Based on interview and record review, the facility failed to ensure medication was given according to the physician's order for three of three sampled residents (Resident 1, 2, 3) when: 1. Resident 1 did not receive the medication Gabapentin (used for nerve pain, which can be caused by different conditions, including diabetes.) 2. Resident 2 did not receive the medication Humalog insulin (helps control blood sugar levels after meals.) 3. Resident 3 did not receive the medication Hydralazine (used to treat high blood pressure.) This deficient practice had the potential for worsening of Resident 1, 2 and 3's clinical condition. Findings: 1. During a record review of Resident 1's undated admission Record , the admission Record printed on 2/6/25 indicated, Resident 1 was admitted in the facility on 6/29/16 with an admission diagnosis of diabetes mellitus (a condition that happens when blood sugar is too high). During a record review of Resident 1's Minimum Data Set (MDS- an assessment used to guide plan of care) dated 11/19/24, indicated Resident 1's Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 13 out of 15, indicating intact cognitive status. During a concurrent interview and record review on 1/24/25 at 1:39 p.m. with Registered Nurse (RN) 1, Resident 1's Medication Administration Record (MAR) was reviewed. The MAR indicated, Resident 1's three capsules of Gabapentin 300 milligrams (mg) scheduled at 1:00 p.m. on 12/14/24 was blank. RN 1 stated the blank record in the MAR meant the medication administration was not documented. RN 1 stated MAR documentation made sure there was a record that the medication was given. During a concurrent observation and interview on 2/6/25 at 12:43 p.m. with Resident 1, in Resident 1's room, Resident 1 stated yes when asked if she was aware of taking Gabapentin for nerve pain. Resident 1 was unable to state the location of the pain. During a record review of Resident 1's Order Summary dated 1/19/22, the order indicated, Resident 1 had an order of three capsules of Gabapentin 300 mg three times a day for neuropathic pain (a chronic pain condition caused by damage or dysfunction in the nerves themselves). During a record review of Resident 1's Pain Medication Therapy Care Plan dated 9/10/21, indicated, one of the pain medication therapy interventions was to administer medications that relieve pain as ordered by the physician. 2. During a record review of Resident 2's undated admission Record , the admission Record printed on 2/6/25 indicated, Resident 2 was admitted in the facility on 2/24/24 with an admission diagnosis of diabetes mellitus. During a record review of Resident 2's MDS dated 11/26/24, indicated Resident 2's BIMS score was 12 out of 15, indicating moderate impairment of cognitive status. During a concurrent interview and record review on 2/6/25 at 3:29 p.m. with the Director of Nursing (DON), Resident 2's MAR was reviewed. The MAR indicated, Resident 2's 17 units of Humalog 100 unit/ milliliter (ml) insulin scheduled at 12:00 p.m. on 12/14/24 was blank. The DON stated the nurse probably forgot to document. During an interview on 2/6/25 at 3:59 p.m. with Resident 2, in Resident 2's room, Resident 2 stated it was important for him to receive his medication as scheduled. Resident 2 stated staff checked his blood sugar daily. During a record review of Resident 2's Order Summary dated 10/28/24, the order indicated, Resident 2 had an order of 17 units of Humalog 100 unit/ milliliter (ml) insulin with meals. 3. During a record review of Resident 3's undated admission Record , the admission Record printed on 2/6/25 indicated, Resident 3 was admitted in the facility on 10/15/21 with a diagnosis of hypertension (high blood pressure). During a record review of Resident 3's MDS dated 12/24/24, indicated Resident 3's BIMS score was 6 out of 15, indicating severe cognitive impairment. During a concurrent interview and record review on 2/6/25 at 3:32 p.m. with the Director of Nursing (DON), Resident 3's MAR was reviewed. The MAR indicated, Resident 3's one tablet of Hydralazine 50 mg scheduled at 6:00 a.m. and 12:00 p.m. on 12/14/24 was blank. The DON stated the nurse probably forgot to document. During a record review of Resident 3's Order Summary dated 4/18/24, the order indicated, Resident 3 had an order of one tablet of Hydralazine 50 mg three times a day. During a record review of Resident 3's Hypertension Care Plan dated 12/18/21, indicated, one of the hypertension interventions was to give antihypertensive (drugs used to treat high blood pressure) medication. During an interview on 2/6/24 at 3:39 p.m. with the Administrator (ADM), the ADM stated, nurses should document the medication given to the resident to know the medication was administered. During a follow up phone interview on 2/19/25 at 12:09 p.m. with RN 1, RN 1 stated if the medication administration was not documented in the MAR, it meant the medication was not given. During a review of the facility's policy and procedure (P&P) titled Medication Administration , dated 1/1/12, the policy indicated, IX. Documentation: A. The time and dose of the drug administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug; B. Recording will include the date, the time and the dosage of the medication; C. Initials is recorded on the medication record.

