4 stated she was assigned to Resident 1 on 4/8/24 on the night shift. CNA 4 stated she was in Resident 1's room with CNA 1 and a CNA orientee. CNA 4 stated CNA 1 helped her transfer Resident 1 from bed to wheelchair and had sat Resident 1 up on the side of the bed. CNA 4 stated during the transfer CNA 1 called out Resident 1 had bit her and immediately afterwards she heard a slap but did not see it happen. CNA 4 stated when staff hits a resident it was considered elder abuse. Review of facility P&P titled, Abuse-Prevention, Screening, &Training Program dated 07/2018 the P&P indicated, .To address the health, safety, wellness, dignity and respect of residents by preventing abuse .and mistreatment .The facility does not condone any form of resident abuse .and or mistreatment . and to provide a environment free from abuse .The Administrator as the abuse coordinator is responsible for the coordination and implementation of the facility's abuse prevention, screening, and training program .Abuse is defined as the willful, deliberate infliction of injury, .it includes verbal abuse, physical abuse .Physical Abuse is defined as .hitting, slapping, punching and/or kicking .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 359) received information on their plan of care in a language they could understand when staff did not consistently provide an interpreter when communicating to Resident 359 in her preferred language. This failure violated Resident 359's rights to participate in the development and implementation of his plan of care in a language he could understand and placed Resident 359 at risk for not making informed decisions about his care and treatment decisions. Findings: During an observation on 12/14/2022, at 12:09 p.m., in Resident 359's room, there was no communication board (a tool used to help staff communicate with residents) visible in Resident 359's room. During a concurrent observation and interview, on 12/14/2022, at 12:15 p.m., with Resident 359, in the living room, the transport staff arrived to pick resident up for his dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood)) appointment. Resident 359 stated in Spanish, [I] don't know what I'm waiting for. LVN 2 stated in English to Resident 359, It will be one moment. Getting a sack lunch for you. Resident 359 stated he did not understand what LVN 2 told him. Resident 359 stated he had been told his appointment time for dialysis had changed but had not been told why. During a concurrent interview and record review, on 12/15/2022, at 2:45 p.m., with the Social Services Director (SSD), Resident 359's Plan of Care (POC), dated 12/7/2022 was reviewed. The POC indicated, .[Resident 359] is Spanish speaking and is able to verbalize wants and needs to staff .Goal . the resident will improve communication function by using communication board & writing messages through the review date . Interventions .anticipate and meet needs ., be conscious of resident position when in groups, activities, dining room to promote proper communication with others ., communication: resident prefers to communicate in Spanish, resident requires a translator with communication . the resident is able to communicate by a communication board, and translator . The SSD stated, [Resident 359] is Spanish speaking. The SSD stated, she does assessments with new admissions and upon admission I like to know the plan for the resident. The SSD stated the SSD Care Plan Assessment was completed on 12/7/2022 and Resident 359 was admitted on [DATE]. The SSD stated, Some CNAs are Spanish speakers. We have a language communication board. The SSD stated that a communication board was not provided to Resident 359. The SSD stated, I don't know how staff get communication boards for residents. Managers on weekends would know. During an interview on 12/16/22, at 11:56 a.m., with the Director of Staff Development (DSD), the DSD stated there was a high population of Spanish Speaking residents in the facility and staff were expected to provide a communication board and an interpreter in the resident's language of choice. The DSD stated Resident 359 required the use of a communication board and a Spanish interpreter to meet Resident 359's cultural needs and follow his plan of care and this was not provided to Resident 359. During an interview on 12/19/22, at 10:09 a.m., with the Director of Nursing (DON), the DON stated staff should follow Resident 359's plan of care and should provide a Spanish speaking interpreter when communicating with Resident 359. The DON stated a communication board and a Spanish interpreter should have been provided to Resident 359 and was not provided. The DON stated Resident 359 might not understand the instructions or information shared by staff and Resident 359's rights to understand and participate in his plan of care in a language he preferred and understand was not done. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/1/2012, the P&P indicated, The facility's staff encourages residents to participate in planning their daily care routines (including ADL's) .Residents are encouraged to participate in activities of their choice, including community activities .Each resident is allowed to choose activities, schedules and healthcare that are consistent with his or her interests, assessments and plans of care .In order to facilitate resident choices, Facility staff will: inform (and regularly remind) the resident and family members of the resident's right to self-determination and participate in preferred activities .Gather information about the Resident's personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; and include information gathered about the resident's preferences in the in the care planning process .Residents are provided assistance as needed to engage in their preferred activities on a routine basis . During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning undated, the P&P indicated, The summary must be in a language and conveyed in a manner that the resident and/or resident representative can understand . During a review of the facility's P&P titled, Translation or Interpretation Services, dated 12/1/2013, the P&P indicated, Purpose: To ensure that resident with limited English Proficiency or who have [NAME] deficiencies have the same access to Facility services as other residents .Facility Staff will orally inform the resident in a language they can understand of their right to obtain competent oral translation services free of charge .Family members and friends are not to be relied upon to provide interpretation services for resident, unless explicitly requested by the resident .If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality when: 1. Licensed Vocational Nurse (LVN 3) used an unapproved medication administration technique while using an insulin flex pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) for one of two sampled residents (Resident 25) during a medication pass observation. This failure placed Resident 25 at risk for dosing errors and had the potential for adverse side effects such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). 2. Licensed nurses did not administer oxygen per physician's order for two of three sampled residents (Resident 14 and 17) when physician ordered parameters for oxygen administration were not followed. This failure had the potential for Resident 14 and 17 to receive inadequate amount of oxygen. 3. The facility did not notify the State Agency per facility policy for one of three sampled residents (Resident 22) when Resident 22 experienced an unwitnessed fall on 10/18/22 onto the floor at the facility's hallway, resulting in loss of consciousness, sustaining a laceration (skin tear) and the use if antibiotic. This failure resulted in the facility not reporting Resident 22's fall. Findings: 1. During an observation 12/15/22, at 11:41 a.m., in Resident 25's room, LVN 3 administered Lispro (fast acting insulin) 8 units (unit of measurement) SQ (subcutaneous - injection given in the fatty tissue, just under the skin) to Resident 25's right upper arm using an insulin pen. LVN 3 did not prime (remove bubbles from the needle) the insulin pen before administering the insulin to Resident 25. During a review of the clinical record for Resident 25, the Face Sheet (a document with demographic, personal and medical information) undated, indicated Resident 25 had diagnoses which included Type 1 Diabetes (body's inability to produce any or enough insulin). During a review of Resident 25's Physician Order(PO) dated 11/21/22, the PO indicated, .Insulin Lispro .inject as per sliding scale .before meals . During an interview on 12/15/22, at 11:58 a.m., with LVN 3, LVN 3 stated, the correct process for medication administration using an insulin pen was to disinfect the rubber seal on the insulin flex pen, place the needle on the insulin pen, dial the insulin to the proper dose, and administer the appropriate dose. LVN 3 stated she was unaware of how to prime the insulin pen. During a concurrent interview and record review, on 12/16/22, at 2:24 p.m., with the Director of Nursing (DON), the manufacturer guideline titled Instructions for Use Insulin Lispro Injection KwikPen dated 6/2020 was reviewed. The manufacturer guideline indicated, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin .To prime your Pen, turn the Dose Knob to select 2 units .Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top .Continue holding your Pen with Needle pointing up. Push the Dose Knob until it stops .Hold the Dose Knob in and count to 5 slowly . The DON stated, the facility did not have an insulin pen policy and followed the manufacturers guidelines. The DON stated, the insulin pen should be primed prior to use to prevent too much or too little insulin injection. During review of the professional reference retrieved from https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections#:~:text=To%20prime%20the%20insulin%20pen,step%20until%20a%20drop%20appears. titled, Insulin Pen Injections dated 8/18 indicated, . Prime the insulin pen. Priming means removing air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed before each injection 2. During an observation on 12/13/22, at 9:43 a.m., in Resident 14's room, Resident 14 laid in bed, she had a Nasal Cannula (NC-(thin plastic tube that delivers oxygen directly into the nose through two small prongs) on with the oxygen set at 3 liters. During a concurrent interview and record review, on 12/14/22, at 9:11 a.m., with LVN 3, Resident 14's Order Summary(OS), dated 12/14/22 was reviewed. The OS indicated, Oxygen 2 LMP [liters per minute] VIA NASAL CANNULA Continuously every shift DX: COPD [chronic obstructive pulmonary disease- lung disease making it difficult to breath] . LVN 3 stated she had not checked Resident 14's oxygen rate settings. During a concurrent observation and interview on 12/14/22, at 9:14 a.m., with LVN 3, in resident 14's room, Resident 14 laid in bed, she had a NC on with the oxygen set at 3 liters. LVN 3 stated the oxygen rate was set at 3 liters, it should be set at 2 liters. LVN 3 stated it was professional standard of practice to follow physician orders. During an observation on 12/13/22, at 12:20 p.m., in the facility dining room, Resident 17 was seated in a wheelchair, she had a NC with an oxygen tank behind her wheelchair. The oxygen tank regulator was set at 2 and the pressure gauge was on the red section zero. During an interview on 12/13/22, at 12:29 p.m., with Resident 17, Resident 17 stated she did not feel any air coming from the NC. During an interview on 12/13/22, at 12:35 p.m., with LVN 1, LVN 1 stated, Resident 17's oxygen cylinder was empty. During a concurrent interview and record review on 12/13/22, at 2:34 p.m., with LVN 1, Resident 17's Physician Order(PO) dated 12/3/22, the PO indicated, .O2 via NC 5LPM Continuously . LVN 1 stated, Resident 17's oxygen regulator pressure gauge was on red empty and the regulator was set at 2 Liters which was not the correct rate. LVN 1 stated, it was professional standard of practice to follow physician orders and it was not followed. LVN 1 stated, it was the licensed nurses responsibility to ensure the oxygen cylinder was not empty and set at the correct rate as per physician orders. During an interview on 12/14/22, at 9:21 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated, when she placed the oxygen cylinder on Resident 17's wheelchair it was less than half full. CNA 5 stated, she had taken Resident 17 to the dining room around 11:30 a.m. and did not anticipate that the oxygen would finish. During an interview on 12/15/22, at 10:20 a.m., with LVN 2, LVN 2 stated when Resident 17 returned from the dining room her oxygen was set a t 2 liters. LVN 2 stated, she was the assigned nurse to care for Resident 17 on 12/13/22 and it was her responsibility to ensure the oxygen cylinder was not empty and set at the correct rate as per physician order. LVN 2 stated, it was professional standard of practice to follow physician orders. LVN 2 stated, the purpose of the oxygen was to maintain oxygen level and having no oxygen or not having enough can lead to respiratory distress including death. During a concurrent interview and record review on 12/16/22, at 2:22 p.m., with the DON, the facility policy titled Oxygen Therapy dated 11/2017 was reviewed. The policy indicated, .Licensed Nursing staff will administer oxygen as prescribed .Administer oxygen per physician orders . The DON stated, it was the licensed nurses' responsibility to ensure physician orders were followed. The DON stated, the licensed nurse should ensure there was adequate amount of oxygen in the oxygen cylinder and was not empty. The DON stated, it was professional standard of practice to follow physician orders. During a review of Registered Nursing.org Professional Reference titled, Does a Nurse Always Have to follow a Doctor's Orders? undated, (found at https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/) indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed neglect. Review of Professional Reference titled, Portable Oxygen Cylinders dated 2016, found at https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=521117400 indicated, . Check your pressure gauge often to make sure you don't run out of oxygen . Always check the gauge when the valve is turned on. When the needle gets to the lower part of the red section on the gauge, it is time to change the cylinder . 