Based on interview and record review, the facility failed to thoroughly investigate allegation of abuse for one of two sampled residents ((Resident 75). Resident 75 alleged that a dark young male staff came to his room, knocked him on his head when he inquired about him coming to his room. The Administrator (Admin)/ designated representative did not interview Certified Nursing Assistant (CNA3) a male staff member that was assigned to provide care for Resident 75. This failure had the potential to place Resident 75 at risk for emotional distress, mistreatment or abuse. Findings: During a review of progress notes dated 5/29/23, progress notes indicated, Resident 75 reported to his daughter that a dark young staff came to his room around 3:00 p.m. on 5/27/23, knocked him on his head when he inquired about him coming to his room. During a review of Minimum Data Set (MDS), Resident assessment and care guide tool, dated 7/1/23, the MDS indicated, Resident 75 had clear speech able to make self understood and understand others. Resident 75's Brief Interview for Mental Status score was 08 (moderately impaired cognition). Resident 75 was not able to recall correct year and day of the week. Resident 75's diagnoses included Seizure Disorder or Epilepsy (a disorder of the brain). During an interview on 7/18/23 at 4:19 p.m., with Certified Nursing Assistant (CNA3), CNA3 stated, he was a care giver for Resident 75 during the night shifts . CNA3 stated, he was not aware of any allegation of abuse regarding Resident 75. CNA3 stated, that he was not interviewed or informed that Resident 75 alleged that a dark young male knocked him on his head. During an interview on 7/19/23 at 10:33 a.m., with Language Translator (LT), Resident 75 stated that everything is Ok and not to worry. During an interview on 7/19/23 at 1:28 p.m., with the Case Manager (CM), CM stated, CM and Social Services Director (SSD) were assigned by the Admin to investigate Resident 75's allegation of abuse. CM stated with SSD the language translator was used to interview Resident 75 and his daughter. CM stated Resident 75 stated that a tall dark and skinny male smacked him in the head. Case manager stated the description of the alleged perpetrator did not fit any facility staff member, so no further interview was done. CM stated, CNA3 was not interviewed. During an interview on 7/19/23 at 10:33 a.m., Administrator (Admin) stated facility process was to interview staff when the allegation involved staff member. Admin could not provide documentation of staff interview regarding Resident 75's alleged abuse. During a review of the facility's policy and procedure, titled, Abuse-Reporting and Investigations, revised March 2018, policy and procedure indicated, . To protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and maintain a care plan that was comprehensive and person-centered to meet the resident needs, for one resident (Resident 60) out of 26 sampled residents. This failure had the potential for one resident to not attain or maintain her highest practicable quality of life and/or receive quality care and services. Findings: Review of the policy and procedure titled Comprehensive Person-Centered Care Planning revised November 2018, showed it is the policy of the facility to provide person-centered, comprehensive care that reflects best practice standards for meeting health needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Procedures include creating and updating a comprehensive care plan based on the assessed needs of the resident. A Record review showed Resident 60 was a [AGE] year-old female, was admitted on [DATE] with a diagnoses including but not limited to malignant neoplasm (cancer) of the endometrium (membrane lining the uterus), type 2 diabetes (a condition that affects the way the body processes blood sugar), adult failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and depression. A record review showed in the MDS [Minimum Data Set] 3.0 Nursing Home Quarterly (NQ) Version 1.17.2 dated June 19, 2023, Resident 60 had a BIMS [Brief Interview for Mental Status; a test used to get a quick snapshot of how well a resident is functioning cognitively at the moment. A score of 13-15 suggests the resident is cognitively intact, 8-12 suggests moderately impaired, and 0-7 suggests severe impairment) score of 9. Resident 60 had documented significant weight loss over six months (10 percent weight loss in six months is considered significant) and insidious weight loss (continuous and gradual weight loss) since her admission on [DATE], poor appetite, a dislike for food at the facility, and poor intake of food (Cross-reference F806 and F809). In addition, per interviews with Resident 60 and Resident 60's brother (Family member 1, FM1), Resident 60 did not receive food she preferred from the facility (Cross-reference F806). Furthermore, Resident 60 did not receive snacks ordered twice a day by the physician (Cross-reference F808). During a record review for Resident 60, comprehensive care plans were reviewed and showed three plans related to nutrition that did not have measurable goals and interventions that reflected Resident 60's specific needs: - Plan 1 included focus areas with an initiation date of 3/22/23 and revised on 6/26/23 and were: the resident has nutritional problems or potential nutritional problems related to diagnoses including but not limited to urinary tract infection, type 2 diabetes, chronic kidney disease, depression; resident is on a therapeutic diet as ordered; resident has multiple food preferences and complaints of the taste of many foods and the resident complains she does not like the food served at the facility; poor oral intake, weight loss, and wounds noted. There was one goal created on 6/26/23 for these focus areas which read stop weight loss. Interventions for this focus area included but not limited to: supplement as ordered initiated on 6/26/23, provide, serve diet as ordered . initiated on 3/22/23, administer medication as ordered initiated on 3/22/23. - Plan 2 included a focus area initiated on 5/9/23 which read The resident has weight loss of 13.6 lbs [pounds] in 90 days. The goal initiated on 5/9/23 showed The resident will regain lost weight through the review date and showed a target date of 6/20/23. Interventions included but were not limited to: Give the resident supplements as ordered initiated on 5/9/23, alert dietitian if consumption is poor for more than 48 hours initiated on 5/9/23, monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss initiated on 5/9/23. - Plan 3 included a focus area initiated on 5/23/23 which read the resident has weight loss of 5.6 in a week. The goal for this focus area showed resident will have an increase of weight to return back to the previous weight last week with a target date of 6/20/23. The interventions for this focus area included but were not limited to alert dietitian if consumption is poor for more than 48 hours. Give the resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis. If weight declines, persists, contact physician and dietician immediately. Determine percentage lost and follow the protocol for weight loss. Offer substitutes as requested or indicated and initiated on 5/23/23. In an interview with the Director of Nutrition Services (DNS) and the Regional Registered Dietitian (RRD) on 7/20/23 10:15 a.m., the care plan for Resident 60 was reviewed. DNS stated when she developed and updated the care plan, she used the generic pull down screen in the software to add goals and interventions. RRD stated Resident 60's care plan was generic as opposed to resident-centered. She stated interventions such as provide snacks as ordered were generic and not specific to the resident. RRD stated the care plan should be resident-centered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive plan of care for one resident (Resident 60) out of 26 sampled residents, was written by a qualified staff. This failure placed one resident at risk for not attaining or maintaining her highest practicable quality of life and/or receive quality care and services. Findings: According to the California Code, Business and Professions Code, a registered dietitian may perform nutritional assessments and initiate nutritional interventions within parameters of the prescribed diet order. The dietitian shall collaborate with a multidisciplinary team, which shall include the treating physician and the registered nurse, in developing the patient's nutrition care plan. The services described may be termed medical nutrition therapy. Review of the job description titled Registered Dietitian dated 11/27/17, showed the Registered Dietitian (RD) was responsible for evaluating the Medical Nutrition Therapy needs of the residents and implementing appropriate interventions to improve their nutritional status, as well as coordinating resident care with the Interdisciplinary Team. Review of the undated job description titled Director of Nutrition Services showed principle clinical responsibilities included ensuring the timely preparation and delivery of nutritious and attractive meals and supplements to all residents according to physician's order, maintaining a safe and sanitary working environment, ensuring meals are served according to