3. During an observation on 12/13/22, at 9:41 a.m., in Resident 22's room, Resident 22 laid in bed, her forehead had a healing red scar approximately 3cm (centimeters-unit of measure) in length above her right eyebrow caused by Resident 22's fall on 10/18/22. During a review of Resident 22's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 22 was admitted to the facility on [DATE]. Resident 22' s diagnoses included muscle weakness, cognitive communication deficit and dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons). During a review of Resident 22's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 22's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 3 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 22 had severe cognitive impairment. During a review of Resident 22' s Progress Note (PN), dated 10/18/22, the PN indicated, .Date/Time of Fall: 10/18/22 1:00 PM Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: leaning forward in w/c [wheelchair] .face first in hallway with wheelchair behind her. Resident is known to lean forward in her wheelchair when she is tired and has had a hx [history] of a similar fall. resident had just finished eating and was sat up in her w/c, tilt back was not engaged at the time the incident occurred. assessment findings showed a 2.5cm [centimeters-unit of measure] x 1cm laceration on the right side of resident's forehead .Any similarities between current and post falls: Yes. Prior Fall Note: resident fell forward from w/c resulting in broken nose . During an interview on 12/16/22, at 9:28 a.m., with CNA 2, CNA 2 stated she had left Resident 22 unattended in the hallway near the dining room on 10/18/22 with the wheelchair in the upright position. CNA 2 stated, she did not place the wheelchair in the tilt back position to prevent fall and went to search for a CNA to assist her in transferring Resident 22 back to bed. CNA 2 stated, she was aware of Resident 22's history of fall and should have reviewed Resident 22's fall car plan interventions in the [NAME] prior to caring for Resident 22 but did not. CNA 2 stated, Resident 22 had fallen to the ground with the wheelchair behind her resulting in her hitting her face on the ground and bled. During a concurrent interview and record review on 12/16/22, at 10:18 a.m., with LVN 4, Resident 22's Care Plan (CP), dated 8/12/22 was reviewed. The CP indicated, The resident has had an actual fall 8/12/22-Fall out of wheelchair resulting in fractured nose .10/18/22-fall from w/c .Tilt back wheelchair .Ensure that the tilt back is engaged . LVN 4 stated, Resident 22's fall was avoidable if CNA 2 had implemented the care plan intervention to tilt back the wheelchair. LVN 4 stated, this was Resident 22's second fall from the wheelchair. LVN 4 stated, on 10/18/22 Resident 22 was found on the floor bleeding from her forehead and was sent to the emergency department via ambulance. LVN 4 stated, Resident 22 had a loss of consciousness when she had assessed Resident 22 on the ground. LVN 4 stated, CNA 2 did not tilt back the wheelchair resulting in Resident 22's fall, CNA's have access to the care planned interventions in the resident [NAME] and should review at the start of their shift. During a review of Resident 22's PN, dated 10/19/22, the PN indicated, .IDT [Interdisciplinary Team] met to review .chart due to fall on 10/18/22 .was found on the floor in the hallway with her wheelchair behind her on the floor .is known to lean forward in her wheelchair when she is tired and has had a history of similar fall .was placed in hallway by staff, while the CNA went to find someone to help lay the patient down .leaned forward and fell out of her wheelchair. Upon investigation it was noted that the tilt back was not engaged on the wheelchair . During a review of Resident 22's General Acute Care Hospital (GACH) titled, ED (Emergency Department Reports), dated 10/18/22, was reviewed. The ED Reports indicated, .female with history of dementia presents brought in by ambulance after a fall from her wheelchair earlier today. There was possible loss consciousness. She did suffer a small head laceration. She was mildly short of breath after she fell, briefly was at low oxygen but now is back on room air .+3cm linear forehead laceration .Laceration is 3 cm in length . [skin adhesive] was applied .prescribed cephalexin [antibiotic] prophylactically [preventative measure] . x[times] 5 days . During a concurrent interview and record review on 12/16/22, at 2:28 p.m., with the DON, the facility policy titled Fall Management Program dated 3/2021 was reviewed. The policy indicated, .The facility will implement a Fall Management Program that supports providing and environment free from fall hazards .If a fall factor is identified, document interventions on the Resident's care plan . The DON stated, Resident 22's fall was avoidable if CNA 2 had implemented the care planned intervention to tilt back the wheelchair but didn't. The DON stated, Resident 22 had hit her head on 10/18/22 fall which resulted in the laceration and was sent out to the hospital to rule out brain bleed. The DON stated, CNA 2 had not implemented the care planned intervention to tilt back the wheelchair. The DON stated, it was her expectation for the CNA's to review the residents fall care plan interventions within the beginning of their shift to ensure they were aware and implement fall interventions. The DON stated, she did not report Resident 22's fall on 10/18/22 to the State Agency because she did not feel the need to do so. The DON stated, the reason Resident 22 was sent to the hospital was to rule out brain bleed otherwise the facility could have applied steri-strips (sticky band placed across wound to help hold skin together) to Resident 22's laceration. During a review of the facility policy titled Unusual Occurrence Reporting dated 8/2012. The policy indicated, .The Facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences .The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies .Other occurrences that interfere with Facility operations and affect the welfare, safety, or health of residents, employees or visitors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are receiving dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment received services consistent with professional standards of practice for one of two sampled residents (Resident 50) when Resident 50 received more than her physician prescribed 1500 milliliters (ml- a unit of measurement) of fluids per day during lunch on 12/13/22. (Cross Reference F 656). This failure placed Resident 50's care needs to go unmet and had the potential to result in fluid overload. Findings: During a review of Resident 50 's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated Resident 50 was readmitted to the facility on [DATE] with diagnosis which included End Stage Renal Disease (a disease with kidney failure) dependence on Renal Dialysis (a medical procedure involves diverting blood to a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly). During a concurrent lunch dining observation and interview, on 12/13/22, at 12:26 p.m., with Resident 50 in the dining room. Resident 50's meal tray ticket indicated 1500 milliliter (ml) fluid restriction (fluid allowed to drink within 24 hour). Beverages: 4 ounces (oz- a unit of measurement) (120 ml) Non-Dairy Milk, 8 oz (240 ml) Iced Tea. Resident 50 had 2 cup of 8 oz of Iced tea on her lunch tray. Resident 50 stated, I am on fluid restriction because I am a dialysis patient. I only can have 1 cup 8oz (240 ml) iced tea and another cup fluid smaller than this cup which resident pointed 8 oz cup. During an interview on 12/13/22, at 12:30 p.m., with Certified Nursing Assistant 1 (CNA) 1, CNA 1 read Resident 50's meal tray ticket and stated, Resident 50 is on 1500 ml fluid restriction, 4 oz Non-Dairy milk and 8 oz Iced Tea. CNA 1 stated Resident 50 received 2 cups of 8 oz iced tea on the meal tray. During an interview on 12/13/22, at 12:36 p.m., with the Director of Staff Development (DSD), the DSD read Resident 50's meal tray ticket and stated, Resident 50 is on 1500 ml fluid restriction, 4 oz Non-Dairy milk and 8 oz Iced Tea. The DSD stated Resident 50 received 2 cups of 8 oz iced tea on meal tray. DSD stated, Resident [50] is supposed to have only 1 cup 8 oz iced tea. During an interview on 12/14/22, at 3:24 p.m., with CNA 1, CNA 1 stated she missed the huddle (meeting usually held beginning of the shift regarding specific care of residents) so she was not aware Resident 50 was on fluid restriction and staff needs to monitor her fluid intake. CNA 1 stated if a resident was on fluid restriction, staff needed to closely monitor their fluid intake and checked with the Licensed Nurse (LN) how much liquids the resident is allowed to consume per meals and per day and to document the fluid intake of the resident in their medical record. During an interview on 12/13/22, at 3:35 p.m., with the DSD, the DSD stated at the beginning of every shift, a huddle is conducted to the nursing staff regarding residents' special care like those on fluid restriction. The DSD stated, It is important for nursing staff to know which residents are on fluid restriction so nursing staff could closely monitor them. The DSD stated CNAs and LNs would document the amount of fluid intake in the medical record of the residents who are on fluid restriction. The DSD stated if fluids were provided more than what the physician has prescribed, LNs would need to notify the physician and monitor the residents for signs and symptoms of edema, shortness of breath and fluid overload. During an interview on 12/13/22, at 3:43 p.m., with Licensed Vocational Nurse 1 (LVN), LVN 1 stated Resident 50 was on 1500 ml fluid restriction as prescribed by the physician. LVN 1 stated she monitored Resident 50's fluid intake during medication pass and whatever she drank during meals. LVN 1 stated she would also check throughout mealtimes to see how much Resident 50 drank or would ask Resident 50 how much she drank during mealtime then would document in the medical record. LVN 1 stated she would also check with CNAs Resident 50's fluid intake as CNAs also monitors fluid intake of the residents and would document it in their medical record. LVN 1 stated Resident 50 should be on a 1500 ml/day fluid restriction as prescribed by the physician as she is at risk to develop shortness of breath, edema, weight gain and fluid overload if she consumes more than 1500 ml/day of fluids. During an interview on 12/15/22, at 9:36 a.m., with the Food and Nutrition service Director (FND), the FND stated Licensed Nurses (LNs) received an ordered from the physician regarding fluid restriction and would send the diet communication slip to the kitchen regarding the fluid restriction ordered. The FND would discuss with the nurse the breakdown of fluid restriction during mealtimes and medication pass. The FND stated the potential risk of going over the prescribed fluid restriction of 1500 ml/day was for Resident 50 to experience fluid overload. The FND stated she expected dietary staff to follow and provide the prescribed amount of fluids in the meal tray ticket for residents on fluid restriction. During a telephone interview on 12/15/22, at 12 p.m., with the Renal Registered Dietitian (RRD), the RRD stated Resident 50 was admitted to the Hemolysis Center on 9/23/22. The RRD stated the Nephrologist (doctor who specialty in kidney disease) at the Hemolysis Center prescribed 1500 ml fluid restriction and target weight (goal weight used for treatment of dialysis patients) of 64 kilograms (kg- a unit of measurement) for Resident 50. The RRD stated she could not recall she discussed with the facility RD regarding Resident 50's target weight. During a concurrent interview and record review, on 12/15/22 at 2:27 p.m., Resident 50's care plan was reviewed with the Director of Nursing (DON), the DON stated the process of fluid restriction started first with the prescribing physician then the LN would send the fluid restriction order to the dietary department via a Diet Communication Slip. The DON stated the FND, and LN would discuss the amount distribution of fluid breakdown between dietary and nursing and the FND would put the amount of fluid allowed in the meal tray ticket for each meal from dietary. The DON stated her expectation was for Certified Nursing Assistants (CNAs) and staff to read the meal tray ticket and to ensure the fluid amount indicated in the meal tray ticket to be provided accurately to the residents. The DON stated her expectation was for charge nurses to closely monitor residents on fluid restriction to prevent fluid overload. The DON stated, There was no indication of monitoring residents on fluid restriction by the nurse or a sign off for fluid restriction residents by the nurses . The DON stated the possible outcome for residents who consumed fluids more than their prescribed amount would be fluid overload, respiratory distress, and edema. The DON stated her expectation was for LNs to notify the physician if residents consumed fluids more than their prescribed amount. The DON stated it has been two weeks LNs did not notify Resident 50's physician that Resident 50 consumed fluid more than his prescribed amount of 1500 ml/day. The DON stated, There is no goal weight or target weight for Resident 50's care plan. The DON stated, It could be a good idea to have a target weight or goal weight in her care plan. During a concurrent telephone interview and record review, with the facility's RD 12/16/22, at 11:32 a.m., the RD reviewed Resident 50's care plan stated, I do not know Resident 50 's goal weight because I did not discuss with her. The RD stated she did not know Resident 50's target weight because she did not discuss with the RRD. The RD stated, I did not see any care plan regarding 1500 ml fluid restriction breakdown in care plan for Resident 50. During a review of Resident 50's physician order, dated 12/14/22, the Physician Order indicated, Diet: Fluid restriction 1500 daily . During a review of Resident 50 's Minimum Data Set (MDS- standardized assessment and care-planning tool), dated 11/30/22, the MDS indicated, Resident 50 had a BIMS (Brief Interview for Mental Status- assessment of cognitive function) score of 14 which indicated Resident 50 had no cognitive impairment. The MDS indicated Resident 50 had active diagnoses which included, End Stage Renal Disease on dialysis. During a review of Resident 50's medical record for fluid intake, the fluid intake indicated, Total By day fluid intake (ml): 11/24/22: 3220.0 [ml], 11/25/22: 2220.0 [ml], 11/27/22: 2300.0 [ml], 11/28/22: 1980.0 [ml], 11/29/22:3170.0 [ml], 11/30/22: 2610.0 [ml], 12/1/22: 3150.0 [ml], 12/2/22: 1950.0 [ml], 12/3/22: 3540.0 [ml], 12/4/22: 2660.0 [ml], 12/6/22: 3080.0[ml], 12/7/22:3000.0 [ml], 12/8/22:2640.0[ml], 12/9/22: 2100.0[ml], 12/10/22: 2300.0 [ml], 12/11/22:2840.0 [ml], 12/12/22: 1720.0[ml], 12/13/22: 2080.0 [ml]. During a review of Resident 50's lunch meal tray ticket, dated on 12/14/22, the lunch meal tray ticket indicated 1500 ml fluid restriction, beverages: 4 oz (120 ml) Non-Dairy milk, 8 oz (240 ml) Iced Tea. During a review of the facility's policy and procedure (P&P) titled, Diet Record Maintenance, Revised date 6/1/14, the P&P indicated, Purpose: To ensure that the Facility provides residents with meals that meet the nutritional and consistency requirements per physician orders. Policy: The dietary department will maintain a system to record dietary information necessary to use on the resident's tray card (meal tray ticket). Procedure: I. The diet record system will contain the following information to be reflected on the resident's tray card: A. Name; B. Room number and bed location; . D. Diet order; .II. Additional information should be added as relevant to the resident's dietary needs. During a review of the facility's P&P titled, Fluid Restrictions, Revised date 04/21/2022, the P&P indicated, Purpose: To ensure the adequate provision of care and comfort measures for residents who are on fluid restrictions. Policy: Residents on Fluid restriction will be monitored for intake . for the duration of the Attending Physician order. Procedure: I. Residents on fluid restriction must have an Attending Physician order for the restriction which indicates the amount of fluid allowed within a 24-hour timeframe. III. The Licensed Nurse will: .B. Initiate strict intake measurement per the Attending Physician order.H. Total the amount of fluid each 24 hours and compare it against the fluid restriction guidelines.J. Review intake .summary weekly and address the adequacy of fluids and accuracy of documentation .