expressed resident preferences, implementing and revising menus to meet resident needs, and interacting effectively with other resident services according to the total Care Plan approach. Qualifications included a graduate of State approved course or equivalent in food service. Review of the document titled [name of college] Certificate of Completion dated June 8, 1988, showed DNS completed the State approved program for a Dietetic Service Supervisor to qualify her for the Director of Nutrition Services Position. The Dietary Services Supervisor is a certificate obtained through a program in California community colleges. This certificate is designed for those interested in food service management, especially in the healthcare field. (Information accessed on-line 7/28/23 [NAME].edu) A Dietary Services Supervisor does not have a scope of practice in the California Code, Business and Professions Code to allow the provision of Medical Nutrition Therapy During a record review for Resident 60, comprehensive care plans were reviewed and showed three plans related to nutrition that did not have measurable goals and interventions that reflected Resident 60's specific needs. (Cross-reference F657). In an interview with the Director of Nutrition Services (DNS) on 7/20/23 10:15 a.m., the care plan for Resident 60 was reviewed. DNS stated she always initiated care plans for residents and she developed the nutrition care plan for Resident 60 and added interventions.

Based on observation, interview and record review, the facility failed to provide assistance needed for toenail care as ordered by the physician for one (Resident 54) of two sampled residents when Resident 54 had crooked ingrown toenails (a condition in which the corner or side of a toenail grows into the flesh). This failure had the potential for residents prone to injury and infection Findings: During an observation on 7/17/23 at 12:05 p.m., Resident 54 was seated up in bed in her room. Resident 54 had crooked ingrown toenails During a review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/26/23, the MDS indicated, Resident 54's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 54 had clear speech. had difficulty communicating some words or finishing thoughts but is able if prompted or given time to respond. Resident 54 needed extensive assistance with personal hygiene, including combing hair, brushing teeth, washing /drying face and hands. Resident 54's diagnoses included cerebrovascular accident (CVA) or stroke. During a review of order summary report dated 4/25/23, the summary report indicated, the physician ordered Resident 54 to received podiatry service as clinically indicated. During an interview on 7/17/23 at 1:01 p.m., with Social Services Director (SSD), SSD stated, resident 54 had private insurance. SSD stated, Resident 54's family did the toe nail trimming because the toe nails were not necrotic (death of cells or tissue). During an interview on 7/18/23 at 9:31 a.m., with Director of Nursing (DON), DON stated, nursing staff are responsible for finger nail trimmings and toenail care are referred to podiatrist. DON stated Resident 54 had crooked ingrown toenails. During a concurrent interview and review of Resident 54's physician order on 7/20/23 at 9:24 a.m., with Social Services (SS) and Social Services Director (SSD), SS stated, she was not aware that Resident 54 had an order to receive podiatry services. SSD stated, facility process was for nursing department to refer resident with podiatry order to social services department. SSD stated, Resident 54 did not receive podiatry service for crooked ingrown toe nails. During a review of facility's policy and procedures, titled, Referrals to Outside Services, revised December 01, 2013, the policy and procedures indicated, .To provide residents with outside services as required by physician orders or the care plan. The Director of Social Services is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider contracts, and referring residents to existing contracted providers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one (Resident 41) of six sampled resident received treatment services to address functional limitation in range of motion when; the Rehabilitation Department did not provide Resident 41 Physical and Occupational therapy {PT/OT} as ordered by the physician. {Physical Therapy- the treatment of disease, injury, or deformity by physical methods such as massages, heat treatment, and exercise rather than by drugs or surgery}. {Occupational Therapy- a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life}. This failure had the potential to cause Resident 41 decline in mobility, range of motion, difficulty with transfers, turning and repositioning. Findings: During the Resident Council Meeting on 7/18/23 at 11:05 a.m., Resident 41 stated, she had not received any form of exercise since her admission to the facility on 5/31/22. Resident 41 stated, she did not know if she could standup by herself any more. Resident 41 stated, prior to admission she was able to transfer from bed to chair with staff assistance. Resident 41 stated, Certified Nursing Assistants' did not want to transfer her without the use of Hoyer lift (an assistive mechanical device that allows patients in nursing homes to be transfered between a bed and a chair or other similar resting places by the use of electrical or hydraulic power). During a review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/15/23, the MDS indicated, Resident 41's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 41 had clear speech, able to express ideas and wants and understood others. Resident 41 had limited range of motion and impairment to upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle and foot). Resident 41 required extensive assistance with one person physical assist with transfer to and from bed, chair, wheelchair and standing position Resident 41's diagnoses included cerebrovascular accident (CVA) or stroke. During an interview on 7/19/23 at 8:10 a.m., with Certified Nursing Assistant (CNA1), CNA1 stated, hoyer lift with 2 person assistance was used to transfer Resident 41 between bed and wheelchair. CNA1 stated, Resident 41 was total care with transfers and activities of daility living (ADLs). CNA1 stated, Resident 41 was able to hold on to side [NAME] for repositioning. During a concurrent interview and physician order summary review on 7/19/23 at 11:33 a.m., with Director of Rehabilitation (DOR1) accompanied by DOR2, DOR1 stated, she was not aware that Resident 41 had an order to receive PT/OT treatment order dated 5/10/23. DOR1 stated, Resident 41's physician order to received PT/OT was not acted upon.

Based on observation, interview and record review, the facility failed to assess and evaluate one (Resident 54) of three sampled residents for an appropriate size wheelchair when; Director of Rehabilitation (DOR1) provided Resident 54 a wheel chair that was small and tight. Resident 54 sustained a bruise (an injury appearing as an area of discolored skin on the body caused by a blow or impact rupturing underlying blood vessels) to right lateral thigh. This failure caused Resident 54 bruise to her right lateral thigh and potential to cause wheelchair bound residents injuries. Findings: During a concurrent observation and interview on 7/17/23 at 12:05 p.m., Resident 54 was seated up in bed in her room. Resident 54 showed surveyor the bruise on her right lateral thigh. Resident 54 had bruised skin discoloration area on the right lateral thigh. Resident 54's son (FM2) was at her bedside also. FM2 stated, the wheelchair assigned to Resident 54 was small for her and had caused her injury to right lateral thigh. FM2 stated, he had requested a replacement of wheelchair from the Rehabilitation Department and was told to buy his own wheelchair. During a review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/26/23, the MDS indicated, Resident 54's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 54 had clear speech but had difficulty communicating some words or finishing thoughts but is able if prompted or given time to respond. Resident 54 used wheelchair for mobility. Resident 54's diagnoses included cerebrovascular accident (CVA) or stroke. During a concurrent observation and interview on 7/17/23 at 12:10 p.m., with Director of Nursing (DON) accompanied by DOR2 at Resident 54's bedside. DON checked the bruised area on Resident 54's right lateral thigh. DON stated she was not aware of Resident 54's wheelchair was small and tight. During an interview on 7/18/23 at 10:06 a.m., DOR1 accompanied by DOR2, DOR1 stated, FM2 had requested a change of wheelchair for Resident 54. DOR1 stated, Resident 54' wheelchair was not changed or replaced because the wheelchair was appropriate. DOR1 stated, the facility process was to complete a wheelchair evaluation before wheelchair was assigned to residents. DOR1 and DOR2 could not provide documentation of wheelchair evaluation or assessment that was completed before the wheelchair was assigned to Resident 54.