Based on observation, interview and record review, the facility failed to maintain all mechanical equipment in a safe operating condition for one of three sampled residents (Resident 2) when the low air loss (LAL- an air mattress with fluctuating air) digital control unit (pressure redistribution device to stimulate blood flow) was not powering on. This failure had the potential for Resident 2 to have ineffective pressure management surface for the prevention and treatment of pressure ulcer (an injury that breaks down the skin and underlying tissue). Findings: During an observation on 12/13/22, at 10:12 a.m., in Resident 2's room, Resident 2 was lying in bed with the digital control unit attached to the foot of the bed. The digital control unit indicators were not illuminated. During an observation on 12/13/22, at 2:33 p.m., in Resident 2's room, Resident 2 was lying in bed with the digital control unit attached to the foot of the bed. The digital control unit indicators were not illuminated. During a concurrent interview and record review on 12/13/22, at 2:41 p.m., with Licensed Vocational Nurse (LVN 3), Resident 2's Braden Scale for Predicting Pressure Ulcer Risk (BR), dated 11/18/22 was reviewed. The BR indicated, .High Risk . LVN 3 stated, Resident 2 was at high risk for skin breakdown and benefits for the use of the LAL mattress. During a concurrent observation and interview on 12/13/22, at 2:49 p.m., with LVN 3, in Resident 2's room, Resident 2 was lying in bed with the digital control unit attached to the foot of the bed, the digital control unit indicators were not illuminated. LVN 3 stated, digital control unit was plugged into the electrical outlet but was not working. LVN 3 stated, the lights on the digital control unit were not illuminated indicating the unit was not working. During a concurrent interview and record review on 12/16/22, at 2:37 p.m., with the Director of Nursing (DON), the facility policy titled Mattresses dated 1/2012 was reviewed. The policy indicated, .To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure .To reduce pressure and evenly distribute body weight over a larger area of body surface .Be sure the mattress is inflating properly .Check air mattress routinely to ensure that it is working properly .Record the use of the mattress and resident outcome in the resident's medical record . The DON stated, the purpose of the LAL mattress was to prevent pressure injury. The DON stated, the pump (digital control unit) should be in good operating condition and it was the Licensed Nurses responsibility to ensure it was working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation during the survey period of 12/13/22 through 12/19/22, the facility failed to maintain rooms that measured at least 80 square feet per resident in 16 of 29 resident rooms. This failure had the potential to place residents and families at risk for not having sufficient space to accommodate residents' needs, privacy, and comfort. Findings: During the initial tour of the facility on 12/13/22, the following rooms did not provide the minimum square footage as required by regulation: Rooms 101, 102, 103, 104, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, and 121. However, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Rm # Square Feet # of Residents 101 152 2 102 152 2 103 154 2 104 150 2 110 214 3 111 146 2 112 225 3 113 152 2 114 225 3 115 152 2 116 225 3 117 152 2 118 225 3 119 152 2 120 226 3 121 154 2 Recommend waiver continue in effect. [NAME], HFEIIS 12/29/22 ---------------------------------------------------------- Health Facilities Evaluator Supervisor Date Request waiver continue in effect. ----------------------------------------------------------- Administrator Signature Date

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for three of 17 sampled residents (Residents 34, 50 and 2) when: 1. Resident 34 was identified as having a behavior of yelling, cursing and threatening staff on 12/1/22 and licensed nursing staff did not develop an individualized care plan and implement effective interventions. This failure had the potential for Resident 34 to not receive appropriate care and not meet his health, safety, psychosocial, and behavioral needs. 2. Resident 50 did not have an individualized care plan to identify his 1500 milliliters (ml- a unit of measurement) fluid restriction. This failure placed Resident 50's care needs to go unmet and had the potential to result in fluid overload. 3. Resident 2 did not have an individualized care plan to identify the use of low air loss (LAL- an air mattress with fluctuating air). This failure had the potential for Resident 2 to have ineffective pressure management surface for the prevention and treatment of pressure ulcer (an injury that breaks down the skin and underlying tissue). Findings: 1. During a concurrent interview and record review, on 12/16/22, at 2:25 p.m., with Licensed Vocational Nurses (LVN) 5, Resident 34's Nursing Care Plan (CP), dated 12/16/22 was reviewed. The CP indicated, . Focus: . Behavior problem . 12/1/22 cursing, yelling, threatening staff . LVN 5 reviewed Resident 34's CP interventions and stated there were no specific interventions to address Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. LVN 5 stated there was no behavior monitoring related to Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. LVN 5 stated specific nursing interventions and monitoring should be created on the same day the behavior was observed. LVN 5 stated without specific nursing interventions and monitoring, Resident 34's behavior of cursing, yelling and threatening staff could worsen. During a concurrent interview and record review, on 12/19/22, at 9:33 a.m., with the Minimum Data Set Nurse (MDSN), Resident 34's CP, dated 12/19/22 was reviewed. The CP indicated, . Focus: Behavior problem . 12/1/22 cursing, yelling, threatening staff . The MDSN reviewed Resident 34's CP interventions and stated there were no specific interventions to address Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. The MDSN stated there was no behavior monitoring related to Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. The MDSN stated specific nursing interventions and monitoring should have been created on the same day the behavior was observed to meet Resident 34's needs. During an interview with the Director of Nursing (DON) on 12/19/22, at 10:08 a.m., the DON stated Resident 34's nursing care plan and interventions should have been created on the same day the behavior was observed to meet Resident 34's needs. The DON stated nursing interventions serves as a guide for care staff on how to address the identified behavior. The DON stated without the appropriate interventions, Resident 34's behavior could worsen. During a review of Resident 34's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/16/22, the AR indicated, Resident 34 was admitted from the general acute care hospital (GACH) on 7/27/22 to the facility, with diagnoses which included Mild Cognitive Impairment (decline in memory and thinking), Obsessive-Compulsive Disorder (repeated, persistent and unwanted thoughts, urges or images that are intrusive and cause distress or anxiety) and Hypertension (high blood pressure). During a review of Resident 34's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 12/3/22, the MDS indicated Resident 34's Brief Interview for Mental Status (BIMS) score was 14 of 15 points (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, The P&P indicated, . It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting, health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing . IV. Comprehensive Care Plan . b. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident . In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition . 2. During a review of Resident 50 's AR, the AR indicated Resident 50 was re-admitted to the facility on [DATE] with diagnosis which included End Stage Renal Disease (a disease with kidney failure) dependence on Renal Dialysis (a medical procedure involves diverting blood to a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly). During a concurrent lunch dining observation and interview, on 12/13/22, at 12:26 p.m., with Resident 50 in the dining room. Resident 50's meal tray ticket indicated 1500 milliliter (ml) fluid restriction (fluid allowed to drink within 24 hour). Beverages: 4 ounces (oz- a unit of measurement) (120 ml) Non-Dairy Milk, 8 oz (240 ml) Iced Tea. Resident 50 had 2 cup of 8 oz of Iced tea on her lunch tray. Resident 50 stated, I am on fluid restriction because I am a dialysis patient. I only can have 1 cup 8oz (240 ml) iced tea and another cup fluid smaller than this cup which resident pointed 8 oz cup. During an interview on 12/15/22, at 9:36 a.m., with the Food and Nutrition service Director (FND), the FND stated Licensed Nurses (LNs) received an ordered from the physician regarding fluid restriction and would send the diet communication slip to the kitchen regarding the fluid restriction ordered. The FND would discuss with the LN the breakdown of fluid restriction during mealtimes and medication pass. The FND stated the potential risk of going over the prescribed fluid restriction of 1500 ml/day was for Resident 50 to experience fluid overload. The FND stated she expected dietary staff to follow and provide the prescribed amount of fluids in the meal tray ticket for residents on fluid restriction. During a telephone interview on 12/15/22, at 12 p.m., with the Renal Registered Dietitian (RRD), the RRD stated Resident 50 was admitted to the Hemolysis Center on 9/23/22. The RRD stated the Nephrologist (doctor who specialty in kidney disease) at the Hemolysis Center prescribed 1500 ml fluid restriction and target weight (goal weight used for treatment of dialysis patients) of 64 kilograms (kg- a unit of measurement) for Resident 50. The RRD stated she could not recall she discussed with the facility RD regarding Resident 50's target weight. During a concurrent interview and record review, on 12/15/22 at 2:27 p.m., Resident 50's care plan was reviewed with the DON, the DON stated the process of fluid restriction started first with the prescribing physician then the LN would send the fluid restriction order to the dietary department via a Diet Communication Slip. The DON stated the FND, and LN would discuss the amount distribution of fluid breakdown between dietary and nursing and the FND would put the amount of fluid allowed in the meal tray ticket for each meal from dietary. The DON stated her expectation was for Certified Nursing Assistants (CNAs) and staff to read the meal tray ticket and to ensure the fluid amount indicated in the meal tray ticket to be provided accurately to the residents. The DON stated her expectation was for charge nurses to closely monitor residents on fluid restriction to prevent fluid overload. The DON stated, There was no indication of monitoring residents on fluid restriction by the nurse or a sign off for fluid restriction residents by the nurses . The DON stated the possible outcome for residents who consumed fluids more than their prescribed amount would be fluid overload, respiratory distress, and edema. The DON stated her expectation was for LNs to notify the physician if residents consumed fluids more than their prescribed amount. The DON stated it has been two weeks LNs did not notify Resident 50's physician that Resident 50 consumed fluids more than his prescribed amount of 1500 ml/day. The DON stated, There is no goal weight or target weight for Resident 50's care plan. The DON stated, It could be a good idea to have a target weight or goal weight in her care plan. During a concurrent telephone interview and record review, with the facility's RD 12/16/22, at 11:32 a.m., the RD reviewed Resident 50's care plan and stated, I do not know Resident 50 's goal weight because I did not discuss with her. The RD stated she did not know Resident 50's target weight because she did not discuss with the RRD. The RD stated, I did not see any care plan regarding 1500 ml fluid restriction breakdown for Resident [50]. During a concurrent interview and record review, on 12/16/22 at 2:19 p.m. with LVN 4, LVN 4 reviewed Resident 50's clinical record and stated residents on fluid restriction needs to have a care plan and interventions indicating breakdown of fluids for dietary and nursing. LVN 4 stated there was no evidence in Resident 50's clinical record of the 1500 ml fluid restriction breakdown for Resident 50 prior to 12/14/2022. During a review of Resident 50's Nutrition Care plan, undated, the Nutrition Care plan indicated, Focus: Nutrition: Resident is at risk for weight loss, malnutrition, and dehydration due to diagnosis End stage renal disease on hemodialysis (a medical procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) .Diet: . fluid restriction 1500 ml daily, dated Initiated: 12/08/22; Interventions/Tasks: .Dietary will provide following fluid restriction .Date initiated: 12/08/2022; LVN TO CHECK MEAL TRAY FOR ACCURACY TO PHYSICIAN ORDERS three times a day, Date initiated: 11/22/2022; Provide and serve diet as ordered: .1500 ml fluid restriction, Dated initiated: 12/08/22; .Monitor intake and record every meal, dated initiated 12/8/2022 . In the care plan, there were no evidence documentation of goal weight/target weight, no evidence documentation of intervention indicating breakdown of fluid for dietary and nursing; no evidence documentation of intervention indicating notified doctor if resident consumed fluid more than prescribed fluid restriction. During a review of the facility's P&P titled, Fluid Restrictions, Revised date 04/21/22, the P&P indicated, Purpose: To ensure the adequate provision of care and comfort measures for residents who are on fluid restrictions. Policy: Residents on Fluid restriction will be monitored for intake . for the duration of the Attending Physician order. Procedure: I. Residents on fluid restriction must have an Attending Physician order for the restriction which indicates the amount of fluid allowed within a 24-hour timeframe. III. The Licensed Nurse will: .D. Update the resident's Care Plan. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, Revised date November 2018, the P&P indicated, Purpose: To ensure that a comprehensive person- centered care plan is developed for each resident. Policy: It is the policy of this Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Procedure: . IV. Comprehensive Care Plan a.All goals, .interventions .will be included in the resident's comprehensive care plan. 3. During an observation on 12/13/22, at 10:12 a.m., in Resident 2's room, Resident 2 laid in bed with the digital control unit attached to the foot of the bed. The digital control unit indicators were not illuminated. During an observation on 12/13/22, at 2:33 p.m., in Resident 2's room, Resident 2 laid in bed with the digital control unit attached to the foot of the bed. The digital control unit indicators were not illuminated. During a concurrent interview and record review, on 12/13/22, at 2:41 p.m., with LVN 3, Resident 2's Braden Scale for Predicting Pressure Ulcer Risk (BR), dated 11/18/22 was reviewed. The BR indicated, .High Risk . LVN 3 stated, Resident 2 was at high risk for skin breakdown and benefits for the use of the LAL mattress. LVN 3 stated, there was no care plan for the use of the LAL mattress. LVN 3 stated, it was the LNs responsibility to develop the care plan when the LAL mattress was implemented. LVN 3 stated, the purpose of the care plan was to develop interventions such as checking the LAL mattress to ensure it was working. During a concurrent observation and interview, on 12/13/22, at 2:49 p.m., with LVN 3, in Resident 2's room, Resident 2 laid in bed with the digital control unit attached to the foot of the bed, the digital control unit indicators were not illuminated. LVN 3 stated the digital control unit was plugged into the electrical outlet but was not working. LVN 3 stated, the lights on the digital control unit were not illuminated indicating the unit was not working. During a concurrent interview and record review, on 12/16/22, at 2:37 p.m., with the DON, the facility policy titled Mattresses dated 1/2012 was reviewed. The policy indicated, .To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure .To reduce pressure and evenly distribute body weight over a larger area of body surface .Be sure the mattress is inflating properly .Check air mattress routinely to ensure that it is working properly .Record the use of the mattress and resident outcome in the resident's medical record . The DON stated, the purpose of the LAL mattress was to prevent pressure injury. The DON stated, the pump (digital control unit) should be in good operating condition and it was the LNs responsibility to ensure it was working. The DON stated, the LAL mattress should be care planned, the care plan should have been developed when the LAL mattress was implemented. The DON stated, the purpose of the care plan was for staff to be aware of the plan of care for residents. During a review of the facility P&P titled Comprehensive Person-Centered Care Planning dated 11/2018. The P&P indicated, .It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety .needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. Licensed Vocational Nurse (LVN) 2 left the sharps container unlocked and unattended for one of three medication carts (medication cart 2). This failure had the potential for unauthorized access to used medications and sharps which placed residents at risk for needlestick injuries. 2. One of three medication cart was left unlocked and unattended by LVN 2. This failure had the potential for residents and staff to have unauthorized access to medications. Findings: 1. During a concurrent observation and interview, on 12/13/22 at 10 a.m., with LVN 2 at station 3, the sharps container on medication cart 2 was unlocked and unattended on the hallway wall outside room [ROOM NUMBER]. LVN 2 stated, Normally the sharps container is locked. LVN 2 stated, The sharps container should be locked for patient safety. During a concurrent interview and record review, on 12/16/22, at 2:27 p.m., with the Director of Nursing (DON), the facility policy titled Storage of Medications dated 2014 was reviewed. The policy indicated, .Medications and biologicals are stored, securely, and properly . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . The DON stated the medication cart should be locked when unattended for resident safety. During an interview, on 12/19/22, 10:09 a.m., with the DON, the DON stated, Staff should keep the sharps container locked at all times for patient safety to prevent accidental access [used medications and sharps]. 2. During an observation on 12/15/22, at 3:22 p.m., at station 3, LVN 2 was seated at the nurse's station. The medication cart was located across the nurse's station against the wall, the medication cart drawers was facing the hall. The medication cart was unlocked and unattended. During an observation on 12/15/22, at 3:28 p.m., at station 3, LVN 2 was seated at the nurse's station. The medication cart remained unlocked and unattended. During an observation on 12/15/22, at 3:29 p.m., at station 3, LVN 2 left the nurses station and proceeded to walk to the end of the hallway into room [ROOM NUMBER]. The medication cart remained across the nurse's station against the wall, the medication cart drawers was facing the hall. The medication cart remained unlocked and unattended. During a concurrent observation and interview on 12/15/22, at 3:34 p.m., with LVN 2 at nursing station 3. LVN 2 stated, the medication cart was unlocked and she did not have visualization of the cart while in room [ROOM NUMBER]. LVN 2 stated, the medication cart should be locked so residents did not have access to medications they were not supposed to have. LVN 2 stated, leaving the medication cart open could allow unauthorized access to medications and the consequences could be adverse effects leading up to death. During a concurrent interview and record review on 12/16/22, at 2:27 p.m., with the DON, the facility policy titled Storage of Medications dated 2014 was reviewed. The policy indicated, .Medications and biologicals are stored, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . The DON stated, the medication cart should be locked when unattended for resident safety.

Based on observation, interview, and record review, the facility failed to ensure 1. The Controlled Carbohydrate Diet (a meal plan for diabetic residents) lunch dessert was provided for 17 (Resident 2, 3, 5, 15, 22, 23, 25, 29, 32, 36, 37, 38, 40, 48, 50, 51, 52) of 17 sampled residents who have a physician order to receive Controlled Carbohydrate Diet (CCHO) diet received a regular dessert for lunch on 12/14/22. 2. The fortified dessert was provided for one of one sampled resident (Resident 10) who have a physician order to receive fortified diet (diet with added extra nutrients to increase the calories and/or protein density to promote improvement residents' nutrition status) received a regular dessert for lunch on 12/14/22. These failures had the potential to negatively impact the residents' nutritional status and further compromising residents' medical status. Findings: 1. During a dietary production observation, on 12/14/22, at 10:53 AM, in kitchen, Diet Aide 1 (DA) used a spatula to cut the Apple Hill cake from a 15-inch width x 21-inch length x 1-inch depth sheet pan into a single serving size and then put the single serving size Apple Hill cake into a white serving bowl. During a concurrent observation and interview on 12/14/22, at 11:03 a.m., with DA 1, DA 1 stated she cut 40 pieces single size Apple Hill cake with the same size and she was going to serve those Apple Hill cake to regular diet residents, CCHO diet residents and Renal diet residents. During trayline observation on 12/14/22, at 12 p.m., CCHO diet residents received regular dessert. During a concurrent interview and record review, on 12/15/22, at 9:30 a.m., with the Regional Dietary Manager (RDM) and Food and Nutrition service Director (FND), the RDM and FND reviewed the Cooks Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) on 12/14/22 CCHO dessert. The RDM and FND stated The CCHO dessert was supposed to get ½ size of regular dessert. The FND stated the potential risk for CCHO diet residents who received regular dessert could cause high blood sugar. The FND stated her expectation was for dietary staff to read and follow the Cooks Spreadsheet accurately. During a concurrent telephone interview and record review, on 12/16/22, at 11:32 a.m., with the facility Registered Dietitian (RD), the RD stated dietary staff should cut regular dessert into ½ serving size and served to the CCHO diet residents on 12/4/22 lunch dessert. The RD also stated her expectation was for dietary staff to follow Cooks Spreadsheet. The RD stated the potential risk for CCHO residents who received regular dessert would be minor if it occurred only one time but if the incident occurred frequently, it would cause an increase in the residents' blood sugar. During a review of the facility's provided physician diet orders, dated 12/14/22, the physician diet orders indicated, 17 Residents (Resident 2, 3, 5, 15, 22, 23, 25, 29, 32, 36, 37, 38, 40, 48, 50, 51, 52) on Controlled Carbohydrate diet. During a review of the facility's Cooks Spreadsheet, dated 12/14/22, the Cooks Spreadsheet indicated, .Apple Hill Cake (dessert) for Regular diet: 1 piece; CCHO: ½ piece. During a review of the facility provided Controlled Carbohydrate Diet, dated 2020, the Controlled Carbohydrate Diet indicated, DESCRIPTION: A controlled carbohydrate diet, (CCHO), is a meal plan .for diabetic residents.the carbohydrates are evenly, systematically and consistently distributed through three meals and H.S. (evening) snack in effort to maintain a stable blood sugar level through the day. 2. During a concurrent observation and interview, on 12/14/22, at 10:05 a.m., in the kitchen, with the RDM and Dietary Aide (DA) 1, DA1 prepared the Apple Hill cake dessert for residents during lunch. DA 1 stated Only fortified diet residents need whipped topping on the Apple Hill cake. During a concurrent dining observation and interview, on 12/14/22, at 12:48 p.m., with the Director of Staff Development (DSD), there was no whipped topping on Apple Hill cake. The DSD read Resident 10's meal tray ticket and stated Resident 10 was on Fortified diet. The DSD validated there was no whipped topping on the Apple Hill cake. During an interview on 12/14/22, at 12:50 p.m., with the RDM, the RDM read Resident 10's meal tray ticket and stated Resident 10 was on Fortified diet. The RDM stated there was no whipped topping on the Apple Hill cake. The RDM stated Fortified diet needs whipped topping on the Apple Hill cake. During a concurrent interview and record review on 12/15/22, at 9:30 a.m., with the RDM and the FND, the RDM and FND reviewed Cooks Spreadsheet on 12/14/22 for fortified diet lunch. The RDM and FND stated The dessert needs whipped topping. The RDM and FND stated their expectation for dietary staff was to read and follow the Cooks Spreadsheet accurately and serve fortified food items to residents on fortified diet. The FND stated the potential risk for residents on fortified diet who did not receive fortified food items was for the residents not to get the extra calories from fortified food items which could cause weight loss. During a concurrent phone interview and record review, on 12/16/22, at 11:32 a.m., with the facility RD, the RD stated her expectation was dietary staff should know how to serve whipped topping dessert to residents on fortified diet. The RD stated because of weight loss, Residents were put on fortified diet. The RD stated the potential risk for residents on fortified diet not receiving fortified food items could cause residents to experience further weight loss. During a review of the Resident 10's physician diet order, dated 12/15/22, the physician diet order indicated, Fortified diet. During a review of the facility's Cooks Spreadsheet for fortified, undated, the Cooks Spreadsheet for fortified indicated, .Dessert: Whipped topping . During a review of the facility's policy and procedure (P&P) titled, Diet Record Maintenance, revised date 06/01/2014, the P&P indicated, Purpose: To ensure that the Facility provides residents with meals that meet the nutritional and consistency requirement per physician orders. Policy: The dietary department will maintain a system to record dietary information necessary to use on the resident's tray card (meal tray ticket). Procedure: I. The diet record system will contain the following information to be reflected on the resident's tray card: A. Name; B. Room number and bed location; . D. Diet order; . During a review of the facility provided FORTIFIED DIET, dated 2020, the FORTIFIED DIET indicated, DESCRIPTION: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. NUTRITIONAL BREAKDOWN: The goal is to increase the calories density of the foods commonly consumed by the residents.

Based on observation and interviews, the facility failed to provide appetizing foods for eight of 65 sampled residents (Resident 24, 33, 34, 53, 209, 357, 359, 360). This failure placed Resident 24, 33, 34, 53, 209, 357, 359 and 360 at potential risk of decreased nutritional intake and affect the residents' nutrition status which could compromise their medical status. Findings: During an interview on 12/13/22, at 9:25 a.m., with Resident 357, Resident 357 stated, Food is not good. During an interview on 12/13/22, at 9:42 a.m., with Resident 33, Resident 33 stated, Food is terrible. During an interview on 12/13/22, at 9:53 a.m., with Resident 359, Resident 359 stated, Food is so so. During an interview on 12/13/22, at 9:59 a.m., with Resident 209, Resident 209 stated, Food is not good . Bland and does not taste good. During an interview on 12/13/22, at 10:02 a.m., with Resident 53, Resident 53 stated, Food is terrible. All of it tasted bland. I cannot hardly eat it. During an interview on 12/13/22, at 10:15 a.m., with Resident 360, Resident 360 stated, Provided food could be better. During an interview on 12/14/22, at 12:38 p.m., with Resident 34, Resident 34 stated, All provided meals are so so. It could be better. I told staff here. They know about it, but nothing gets done about it. During a concurrent dining observation and interview, on 12/14/22, at 12:45 p.m., with Resident 24. Resident 24 only consumed 10 percent of the provided entrée. Resident 24 stated, Lunch is so so . During an interview on 12/14/22, at 1:27 p.m., with Resident 53, Resident 53 stated, Food is awful. During an interview on 12/15/22, at 9:17 a.m., with the Activities Director (AD), the AD stated during resident council meetings, residents always complained about foods. During an interview on 12/15/22, at 9:22 a.m., with the Regional Registered Dietitian (RRD), the RRD stated there was no policy and procedure regarding palatability, taste, or flavor of the provided foods. During an interview on 12/15/22, at 10 a.m., with the Regional Dietary Manager (RDM) and the Food and Nutrition service Director (FND), the FND stated her expectation was to serve appetizing foods to meet the need of the residents. The RDM and FND stated the potential risk of serving unappetizing foods could result in residents not eating which could cause unintended weight loss. During a telephone interview on 12/16/22, at 11:32 a.m., with the facility Registered Dietitian (RD), the RD stated, I do not know there is a test tray policy in the facility. The RD stated the potential risk for serving unappetizing foods was the residents would not eat and could result in residents losing weight. During a review of the regulation F 804: § 483.60 (d) Food and drink , F 804 indicated, Each resident receives and the facility provides - .§483.60(d)(2) Food and drink that is palatable Food palatability refers to the taste and/or flavor of the food.

Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food safety when: 1. The fire hood and ventilators above the stove had black debris and had grease. This failure had the potential risk to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for 65 of 65 sampled residents who received food from the kitchen. 2. The reach in refrigerator number (#) 1 and # 2 ventilators had black debris. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 3. The oven had black substance on the bottom and a yellow/brown discoloration around the knobs. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 4. The can opener blade and based in the kitchen was not kept in sanitary condition. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 5. The stainless shelves used to store clean kitchenware were covered with brown grime. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 6. The Dome (a piece of kitchen equipment used as a cover to keep food hot) rack was covered with dust. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 7. There were 4 plastic containers' covers used to store oatmeal, pancake mix, sugar, flour was covered with dust and brown debris. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 8. The reach in refrigerator (facility referred as Milk Fridge) and reach in refrigerator # 2 gray shelves had peeling paint and brown substances. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 9. The floor under the reach in refrigerator # 2, reach in vegetable freezer and refrigerator had food crumbs, trashes, dust, black/brown debris. This failure had the potential risk to promote bacteria and virus grow and attract pests which could cause cross contamination for 65 of 65 sampled residents who received food from the kitchen. 10. A package of opened expired English muffin was found in the kitchen. This failure had the potential risk for 65 of 65 sampled residents who received food from the kitchen consumed expired foods. 11. There were five condiments that were covered with brown and black debris. This failure had the potential risk to promote bacteria and virus grow and attract pests which could cause cross contamination for 65 of 65 sampled residents who received food from the kitchen. 12. There were several food items that were open and exposed to the air in the 3 reach in freezers. Having the food exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the food for 65 of 65 sampled residents who received food from the kitchen. The facility's failures to ensure a safe and sanitary condition resulted in the likelihood of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) to come in contact with residents' food which would cause food-borne illness to a population of 65 of 65 residents who received food from the kitchen and are medically compromised. Findings: 1. During an observation on 12/13/22, at 10:21 a.m., in the kitchen above the stoves, there were black/brown debris hanging on the fire hoods. The ventilators above the stove were covered with black debris. [NAME] 1 (CK1) was using the stoves preparing the residents meals. During a concurrent observation and interview, on 12/13/22, at 3:19 p.m., with the Registered Dietitian (RD) and the Food and Nutrition service Director (FND). The RD and FND stated there were black/brown debris hanging on the fire hoods and there were black debris ont he ventilator covers. The RD and FND stated the black/brown debris hanging on the fire hoods were dust and the black debris covered on ventilators was grease with dust. The FND and RD stated the dust and grease should not be in the fire hoods and ventilators because it could potentially cause cross contamination. During an interview on 12/15/22, at 09:22 a.m., with the Regional Registered Dietitian (RRD), The RRD stated there was no policy and procedure for general cleanliness and sanitation of the kitchen. During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, Section 4-204.11 Ventilation Hood Systems, Drip Prevention, indicated, The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. 2. During a concurrent observation and interview, on 12/13/22, at 2:52 p.m., with the RD and FND, the FND and RD stated the black debris on the ventilator inside the reach in refrigerator # 2. The RD stated, The black debris was buildup of dust and not supposed to be there because there was a potential for dust to fall into foods. During a concurrent observation and interview, on 12/13/22, at 3:03 p.m., with the FND and RD, the FND and RD stated theere were black debris on the ventilator in the reach in refrigerator #1. The FND and the RD stated the black debris was build up of dust. The FND and the RD stated the potential risk for dust build up in the reach in refrigerator # 1's ventilator was cross contamination when the dust fell on foods. During a review of facility's policy and procedure (P&P) titled, Cleaning Schedule, dated October 1, 2014, the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 3. During an observation on 12/13/22, at 10:19 a.m., the oven had burning ash/black substance inside on the bottom and there was a yellow/brown discoloration around the knobs of the oven. During a concurrent observation and interview, on 12/13/22, at 3:32 p.m., with the FND and RD, the FND and the RD looked inside the oven and around the oven nozzles and the RD stated, I can't tell if its rust inside the oven or possibly burnt up food, it's not supposed to be there. The FND and the RD stated grease and dust build up around nozzle should be cleaned. The RD and FND stated there was a risk for potential cross contamination if the oven was not cleaned properly. During a review of the facility's P&P titled, Oven-Conventional (Gas)-Operation and Cleaning, dated October 1, 2014, the P&P indicated under .Sanitation of equipment . A. Remove spills, spillovers, and burned food deposits from the over as soon as practicable . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 4. During an observation on 12/13/22, at 10:34 a.m., the can opener blade had white substance and the base had brown debris. During a concurrent observation and interview, on 12/13/22, at 3:28 p.m., with the RD and FND, in front of the space utilized for the can opener, the FND stated There is grime or goo, I don't know what it is on the base of the can opener. The RD stated there was a sticky buildup on the base of the can opener and an unknown white substance on the blade of the can opener. The RD stated, The can opener and the base need to be cleaned on a routine basis due to risk for potential cross contamination. During an interview on 12/15/22, at 9:22 a.m., with the RRD, the RRD stated there was no Policy and Procedure for general cleanliness and sanitation of the kitchen. The RRD stated, This facility followed Food Code. During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, . Food-contact surfaces and utensils are to be clean to sight and touch . 5. During an observation on 12/13/22, at 10:12 a.m., the stainless-steel shelves under the steam table used to store clean kitchenwares was covered with food particles and brown grime. During a concurrent observation and interview, on 12/13/22, at 3:17 p.m., with the RD and FND, the FND stated The brown grime possibly is the accumulation of overspray for pan spray and dust. The RD and the FND stated the stainless-steel shelves needs to be cleaned due to possible cross contamination with the clean kitchenwares. During a review of facility's P&P titled, Cleaning Schedule, dated October 1, 2014, the P&P indicated, . The dietary staff will maintain a sanitary environment in the dietary department . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 6. During an observation on 12/13/22, at 10:49 a.m., the dome rack had brown substance/debris . During a concurrent observation and interview, on 12/13/22, at 3:30 p.m., with the RD and FND, the RD and FND stated the dome rack had visible brown substance/debris buildup. The FND and RD stated the The brown substance/debris buildup is dust and there is a potential for cross contamination if not cleaned. During a review of facility's P&P titled, Cleaning Schedule, dated October 1, 2014, the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department During a professional reference review according to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 7. During an observation on 12/13/22, at 10:32 a.m., the four plastic storage container covers' used to store oatmeal, pancake mix, sugar, and flour were covered with brown debris. During a concurrent observation and interview, on 12/13/22, at 3:23 p.m., the RD and FND stated the four plastic storage container covers used to store oatmeal, pancake mix, sugar, and flour were covered with brown debris. The RD and the FND stated the brown debris were dust and the potential risk for the plastic storage container covers' covered with dust was cross contamination. During a review of facility's P&P titled, Cleaning Schedule, dated October 1, 2014, the P&P indicated, . The dietary staff will maintain a sanitary environment in the dietary . During a professional reference review according to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 8. During an observation on 12/13/22, at 9:22 a.m., in the reach in refrigerator Milk Fridge, there was brown discoloration and peeling of the grey paint on all three food shelves. During an observation on 12/13/22, at 9:50 a.m., the reach in refrigerator's (# 1's) gray shelves had brown discoloration and there was peeling off the grey paint on the shelves. During a concurrent observation and interview, on 12/13/22, at 3 p.m., with the RD and FND, the FND stated the brown discoloration on the gray shelves in the Milk Fridge and reach in refrigerator # 1 was rust. The FND stated There is a potential for the rust on the edge of the shelves could splinter off into the food so it should be replaced. During a review of facility's P&P titled, Sanitation of Reach in Refrigerator, dated October 1, 2014, the P&P indicated The reach in refrigerator will be maintained in a sanitary condition During a review of the Federal Food Code 2017, the Food code indicates, food-contact surfaces and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, pitting, and decomposition. 9. During an observation on 12/13/22, at 9:32 a.m., there were food crumbs, trash and black/brown debris on the floor under the reach in refrigerator (#2-) and the milk fridge. During a concurrent observation and on 12/13/22, at 2:55 p.m., with the RD and FND, the FND and RD stated there were trash, food crumbs, black/brown debris on the floors under refrigerator #2, reach in freezer (facility referred as Vegetable freezer), and Milk Fridge . The FND states Dirty floors could potentially attract rodents. During a review of facility's P&P titled, Cleaning Schedule, dated October 1, 2014, the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 10. During a concurrent observation and interview, on 12/13/22, at 10:05 a.m., with CK 1 (Cook 1), there was an open English Muffin package with a used by date of 12/11/22. CK 1 stated the used by date was on 12/11/22. CK 1 stated, The English muffin is expired. It is not supposed to be in the kitchen. During an interview on 12/13/22, at 3:14 p.m., with the RD and FND, the FND stated the open English Muffin package should have been thrown out as indicated by the used by date. The RD stated The English Muffin what was open was expired. We just do not want to serve it to the residents. During a review of the facility's P&P titled, Food Storage, dated July 25, 2019, the P&P indicated Food items will be stored, .with good sanitary practice . All items will be correctly labeled and dated . 11. During an observation on 12/13/22, at 10:30 a.m., five condiments (A condiment is a spice added to food during preparing/production of foods to enhance the flavor, or to complement the dish) (1 gallon: Browning & seasoning sauce, Worcestershire sauce, liquid smoke concentrated seasoning) (2- 5 pounds containers: Basil leaves and ground black pepper) had sauce spilled over the outside of the bottles and was covered with brown/black debris. During a concurrent observation and interview, on 12/13/22, at 3:26 p.m., with the RD and the FND, the RD and FND stated the 5 condiments - had sauce spilled over outside the bottles and was covered with brown/black debris. The FND and the RD stated The condiments should be cleaned as there is a potential for cross contamination. During a review of facility's P&P titled, Cleaning Schedule, dated October 1, 2014, the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department . During a professional reference review according to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 12. During an observation on 12/13/22, at 9:45a.m., in the meat freezer, a box packaging of pork sausage was open and the package inside was open, unsealed and exposed to air. During an observation on 12/13/22, at 11 a.m., two boxes (cookie dough and chocolate chip cookies dough) were open and the packaging was also open to air in the dry storage freezer. During a concurrent observation and interview, on 12/13/22, at 2:57p.m., the RD and FND stated a box of opened diced carrot was left uncovered and exposed in the reach in vegetable freezer. The RD and the FND stated leaving the food open to air could result in freezer burn and had the potential to alter the food quality and palatability. During a concurrent observation on 12/13/22, at 2:57 p.m., the RD and the FND stated there was a box of opened pork sausages that was left uncovered and exposed in the reach in meat freezer. During a concurrent observation and interview, on 12/13/22, at 3:34 p.m., with the RD and FND, the RD and FND stated the cookie dough package in the box was open and exposed to air in the reach in freezer located in the dry storage room. During a review of the facility's P&P titled, Food Storage, dated July 25, 2019, the P&P indicated Food items will be stored, thawed and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated. Under the .II. Frozen .Food Guidelines .Foods to be frozen should be store in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers .

Based on observation, interview, and record review, the facility failed to dispose garbage under sanitary conditions when trash dumpsters were left uncovered, and trash were found on the floor surrounding the trash dumpsters. This failure had the potential to attract rodents, insects and flies and could spread infection which placed residents at risk for foodborne illness. Findings: During an observation on 12/13/22, at 8:41 a.m., in the facility trash dumpster area near the employee parking spaces, Two of three trash dumpster's lids were open and uncovered. There was an unknown food substance that was yellow in color and there were trashes which included gloves, plastic wrapping and paper on the floor surrounding the trash dumpsters. During a concurrent observation and interview, on 12/13/22, at 3:38 p.m., with the Registered Dietician (RD) and the Food and Nutrition Service Director (FND), outside at the facility's trash dumpster area, two of three trash dumpsters lids were not closed properly, one trash bag hanged over the edge of the dumpster and one bag laid on top of the lid of another dumpster. The RD and FND stated the trash dumpsters should not have bags on top of the trash dumpster lid and there should be no trash bags hanging over the edge of the trash dumpster, The RD stated, It is not okay, it will attract rodents. The FND stated, I am surprised they did not close the lids. The FND and RD stated, it was unacceptable to have the trash dumpsters without the trash lids closed properly because it could attract pests and rodents. During a review of the facility's policy and procedure (P&P) titled, Waste Management, revised April 21,2022, the P&P indicated, .Close and dispose regulated waste according to state and federal regulations . During a review of the Food and Drug Administration (FDA) Food code 2017, Annex 3 section 5-501.15 Outside Receptacles, the FDA food code indicated, Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils.Outside receptacles must be .with tight-fitting lids and covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on 12/13/22, at 11:02 a.m., with Resident 32, in Resident 32's room. Resident 32 had an oxygen cannula (a device used to deliver supplemental oxygen) connected to an oxygen concentrator. The oxygen was being given at 1L/min (LPM/Liters Per Minute, unit of measurement). The oxygen concentrator filter was covered by white and grey material . Resident 32 stated the dirty oxygen filter was not acceptable and possibly the reason for her sneezing today. Resident 32 stated she wanted the oxygen concentrator to be cleaned. During a concurrent observation and interview in Resident 53, Resident 21, Resident 17, Resident 360, Resident 359, Resident 208, and Resident 357's room with Licensed Vocational Nurse (LVN) 2, on 12/13/22, at 11:14 a.m., LVN 2 looked at Resident 53, Resident 21, Resident 17, Resident 360, Resident 359, Resident 208, and Resident 357's oxygen concentrator filters and stated the filters were not clean and were filled with dust and lint. LVN 2 stated facility residents who received supplemental oxygen with dirty filter could contribute to an increase risk of respiratory infections. LVN 2 stated using oxygen concentrators with dirty filter was not acceptable. During an interview with the Director of Central Supply (DCS) on 12/16/22, at 3:40 p.m., the DCS stated he was responsible for checking and cleaning the oxygen concentrator filters on a weekly basis. The DCS stated, I clean the oxygen concentrator filters every Tuesday or Wednesday. The DCS validated Resident 53, Resident 21, Resident 17, Resident 360, Resident 359, and Resident 357's oxygen concentrator filters were dirty. The DCS stated if the oxygen concentrator filters were dirty, the oxygen generated from the machine could cause the residents to become ill. The DCS stated using an oxygen concentrator with dirty filter was not acceptable. The DCS stated he does not have a weekly log of oxygen concentrator filters that he dusted and cleaned. During an interview with the Director of Nursing (DON) on 12/19/22, at 10:12 a.m., the DON stated using supplemental oxygen concentrators with dirty filter was not acceptable and could potentially cause residents to become ill. The DON stated the purpose of the filter was to remove impurities (small particles) and prevent residents from inhaling dirty oxygen. The DON stated residents using supplemental oxygen concentrators with dirty filters could have respiratory infection such as pneumonia or bronchitis. The DON stated she expects oxygen concentrator filters are cleaned weekly and as needed for the safety and well-being of all residents receiving supplemental oxygen. The DON stated, Everyone is responsible in keeping our resident safe. I expect our staff to report dirty oxygen concentrator filters to the charge nurse immediately so she or he can notify the Central Supply Director. During an interview with the Administrator (ADM) on 12/19/22, at 10:50 a.m., the ADM stated using supplemental oxygen concentrators with dirty filter was not acceptable and could potentially worsen resident's respiratory illness. The ADM stated she expects the DCS to follow the physician's order to inspect and clean the oxygen concentrator filters every Tuesday and to report to the ADM or DON for any delay in completing the task. The ADM stated she expects the DCS to have a log for the weekly cleaning of oxygen concentrator filters. During a review of Resident 53's admission Record, dated 12/14/22, the AR indicated, Resident 53 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Respiratory Failure (the inability of the lungs to adequately provide oxygen into the blood), Chronic Obstructive Pulmonary Disease (COPD, (constriction of the airway with difficult breathing), and Hypertension (high blood pressure). During a review of Resident 53's MDS, dated 12/2/22, the MDS indicated Resident 53's BIMS score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 53's OSR dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 1 LPM [Liters Per Minute, unit of measurement] VIA NASAL CANNULA Continuously every shift DX:COPD . Order Date 11/18/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM [morning] . Order Date 11/18/2022 . During a review of Resident 53's CP dated 12/14/22, the CP indicated, . The resident has COPD . Date Initiated 11/18/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 21's AR, dated 12/14/22, the AR indicated, Resident 21 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included COPD, Hypertension, and Congestive Heart Failure (CHF, weakness in the heart where fluid accumulates in the lungs). During a review of Resident 21's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA Continuously every shift DX:COPD . Order Date 11/17/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 11/17/2022 . During a review of Resident 21's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy . Date Initiated 10/20/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 17's AR, dated 12/14/22, the AR indicated, Resident 17 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included COVID-19 (A highly contagious respiratory disease caused by the SARS-CoV-2 virus), Muscle Weakness, Hypertension, and Hyponatremia (low level of sodium in the blood). During a review of Resident 17's Order Summary Report (OSR), dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA as needed for SOB [Shortness of Breath] . Order Date 12/14/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 11/10/2022 . During a review of Resident 17's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy r/t [related to] Ineffective gas exchange . Date Initiated 11/10/22 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 360's AR, dated 12/14/22, the AR indicated, Resident 360 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included COVID-19, COPD, Malignant Neoplasm of Kidney (cancer of the kidney), Right Leg Pain, and Dependence on Supplemental Oxygen During a review of Resident 360's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 4 LPM VIA NASAL CANNULA Continuously every shift . Order Date 12/05/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 12/05/2022 . During a review of Resident 360's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy r/t Ineffective gas exchange . Date Initiated 12/05/22 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 359's AR, dated 12/14/22, the AR indicated, Resident 359 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included COPD, Hypertension, Congestive Heart Failure and End Stage Renal Disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 359's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA Continuously every shift . Order Date 12/01/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 12/01/2022 . During a review of Resident 359's CP, dated 12/14/22, the CP indicated, . The resident has COPD . Date Initiated 12/01/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 208's AR, dated 12/14/22, the AR indicated, Resident 208 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Congestive Heart Failure, Hypertension, and End Stage Renal Disease. During a review of Resident 208's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 3-5 LPM VIA NASAL CANNULA Continuously every shift . Order Date 12/02/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 12/022022 . During a review of Resident 208's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy r/t CHF . Date Initiated 12/02/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 357's AR, dated 12/14/22, the AR indicated, Resident 357 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Respiratory Syncytial Virus (RSV, a common respiratory virus that usually causes mild, cold-like symptoms), Respiratory Failure (a serious condition that makes it difficult to breathe), and Hypertension. During a review of Resident 357's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA as needed for SOB . Order Date 12/09/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 11/09/2022 . During a review of Resident 357's CP, dated 12/14/22, the CP indicated, . Impaired Gas Exchange Pneumonia . Date Initiated 12/13/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of the facility's document titled, Job Description: Director of Central Supply, undated, the document indicated, . Principal Responsibilities . ADMINISTRATIVE . Operates Medical Records and Flotation Therapy Departments . Participates in meetings and in-services as required . Conducts in-services as required . CONSUMER SERVICE . Adheres to Company standards for resolving consumer concerns . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2016, the manual indicated, .Cleaning the Cabinet Filter .1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc. 2. Clean the cabinet filter with a vacuum cleaner or wash with a mild liquid dish detergent and water. Rinse thoroughly. 3. Thoroughly dry the filter and inspect for fraying, crumbling, tears and holes. Replace filter if any damage is found. 4. Reinstall the cabinet filter . During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/2017, The P&P indicated, . Oxygen is administered under safe and sanitary conditions to meet resident needs . E. If oxygen concentrators are used, the filters will be cleaned per manufacturer's guidelines . F. There will be a log to maintained to identify each time the filters are changed . During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident Care Equipment, dated 1/2012, The P&P indicated, . Resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected according to current CDC recommendations for disinfection . 2. During a concurrent observation and interview on 12/15/22, at 9:45 a.m., with Laundry Staff (LS) 1, in the laundry area, LS1 stated there were five plastic bags of wet and soiled mops and cleaning cloths on the floor. LS1 stated the housekeeping staff left the bags on the floor, instead of placing the dirty mops and cleaning cloths in a barrel. LS1 stated the housekeeping staff should place their dirty mops and cleaning cloths in a barrel to prevent the spread of infection. LS1 stated the facility does not have a designated barrel for dirty mops and cleaning cloths. During an interview with Housekeeper (HK) 1 on 12/16/22, at 9:37 a.m., HK 1 stated she left five bags of wet and soiled mops and cleaning cloths on the floor in the laundry area yesterday [12/15/22]. HK 1 stated the housekeeping staff does not have a designated barrel to place soiled mops and cleaning cloths. HK1 stated the current practice of placing plastic bags of wet and soiled mops and cleaning cloths on the floor in the laundry area could result in contamination and spread of infection. During an interview with the Director of Plant Maintenance (MAIND) on 12/16/22, at 11:00 a.m., the MAIND stated the housekeeping staff does not have a designated barrel to place soiled mops and cleaning cloths. The MAIND stated the current practice of placing plastic bags of wet and soiled mops and cleaning cloths on the floor in the laundry area was unsanitary and not according to facility's infection prevention and control policy. The MAIND stated the contaminated fluids could leak through the bag and exposed staff handling the laundry to infectious bacteria and viruses. During a review of the facility's document titled, Job Description: Housekeeper, 12/2022, the document indicated, . The housekeeper cleans and maintains the cleanliness of the facility . Responsibilities . 1. Daily cleaning of all resident rooms and bathrooms as assigned . 3. Terminal cleaning of resident rooms and bathrooms at the time of discharge or death or as directed or assigned . 9. Report supply needs to your supervisor . During a review of the facility's document titled, Job Description: Director of Plant Maintenance, undated, the document indicated, . Principal Responsibilities . Ensure a safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, State and Corporate Requirements . During a review of the facility's policy and procedure (P&P) titled, Soiled Laundry and Bedding, dated 9/2016, The P&P indicated, . Contaminated laundry is placed in a bag or container at the location where it is used to prevent contamination during transport . Housekeeping Staff and Nursing Staff place and transport contaminated laundry that is wet enough to potentially leak or soak through the bag or container in double bags, leak-proof bags or leak proof containers . During a professional reference review retrieved from the American Journal of Infection Control, titled, Are hospital floors an underappreciated reservoir of transmission of health care-associated pathogens? dated 2017, the article indicated, . Effective disinfection of contaminated surfaces is essential to prevent nosocomial transmission of pathogens such as Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Efforts to improve disinfection usually focus on surfaces that are frequently touched by the hand s of health care workers or patients (e.g., bedrails and call buttons). Although health care facility floors are often heavily contaminated, limited attention has been paid to disinfection of floors because they are not frequently touched. However, floors are a potential source of transmission because they are often contacted by objects that are subsequently touched by hands (e.g., shoes and socks). In a recent study, it was reported that nonslip socks worn by hospitalized patients were frequently contaminated with MRSA and VRE . Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Nine of sixteen sampled residents' (Resident 4, 408, 53, 21, 17, 360, 359, 208 and 357) oxygen concentrator (a device that concentrates the oxygen from the ambient air) filters were found with lint and dust. This failure placed Residents 4, 408, 53, 21, 17, 360, 359, 208 and 357 at an increased risk to develop respiratory and healthcare-associated infections. 2. Five bags of wet, soiled mops and cleaning cloths were found on the floor in the laundry area. This failure had the potential to result in cross contamination and placed residents at risk to develop an infection. Findings: 1. During a concurrent observation and interview on 12/13/22 at 11:03 a.m., in Resident 4 and Resident 408's room with Licensed Vocational Nurse (LVN) 1, LVN 1 pulled out the oxygen concentrator filters and stated they were dirty with white and gray dust. LVN 1 stated the filters should be clean and the cleaning schedule was on the medication administration record (MAR). LVN 1 reviewed Resident 4 and 408's December 2022 MAR that cleaning had not been done. During a review of the admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) for Resident 408, the AR indicated Resident 408 was admitted to the facility on [DATE] with diagnoses which included; acute respiratory failure with hypoxia (not enough oxygen in the blood), pneumonia (an infection that inflames the air sacs in one or both lungs), muscle weakness generalized, atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and adult failure to thrive (a decline resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability). During a record review of the Resident 408's Mininum Data Set (MDS-an assessment tool which indicates physical, medical and cognitive abilities), dated 12/13/22, Resident 408's Brief Interview for Mental Status (BIMS-assessment of cognitive function) indicated a score of 14 of 15 points which indicated Resident 408 had no cognitive impairment. During a review of Resident 408's Order Summary Report (OSR), dated 12/14/22, the OSR indicated, Oxygen 2 LPM [liters per minute] NASAL CANNULA Continuously every shift DX:ACUTE RESPIRATORY FAILURE WITH HYPOXIA .Order Date 11/29/22 .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue DX; ACUTE RESPIRATORY FAILURE WITH HYPOXIA .Order Date 11/29/22 . During a review of Resident 408's care plan (CP), the CP indicated, The resident has oxygen therapy r/t [related to] Ineffective gas exchange . Date Initiated12/01/22 .Interventions .Oxygen 2 LPM [liters per minute] NASAL CANNULA Continuously every shift DX: ACUTE RESPIRATORY FAILURE WITH HYPOXIA Date Initiated 12/01/2022 .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue DX: ACUTE RESPIRATORY FAILURE WITH HYPOXIA Date Initiated 12/01/2022 . During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included muscle weakness generalized, anxiety disorder, atrial fibrillation, atherosclerotic heart disease (blood vessels that carry oxygen and nutrients from the heart become thick and stiff, restricting blood flow) and hypertension. During a record review of the Resident 4's MDS, dated [DATE], Resident 4's BIMS score was 6 of 15 points which indicated Resident 4 had cognitive impairment. During a review of Resident 4's OSR, dated 12/14/22, the OSR indicated, Oxygen 5 LPM VIA NASAL CANNULA Continuously every shift DX: COVID .Order Date 11/07/22 .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue .Order Date 11/07/22 . During a review of Resident 4's CP, the CP indicated, The resident has oxygen therapy r/t [related to] Ineffective gas exchange .Date Initiated 11/07/2022 . Oxygen 5 LPM [liters per minute] NASAL CANNULA Continuously every shift DX: COVID .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue .Date initiated 11/07/2022.

Based on interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 5/29/21. This failure placed Resident 1's safety at risk for injuries when Resident 1 was found on 5/29/21 by a passerby at the street in an apartment complex which placed Resident 1 at risk for harm due to exposure to traffic, sun, and increased temperature. Findings: During a review of Resident 1's record dated 5/29/21 at 1:54 p.m., the record indicated licensed vocational nurse (LVN) 1 was called by the police department at approximately 1:10 p.m. notifying her that Resident 1 was down the street at an apartment complex and Resident 1 had said she did not want to stay at the facility anymore. LVN 1 went to the location of Resident 1 and stayed there until the police were on scene. During an interview on 6/18/21 at 1:10 p.m. with the administrator (ADM), the ADM stated she was called at home on Saturday 5/29/21 about Resident 1 by LVN 1 who was working at the facility that day. The ADM stated after getting call, she went to the facility. The ADM stated Resident 1 was with LVN 1 and that the police had been called. The ADM stated the police felt Resident 1 should go to the hospital, so the doctor was called for an order and Resident 1 was transported by ambulance to the emergency department (ED). The ADM stated Resident 1 did not stay at the hospital very long and was returned to the facility. During an interview on 6/18/21 at 2:30 p.m. with LVN 1, LVN 1 stated she was passing meds on 5/29/21 and had given a medication to Resident 1 at 11:30 a.m. and stated Resident 1's demeanor was fine at that time. LVN 1 stated lunch trays get passed around 12 p.m. and staff pick up trays starting around 12:50 p.m. LVN 1 stated Resident 1 had a Wanderguard on, but it did not go off or no one heard an alarm sound. During an interview on 6/18/21 at 3 p.m. with Resident 1, Resident 1 stated she intentionally left the faciity on 5/29/21, Resident 1 stated she was sitting in her wheelchair out in front of the entrance to the facility. Resident 1 stated she was tired of being there that day and had just had enough and wanted to leave so she did. Resident 1 stated she did not have a specific place she planned to go to she just wanted to leave. Resident 1 stated a woman stopped her car when she saw her down the street by the apartments and helped her get to the shade under a tree. Resident 1 stated one of the wheels to her wheelchair seemed to be stuck in an uneven area of the grass. Resident 1 stated she was taken back to the facility and then transported to the emergency department at the nearby hospital. where she was checked out and sent back to the facility. During an interview on 6/18/21 at 3:50 p.m. with the Certified Nursing Assistant (CNA) 1, CNA 1 stated she was on duty on 5/29/21 and took care of Resident 1. CNA 1 stated she recalled Resident 1 was her normal self that day. CNA 1 stated she served Resident 1 her lunch tray in her room around 12 p.m. and would have picked up trays around 12:45 p.m. CNA 1 stated Resident 1 did not appear upset. CNA 1 stated she started rounds at 1 p.m. CNA 1 stated she was not aware Resident 1 had left the facility. During a review of Resident 1's MDS (Minimum Data Set -Resident Assessment Instrument) section C dated 4/26/21, the MDS indicated, Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident 1 had no cognitive impairment. During a review of Resident 1's MDS section G dated 4/26/21, the MDS indicated Resident 1 required assistance to walk and relied on a wheelchair or a walker. During a review of Resident 1's Care Plan, the Care plan dated 10/17/19, the care plan indicated, The resident is at risk for elopement and indicated on 5/4/21 a Wanderguard to be worn at all times. During a review of the facility's policy and procedure (P&P) Elopements dated 5/2020, the P&P indicated, .The facility will identify residents who are at risk for elopement and strive to prevent harm .If identified as at risk for elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain safety . During a review of a professional reference found at:www.weatherunderground.com, it indicated the temperature at the location of the facility on 5/29/21 at the time of Resident 1's elopement was approximately 85 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge Minimum Data Set (MDS- a screening of the resident's clinical and functional status) assessment for one of 16 sampled residents (Resident 1). This failure to complete and submit a discharge MDS resulted in the potential harm of not coordinating needed services upon discharge. Findings: During a review of the clinical record for Resident 1, the admission Record, undated, indicated the resident was admitted to the facility on [DATE] with diagnoses of palliative (specialized medical care to manage symptoms and side effects of chronic or life limiting illness) care and non-Hodgkin lymphoma (a group of blood cancers). During a review of the clinical record for Resident 1, the Resident Transfer Record, dated 10/25/19, at 1:39 PM, indicated Resident 1 was transferred to another facility, Per resident choice. During an interview with the Resident Care Supervisor (RCS), on 4/5/19, at 1:26 PM, she stated Resident 1 was admitted to the facility on [DATE] and then transferred to another facility per Resident 1's request sometime in October of 2018. RCS reviewed the clinical record for Resident 1 and was unable to find documentation of a discharge MDS assessment. RCS stated a discharge MDS assessment for Resident 1 should have been completed. RCS stated, I missed that. RCS stated she was responsible for the coordination and submission of all residents' MDSs. The Long Term Care Facility Resident Assessment Instrument [RAI] User's Manual Version 3.0 [a guide to completing the MDS] dated July 2010 indicated in chapter 2, Discharge assessment-return not anticipated .Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days .

Based on observation, interview, and record review, the facility failed to provide safe storage and labeling of medications when: 1. A Lantus insulin pen (injectable medication to help control elevated blood sugar levels), was found in Medication Cart 3 with no open date written on the pen. 2. Two expired medications were found in Medication Cart 1. These failures had the potential for residents to receive ineffective medication which could lead to a lack of treatment of symptoms for which the medication was prescribed. Findings: 1. During a concurrent observation of Medication Cart 3 and interview with the Director of Nursing (DON), on 4/5/19, at 9:56 AM, an insulin pen was found in a drawer unopened and undated. The medication label indicated the medication was to be refrigerated until opened and discarded 28 days after opened. The DON stated the medication should have been left in the refrigerator until opened or dated. The DON stated when the medication was taken out of the refrigerator it should have dated and then considered opened. The facility policy and procedure titled Medication Storage in the Facility dated 9/25/12, indicated medications requiring refrigeration were kept at temperatures ranging from 36 degrees to 46 degrees in a refrigerator with a thermometer to allow temperature monitoring. 2. During a concurrent observation of Medication Cart 1 and interview with the DON, on 4/5/19, at 10:11 AM, an unopened box of Nitroglycerin (a medication to treat chest pain) sublingual (dissolved under the tongue) tablets 0.3 milligram (mg- a dry unit of measurement) was found with an expiration date of 4/4/19. The DON stated the medication was an as needed medication and the expiration date had passed. During a concurrent observation of Medication Cart 1 and interview with the DON, on 4/5/19, at 10:13 AM, an unopened package of Cyclobensapr (medication used to treat and relax muscle spasms) 10 mg was found with an expiration date of 2/23/19. The DON stated the medication was an as needed medication and the expiration date had passed. The facility policy and procedure titled Medication Storage in the Facility dated 9/25/12, indicated, .Outdated medications were immediately removed from stock, disposed of according to procedures for medications destruction.

Based on observation, interview, and record review, the facility failed to ensure food was prepared to meet the individual needs of residents on finger food diet for one of one sampled resident (Resident 7) when the kitchen staff failed to cut his country fried steak and sweet potato into cubes according to the therapeutic menu. This failure had the potential to result in the resident not being able to feed himself and unplanned weight loss. Findings: During a review of therapeutic diet menu titled Week 3 Tuesday, dated 4/2/19, indicated, residents were to receive glazed ham, one-half of a baked sweet potato, capri blend vegetables, cornbread, and a brownie. The alternative for glazed ham was country fried steak. The menu indicated finger food diet; ham, one-half of a baked sweet potato, and country fried steak were to be cut into cubes. During an observation of the noon meal service, on 4/2/19, at 12:31 PM, Resident 7 was served country fried steak (cut into strips), one-half of a baked sweet potato (left uncut with skin on), capri blend vegetables, cornbread, and a brownie. During a review of Resident 7's noon meal diet slip, on 4/2/19, at 12:32 PM, indicated, Resident 7 disliked pork and was on a finger food diet which required food to be cut into cubes. During a concurrent interview with the Food and Nutrition Director (FND) and record review of the therapeutic diet menu titled Week 3 Tuesday on 4/2/19, at 12:31 PM, the FND reviewed the therapeutic diet menu and stated the country fried steak and sweet potato should have been cut up into cubes. She stated the kitchen staff did not follow the therapeutic diet menu when they did not cut the meal items into cubes. FND instructed the kitchen staff to remake the plate and the country fried steak and sweet potato were cut into cubes. During an interview with the Registered Dietician (RD), on 4/4/19, at 11:44 AM, the RD stated staff should follow the menu spreadsheet and if it states cubed, the foods should be cut into cubes and not cut in strips or left whole. Record review of the facility's Diet Roster, dated 4/2/19 indicated only one resident (Resident 7) was on a finger food diet.

Based on observation, interview, and record review, the facility failed to ensure resident's food preferences were honored for one of 63 sampled residents (Resident 62) and food options of similar nutritive value were offered for one of one residents (Resident 11) on a vegetarian diet when: 1) Carrots, a known food dislike, were served on Resident 62's food tray. 2) Resident 11 was served a grilled cheese sandwich that did not follow the grilled cheese sandwich recipe. These failures had the potential to result in decreased food intake, food of lesser nutritive value, and could result in unplanned weight loss, further compromising the nutritional and medical status of residents. Findings: 1. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2019 indicated, 80 gram (gm - a dry unit of measure) Renal (pertaining to the kidney) diet. lunch meal: Three ounces (oz) Sodium Free (SF) pork chop (one each), #8 scoop (half cup) SF noodles, [half cup] of capri blend vegetables (vegetable mixture of green beans, carrots, zucchini, and yellow squash), brownie (one each), beverage (four fluid oz). During a concurrent observation of lunch meal service, interview with Food and Nutrition Director (FND), and review of Resident 62's lunch tray slip, on 4/2/19, at 11:49 AM, the staff began to serve Resident 62's lunch. The lunch tray slip indicated Resident 62 was on an 80 gram Renal, Mechanical soft/ground texture/consistency diet, dislikes carrots. Review of Resident 62's lunch tray ticket indicated, dislikes: .carrots . [NAME] 1 scooped the capri vegetables and attempted to not scoop carrots. Some carrots remained in the scoop and the scooped vegetable blend was placed on Resident 62's plate. Resident 62's lunch tray was placed on the delivery cart ready to leave the kitchen and be served to residents. During the interview, FND stated Resident 62 should not have been served carrots. Facility policy and procedure titled Menu, dated 2018, indicated .5. Menus will provide a variety of foods .and residents' food preference will be taken into consideration . During a review of the facility document titled In-service Education Program dated 11/14/18 indicated; .Staff .regulations regarding the menus, and accuracy on tray line.; the in-service was conducted by Registered Dietitian (RD); and a total of 5 attendants, including [NAME] 1 and FND signed as in attendance of the in-service. During an interview with RD, on 4/4/19 at 11:44 AM, she stated. If a resident did not like carrots then, it should not be on his tray. 2. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2019, indicated the entrée for regular lunch diet was three ounces of glazed ham. Three ounces of ham was equal to 21 grams of protein (one-ounce protein equals to seven grams of protein). During an observation on 4/2/19, at 12:21 PM, in the kitchen, [NAME] 1 prepared a grilled cheese sandwich (vegetarian option) for Resident 11. [NAME] 1 placed two slices of cheese between two slices of whole wheat bread and cooked it on the stove. [NAME] 1 served Resident 11's lunch tray with a grilled cheese sandwich, mixed vegetables and a brownie. During a review of Resident 11's lunch tray slip, dated 4/2/19, indicated Resident 11 was on a regular diet; likes Yogurt, Grilled cheese sandwich, PBJ (Peanut Butter and Jelly) sandwich, Veggie burger, Dislikes milk. [meal] Tray instructions: baked beans; Feed Instructions: VEGETARIAN, NO MEAT. During a review of the package insert for the American cheese used to prepare the grilled cheese sandwich indicated one slice of American cheese had three grams of protein (two slices of cheese equals six grams of protein). During an interview with [NAME] 1, on 4/3/19, at 9:40 AM, she stated Resident 11 was the only resident on a vegetarian diet in the facility. [NAME] 1 stated the vegetarian food choices depended on what the facility had available. During a concurrent observation in the kitchen and interview with [NAME] 1, on 4/3/19, at 9:42 AM, [NAME] 1 weighed two slices of American cheese on the scale. The two slices weighted 1.2 oz and [NAME] 1 stated that one grilled cheese sandwich should have five slices of cheese and not two. Resident 11 received approximately eight grams of protein on her grilled cheese sandwich. During a review of the recipe titled Grilled Cheese Sandwich on Wheat indicated, .Place 3-1/2 oz Cheese (5 slices of 120 CT, if purchased sliced) on dry side of bread . This would be equal to 24.5 grams of protein. During an interview with the facility RD, on 4/4/19, at 11:45 AM, RD stated that resident 11 should have had five slices of American cheese instead of two slices to be equivalent to the regular entrée portion size.

Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian (RD) approved menus were followed for the lunch meal on 4/2/19 when: 1. Ten of 13 sampled residents (Residents 10, 16, 17, 22, 35, 39, 57, 50, 53, and 219) on a carbohydrate (CC - sugars, starch [foods such as bread], and cellulose [vegetable fibers]) diet were served one-half of a brownie at lunch and the therapeutic diet menu indicated residents should receive one brownie. 2. One of one sampled residents (Resident 23) on a large portion diet was served five and a half ounces of ham instead of four ounces of ham as indicated by the therapeutic menu which resulted in this resident receiving a larger portion than prescribed. 3. One of one sampled residents (Resident 11) on a vegetarian diet was served food items not listed on the vegetarian menu. These failures had the potential to result in residents receiving over nutrition, under nutrition, or repetitive food items which could lead to disinterest of meals and could result in unintended weight loss or gain. Findings: 1. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2/19, indicated the following lunch items were included in the CC diet: 3 ounces glazed ham, one-half baked sweet potato, one-half cup of capri blend vegetables, one cornbread, one brownie, diet beverage, and whole milk. During a concurrent observation of the lunch meal service and interview with Dietary Aid (DA) 1, on 4/2/19, at 11:49 AM, she stated all residents on the CC diet get small (one-half) brownies. During an observation of the lunch meal service on 4/2/19, at 11:49 AM, 10 of 13 residents (Residents 10, 16, 17, 22, 35, 39, 57, 50, 53, and 219) on the CC diet received the small (one-half) brownie on their lunch trays. During a concurrent interview with the Food and Nutrition Director (FND) and record review of the 4/2/19 therapeutic lunch menu, on 4/2/19, at 12:17 PM, she stated all residents on the CC diet get a small (one half) brownie. After reviewing the therapeutic lunch menu, FND stated all residents on the CC diet should have received a full brownie and instructed the kitchen staff to start giving the residents on the CC diet a full brownie on their tray beginning immediately. During a record review of the lunch meal service diet slip titled Noon Meal - Tuesday, dated 4/2/19, indicated, 10 of 13 residents on the CC diet received one-half brownie (Residents 10, 16, 17, 22, 35, 39, 57, 50, 53, and 219) instead of one brownie. During an interview with the RD, on 4/4/19, at 11:44 AM, she stated the kitchen staff should have followed the therapeutic menu prescribed portion size and provided one brownie to residents on the CC diet. 2. During a review of the therapeutic diet menu titled Week 3 Tuesday dated 4/2/19, indicated, the regular portion of ham was three ounces and a large portion should be four ounces. The menu indicated residents on a fortified diet were to receive six ounces of super soup. During an observation of the lunch meal service, and a concurrent record review of the lunch diet slip titled Noon Meal - Tuesday, dated 4/2/19, at 12:22 PM, indicated Resident 23 was on a regular, fortified, large portion, chopped meat diet. Resident 23 was served two slices of ham chopped, one baked sweet potato, one-half cup of capri blend vegetables, one piece of cornbread, one brownie, diet beverage, and six ounces of super soup. During a concurrent observation and interview with [NAME] 1, on 4/2/19, at 12:23 PM, [NAME] 1 stated she served Resident 23 two slices of ham for the large portion. [NAME] 1 stated all slices of meat were sliced to three ounces prior to cooking. She weighed one slice of ham at three ounces and two slices of ham at five and a half ounces. [NAME] I stated resident 23 received the wrong ham portion size. She stated Resident 23 received five and a half ounces of ham instead of four ounces of ham as indicated by the therapeutic larger portion menu. 3. During a concurrent observation of the lunch meal service and record review of therapeutic diet menu titled Week 3 Tuesday dated 4/2/10, at 12:23 PM, indicated, Resident 11 was given a grilled cheese sandwich, vegetable blend, and a brownie. The therapeutic diet menu did not indicate specific vegetarian diet meal options to serve residents. During an interview with [NAME] 1, on 4/3/19, at 9:40 AM, she stated Resident 11 was the only resident on the vegetarian diet and she would ask the FND what the resident was supposed to be served. FND stated Resident 11 was served vegetarian food items depending on what the facility had available. [NAME] 1 stated Resident 11 would have the veggie patty instead of Salisbury steak for lunch that day. During a concurrent lunch meal observation and interview with Resident 11 in the dining room, on 4/3/19, at 12:35 PM, Resident 11 stated the facility did not have many vegetarian options for her. Resident 11's lunch meal tray consisted of: fettuccini Alfredo, one veggie patty, green beans, pineapple pieces and a roll. During an interview with the FND, on 4/3/19, at 2:34 PM, she stated the facility had a vegetarian resident and a vegetarian menu but they did not use it. FND stated the vegetarian menu was the same as the regular menu except for the meat. FND stated the facility did not follow the vegetarian menu because Resident 11 did not like some of the options. FND stated the cooks communicate amongst themselves to make sure Resident 11 did not have the same thing every meal. FND stated the cooks determined the protein equivalent food option for the resident. She stated Resident 11 was not told of her vegetarian options but Resident 11 could ask if she wanted to know. FND stated the facility did not have a written record of vegetarian protein items Resident 11 had served. During an interview with [NAME] 2, on 4/3/19 at 2:47 PM, she stated Resident 11 would receive a veggie patty for dinner. The FND interrupted the interview and told [NAME] 2 that Resident 11 was served a veggie patty for lunch. [NAME] 2 stated she would change the option and Resident 11 would be served a grilled cheese sandwich for dinner. The FND interrupted the interview once again and told [NAME] 2 that Resident 11 was served a grilled cheese sandwich for lunch the day before. [NAME] 2 stated the facility serves Resident 11 what is on the menu. [NAME] 2 stated she would ask the AM cook what Resident 11 was served for lunch and tried not repeat the same item. During a review of facility Vegetarian Menu titled Week 3 .Vegetarian ., dated 4/2/19, indicated, the lunch meal was: sautéed tofu, baked sweet potato, vegetable blend, cornbread with margarine, and brownie. The vegetarian menu dated 4/3/19 indicated, the lunch meal was: black eye pea patty, fettuccini Alfredo, green beans, roll with margarine, and pineapple. The menu dated 4/3/19, indicated, the dinner meal was: Vegetarian chili, green salad, cornbread, and fruit cocktail. During a concurrent interview with the RD and the FND and record review of the Week 3 . Vegetarian Cycle, on 4/4/19, at 10:23 AM, RD and FND stated the facility did not follow the vegetarian menu that was planned and approved. The FND stated the facility did not document and track what they served Resident 11 each day and the cooks did not always accurately communicate about what was served to Resident 11. The RD stated they had a substitution list for the vegetarian menu but had not documented anything regarding Resident 11's preferences on it. The RD and FND stated the facility only had a garden burger patty and no other type of patties. The vegetarian menu had a vegetarian sausage patty, black eye pea patty, oat nut patty, lima bean patty, and vegetable patty listed for the week. The RD stated a variety of vegetarian options was important and the staff needed to follow the menu since she had approved it. The facility policy and procedure titled Menus: Menu Substitution dated 2018, indicated the FND was responsible for supervising meal preparation and service to assure the menu was followed and served as planned. Menu substitutions must be made from the same food group as the omitted item. Menu substitutions remained in effect for the entire menu cycle and should be approved and signed off by the RD. The facility kept a Menu Substitution Record which included the date, food item to be changed, food item substituted and the reason, on file for 30 days. The menu substitutions are noted in writing on the back of the menu or on a separate Menu Substitution Record along with the reason for the change noted.

Based on observation, interview and record review, the facility failed to ensure the kitchen staff demonstrated the appropriate competencies and skills to safely and effectively carry out the functions of the food and nutrition service when: 1. [NAME] 1 failed to follow proper hand hygiene and glove usage while preparing and serving food. 2. [NAME] 2 was not able to verbalize appropriate cool down procedures. These failures placed the 63 residents in the facility at risk of getting food-borne illness. Findings: 1. During an observation of the lunch meal service on 4/2/19, at 11:45 AM, [NAME] 1 used the same gloved hands to touch cooked ham, the paprika container from the spice shelf, and the cooked sweet potatoes. [NAME] 1 then removed her gloves, grabbed a clean spatula, returned to meal service, and donned gloves without washing her hands between tasks. During a concurrent observation of pureed food preparation and interview with [NAME] 1 in the kitchen, on 4/3/19, at 10:58 AM, [NAME] 1 stated there were eight residents on pureed diets and she was preparing 10 servings of pureed Salisbury steak. [NAME] 1 removed the Salisbury steak from the oven; put on gloves without washing her hands; touched a tray, thermometer, counter, and drawer handle; then used a spatula and her gloved hand to stack the Salisbury steak. With the same gloved hands, [NAME] 1 used a thermometer to check the temperature of the Salisbury steak, cleaned the thermometer, and put it away. [NAME] 1 then used the spatula and a gloved hand to transfer the Salisbury steak to a holding tray, removed her gloves, and washed her hands. With bare hands, [NAME] 1 held a measuring cup with her fingers inside, and her thumb outside of the cup; put the measuring cup on the counter; and touched the recipe book. [NAME] 1 then put gloves on her hands without first washing her hands, poured half a cup of milk in the measuring cup, opened the microwave, and put the milk into the microwave. [NAME] 1 proceeded with the same gloved hands to puree fettuccini alfredo. During a concurrent interview with the Registered Dietitian (RD) and review of the facility policy titled Sanitation and Infection Control, Subject: Handwashing dated 2018, on 4/4/19, at 11:44 AM, the policy indicated Hands must be properly and frequently washed to prevent cross contamination of food supplies or equipment .When to wash hands .Before and after handling foods . The RD stated dietary servers were to change their gloves and wash their hands if they changed tasks and between touching foods and touching other items such as a microwave or a refrigerator. During a review of the facility Food Service In-service titled Infection control, kitchen sanitation, hand washing dated 3/27/19, indicated [NAME] 1 attended the in-service. The in-service was conducted by the Food and Nutrition Director (FND). The In-service document did not contain documentation of how the competency was evaluated after the In-Service was given. During a record review of [NAME] 1's Competency Checklist for Department of Nutrition and Food Service dated 1/29/19, indicated the competency criteria/task Sanitation: proper hand washing, use gloves correctly change gloves when necessary . before handling ready to eat food, before beginning a different task . The competency document indicated hand washing was performed with a check mark, but column of the date instruction given and the approved date/initial were left blank. During an interview with FND, on 4/4/19 at 2:11 PM, she stated her check mark on the competency checklists indicated she saw the employee correctly perform tasks over the course of the year by watching the employee and asking the employee questions pertaining to the topics on the competency checklist. FND stated if there were no concerns with the employee's performance, she checked off the task. 2. During a concurrent interview with [NAME] 2 and review of facility document titled .Cooling and Reheating Log, Time and Temperature Log for Potentially Hazardous Food on 4/3/19, at 2:29 PM, [NAME] 2 reviewed the document and stated after two hours the food needed to be 70 degree Fahrenheit (°F), then after an additional four hours needed to be 41 °F or less. If the temperature of the food was 80 degrees F at two hours, [NAME] 2 stated she would keep cooling since they had four more hours to cool the food to 41 degrees F. [NAME] 2 repeated the same process multiple times. The Cooling and Reheating Log indicated This method should not be interpreted as allowing 6 hours to cool food from 140 degrees to 41 degrees! . The facility policy and procedures titled Food Preparation, subject: Cool Down dated 2018, indicated .Food must be cooled to 70 degrees F within two hours and then to 41 degrees F within the next four hours .if food does not reach 41 degrees F within six hours, reheat until the inner temperature reaches 165 degrees F for at least 15 seconds and re-start the process (Allowance one time). During a review of the In-service titled Food Safety and Sanitation: Pre-survey prep with objectives: Reviewing with staff-handwashing .food cooling log . dated 5/2/18, [NAME] 2's signature indicated she attended. The in-service was conducted by RD. The evaluation section in the document indicated RD asked questions of staff to test their knowledge following the in-services, but was not specific about what questions were asked or to which staff. During a record review of [NAME] 2's Competency Checklist for Department of Nutrition and Food Service, dated 1/11/19, indicated one competency criteria/task Cool down (what are cool down logs, how are they used, which food item needs to have a cool down log), but there was no evaluation of competency of cool down procedures on the checklist. There was a check mark next to it dated 1/11/19, but the columns of approved with date/initials and date instruction given were left blank. During a concurrent interview with FND and record review of [NAME] 2's Competency Checklist for Department of Nutrition and Food Service, dated 1/11/19, on 4/4/19 at 2:43pm, she stated the check mark for Cool down (what are cool down logs, how are they used, which food item needs to have a cool down log) meant either she observed [NAME] 2 perform the task correctly or [NAME] 2 answered questions correctly about the task. FND confirmed the column for the date the instruction was given was left blank. The facility policy and procedure titled Orientation, In-service, & Personnel Management undated, indicated, Employee In-service Education indicated, Policy: Employees will be provided with in-services on a regular basis to provide Continuous education .Procedures: .5. Staff will be in serviced monthly on various topics, including but not limited to: a. Sanitation and infection control .g. Food handling (HACCP) and preparation. The facility policy and procedure titled Orientation, In-service, & Personnel Management undated,Employee Orientation Program indicated, Policy: All employees will receive orientation and on-going in-service education to ensure adequate knowledge and competence in all areas of food service. Procedures: .4. New employees will be trained on the job and competence verified before performing assigned duties. 5. Each new employee and DSS will sign and date a formal record of the orientation, such as an Employee Orientation Checklist and Job Skills Evaluation, upon completion. A copy of the checklist is kept on file .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food and ice in accordance with professional standards for food service safety when: 1. The ice machine was not properly sanitized per manufacturer's specifications. 2. One of two cooks (Cook 1) did not follow proper food handling practices during pureed food preparation and lunch meal preparation. 3. Expired chocolate milk was left in the dairy refrigerator and available for resident use. 4. Expired nutritional supplement was left in medication cart 1 and available for resident use. These failures had the potential for the growth of microorganisms (bacterium, virus, or fungus) and could cause foodborne illness to the 63 residents in the facility. Findings: 1. During a concurrent observation and interview with the Environmental Service Director (ESD), on 4/2/19, at 3:25 PM, the facility's ice machine contained a pinkish orange substance on the side of the trough (elongated container). The ESD confirmed the pinkish orange substance was on the side of the ice machine's trough. During an interview with the ESD, on 4/2/19, at 3:26 PM, ESD stated he cleaned the ice machine monthly and sanitized the removable parts and bin of the machine with the kitchen sanitizer ([Brand Name] quaternary ammonium) which was diluted. The ESD stated he did not run the sanitizer through the ice machine. The ESD stated he had [Brand Name] Cleaner (removes lime scale and mineral deposits from the interior of ice machines) but did not use [Brand Name] Sanitizer on the ice machine. During a record review of the [Brand Name] Indigo Series Ice Machines Installation, Use & Care Manual, dated 9/13, indicated, [Brand Name] Ice Machine Cleaner and Sanitizer are the only products approved for use in [Brand Name] ice machines. Step 15 of the Cleaning/Sanitizing Procedure manual indicated the proper amount of [Brand Name] Sanitizer (three to six ounces depending on the model number) was to be added to the water trough. Step 16 indicated [begin] Auto Ice On, check mark was to be selected and the ice machine would automatically start ice making after the sanitize cycle was complete (approximately 24 minutes). During an interview with the ESD and record review of the [Brand Name] Indigo Series Ice Machines Installation, Use & Care Manual, dated 9/13, on 4/2/19, at 4:11 PM, ESD reviewed the care manual and stated he misunderstood the manufacturer's instructions. ESD stated he used the [Brand Name] Sanitizer on the removable parts and bin of the ice machine. ESD stated he did not run the sanitizer through the ice machine as the manufacturer's manual instructed. 2. During an observation in the kitchen, on 4/2/19, at 11:27 AM, [NAME] 1 was wearing gloves while in the kitchen and used the same gloved hands to check the temperature of chopped ham and sweet potatoes. [NAME] 1 put on oven mitts, took off oven mitts, and touched the sliced ham to rearrange the pieces in the baking pan. [NAME] 1 did not remove gloves or wash hands during the observation. During an observation of lunch meal preparation in the kitchen, on 4/2/19, at 11:27 AM, [NAME] 1 used the same gloved hands to touch and chop ham, touched the Paprika container, and touched the baked sweet potatoes. [NAME] 1 then removed the gloves, retrieved a clean spatula with her bare hands, returned to the tray line [Meal service line], and put on another pair of gloves without washing her hands. During a concurrent observation of pureed food preparation and interview with [NAME] 1 in the kitchen, on 4/3/19, at 10:58 AM, [NAME] 1 stated there were eight residents on pureed diets and she was preparing 10 servings of pureed Salisbury steak. [NAME] 1 removed the Salisbury steak from the oven; put on gloves without washing her hands; touched a tray, thermometer, counter, and drawer handle; then used a spatula with her gloved hand to stack the Salisbury steak. With the same gloved hands, [NAME] 1 used a thermometer to check the temperature of the Salisbury steak, cleaned the thermometer, and put it away. [NAME] 1 then used the spatula with a gloved hand to transfer the Salisbury steak to a holding tray, removed her gloves, and washed her hands. With bare hands, [NAME] 1 held a measuring cup with her fingers inside, and her thumb outside of the cup; put the measuring cup on the counter; and touched the recipe book. [NAME] 1 then put gloves on her hands, poured half a cup of milk in the measuring cup, opened the microwave, and put the milk into the microwave. [NAME] 1 proceeded with the same gloved hands to prepare the pureed fettuccini alfredo. During an observation of the lunch meal preparation in the kitchen, on 4/3/19, at 11:30 AM, [NAME] 1 put oven mitts over her gloved hands, opened the oven, took out a tray of cooked Salisbury steaks. [NAME] 1 then took off the oven mitts, did not remove her gloves, cleaned the thermometer, and used one gloved hand and the thermometer to touch Salisbury steaks and check temperature. During an observation of the lunch meal service in the kitchen, on 4/3/19, at 11:39 AM, [NAME] 1 used gloved hands to touch rolls, garnish, and plates; chop food; and microwave alternate food choices. [NAME] 1 then returned to the lunch meal service without changing her gloves or washing her hands. During a record review of the facility's Diet Roster, dated 4/2/19, indicated 63 residents had food trays prepared in the kitchen. During an interview with the Registered Dietitian (RD), on 4/4/19, at 11:44 AM, the RD stated dietary servers were to change their gloves and wash their hands if they changed tasks and between touching foods and touching other items such as a microwave or a refrigerator. The facility policy and procedure titled Sanitation and Infection Control Subject: Handwashing dated 2018, indicated food service workers were to properly and frequently wash hands to prevent cross contamination of food supplies or equipment and hands were to be washed before and after handling foods. 3. During a concurrent initial observation in the kitchen and interview with the FND, on 4/2/19, at 9:03 AM, one unopened half gallon and one partial half gallon of chocolate milk were found in the Dairy Refrigerator with a manufacturer's expiration date of 3/31/19. No hand written open dates were on the half gallons. The FND stated the chocolate milk was expired and should have been thrown out. The FND stated the facility follows the manufacturer's expiration date on the carton. The facility policy and procedure titled Suggested Refrigerated Storage Guidelines dated 2018, indicated, .Opened milk should be discarded 7 days after opening or by the expiration date, if first. 4. During a concurrent observation of Medication Cart 1 and interview with the Director of Nursing (DON), on 4/5/19, at 10:11 AM, an opened 30-ounce bottle of nutritional supplement was found with approximately 28 ounces left and an expiration date of 11/8/18. The DON stated the nutritional supplement was expired and should have been discarded.