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dental services to meet resident's needs for one of 22 sampled residents (Resident 57) when referral to outside dentist was not acted upon. This failure had the potential to result in Resident 57 to have tooth infection, difficulty eating and weight loss. Findings: During a review of Resident 57's admission record, the admission record indicated Resident 57 was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus (an illness when the blood sugar is too high). During an interview on 7/16/23, at 10:16 a.m., with Resident 57, Resident 57 stated, the facility did not take care of her teeth and let them decay. Resident 57 stated, she did not want her teeth to be extracted. During a review of Resident 57's Social Services Director's (SSD) progress notes, dated 8/31/22, the progress notes indicated, Resident 57 was seen by the facility's visiting dentist (a dentist who provides dental examination to residents living in the facility) and was referred by the visiting dentist to outside of facility dentist for tooth fillings of tooth number 11(upper left front tooth) and tooth number 22 (lower left front tooth). During a review of Resident 57's Social Services Director's (SSD) progress notes, dated 12/1/22, the progress notes indicated, Resident 57 refused to go to her first dental appointment, SSD canceled the appointment. The SSD progress notes did not indicate that the dental appointment was rescheduled. During a review of Resident 57's Oral Health Care Patient notes written by the facility's visiting dentist, dated 1/20/23, notes indicated, Resident 57 was complaining of holes in her teeth and was already referred to the outside dentist for filling. The notes also indicated, the visiting dentist followed up with the social worker regarding the referral. During a concurrent observation and interview on 7/20/23, at 10:00 a.m., with Resident 57, in Resident 57's room, Resident 57's right lower inner tooth and left upper tooth observed with black discoloration. Resident 57 stated, she felt hurt that the facility did not schedule her appointment to the outside dentist and that her teeth got worst and rotted. During an interview on 7/19/23, at 10:25 a.m., with SSD, SSD acknowledged she did not reschedule Resident 57's dental appointment when it was canceled on 12/1/22. During an interview on 7/20/23, at 10:15 a.m., with Director of Nursing (DON), DON stated, Resident 57's dental appointment should have been rescheduled by the SSD. DON further stated, that the risks for Resident 57 on missing her dental appointment were infection, toothache, and weight loss. During an interview on 7/20/23, at 1:04 p.m., with Registered Nurse (RN) 2, RN 2 described Resident 57's right lower tooth and left upper tooth as yellow, with black color, chipped and rotting. During a review of the facility's policy and procedure (P&P) titled, Referrals to Outside Services, revised December 2013, the P&P indicated, The Director of Social Services coordinates the referral of residents to outside agencies/ programs to fulfill resident needs for services not offered by the facility. To facilitate this process the facility maintains service provider contracts with a variety of providers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide food preferences for one resident (Resident 60). This failure had the potential to result decreased nutrient intake leading to unplanned weight loss and nutritional related medical complications for one resident out of 26 sampled residents. Findings: Review of the policy and procedure titled Dietary Profile and Resident Preference Interview revised 4/21/22, showed The Dietary Manager will complete a Dietary Profile for residents to reflect current nutritional needs and food preferences . The purpose of the policy was to ensure residents were properly evaluated for dietary needs on an ongoing basis. The procedures included but were not limited to: the dietary department will provide residents with meals consistent with their preferences. If a preferred item is not available, a suitable substitute should be provided, and the Dietary Manager may update food preferences as often as necessary. According to the National Cancer Institute cancer treatments may lower appetite or change the way food tastes or smells. In addition, food preferences can change from day to day. There are days when a favorite food can taste bad. Accessed July 24, 2023. Cancer.gov A Record review showed Resident 60 was a [AGE] year-old female, was admitted on [DATE] with a diagnoses including but not limited to malignant neoplasm (cancer) of the endometrium (membrane lining the uterus), type 2 diabetes (a condition that affects the way the body processes blood sugar), adult failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and depression. A record review showed in the MDS [Minimum Data Set] 3.0 Nursing Home Quarterly (NQ) Version 1.17.2 dated June 19, 2023, Resident 60 had a BIMS [Brief Interview for Mental Status; a test used to get a quick snapshot of how well a resident is functioning cognitively at the moment. A score of 13-15 suggests the resident is cognitively intact, 8-12 suggests moderately impaired, and 0-7 suggests severe impairment) score of 9. Review of the Nutrition/Dietary Note dated 4/26//23 and written by Registered Dietitian 2 (RD 2), showed RD 2 documented Resident 60 had inadequate oral intake related to poor appetite as evidence by poor intakes and weight loss. Review of the Nutrition/Dietary Note dated 5/17/23 and written by RD2, showed RD2 documented that Resident 60 reported a poor appetite and food from home was noted at bedside. She also documented that Resident 60 had inadequate oral intake related to poor appetite and ongoing weight loss. Review of an RD Weight Assessment dated 7/10/23 and written by Registered Dietitian Nutritionist 1 (RDN1), showed RDN1 documented Resident 60 had variable and poor intake by mouth and had significant weight loss in 6 months (10 percent weight loss in six months is considered significant) as well as insidious weight loss (continuous and gradual) in 1 and 3 months. She documented Resident 60 is on medication that can affect weight and appetite. Review of the document tiled Weights and Vitals Summary showed Resident 60 had consistent weight loss with some weight fluctuation since admission. Her documented weights were as follows: 12/26/22 151.8 pounds (lbs), 12/28/22 152.2 lbs, 1/4/23 148.1 lbs, 1/11/23 148.8 lbs, 1/19/23 148.8 lbs, 2/9/.23 137.2 lbs, 4/10/23 121.4 lbs, 4/20/23 125.8 lbs, 4/28/23 116.2 lbs, 5/3/23 112.4 lbs, 5/10/23 117.4 lbs, 5/19/23 113.2 lbs, 6/22/23 110.4 lbs, 7/6/23 113.4 lbs. On 7/19/23 at 12:37 p.m., an observation and concurrent interview with Resident 60, and Resident 60's brother (Family Member 1, FM1), showed Resident 60 sitting up in bed eating food and FM1 standing at the bedside. Resident 60 stated the food she was eating for lunch was brought in by her brother. She also stated the food at the facility was bad including the taste and the presentation of the food. She said the flavor of the facility prepared food was horrible and the menu was repetitive. FM1 and Resident 60 stated the alternate meals that were available lacked variety and were very limited. FM1 stated Resident 60 received a lot of cottage cheese and fruit and the fruit was often bananas. FM1 stated Resident 60 was not asked her food preferences for a while. Resident 60 stated her diet changed to a Regular diet and no one came in to ask her food preferences when her diet changed. Resident 60 stated she was receiving chemotherapy and is no longer receiving chemotherapy treatment. FM1 stated he visited Resident 60 at the facility up to 3 days a week. Review of the Order Listing Report for Resident 60 showed a No Added Salt, Consistent Carbohydrate, Regular Textured Diet was discontinued on 6/22/23. Review of the Order Summary Report for Resident 60 showed a regular textured fortified diet was ordered on 6/22/23. In an interview on 7/19/23 at 2:01 p.m., the Director of Nutrition Services (DNS) stated it was her responsibility to get food get resident food preferences. She stated she asked resident food preferences upon admission and quarterly. She stated she also talked to residents more often about food preferences if the resident asked to speak with her. DNS confirmed the last documented visit she had with Resident 60 was 4/19/23. DNS confirmed Resident 60's food preferences from 4/19/23 were bananas and cream of wheat with margarine. She also confirmed the other documented visit for Resident 60's preferences was upon admission. Review of the Food Questionnaire dated 12/23/22 showed Resident 60 disliked carrots. Review of the Food Questionnaire dated 4/19/23, showed food preferences for Resident 60 were banana and cream of wheat - margarine. Also, under additional information a note read Resident has poor appetite and she has multiple food preferences and complaints about taste of many foods. Resident states that she does not like the food that being served here at the facility. I offer resident for a food alternate and refused. Resident brother brings food from home and has snacks of bedside table. In an interview on 7/20/23 at 9:25 a.m., Resident 60 stated she has a good appetite now and would eat more from the facility if the food was better. She stated her brother brought in food to her one to two times a week. In an interview on 7/20/23 at 10:08 a.m., DNS stated she was aware Resident 60 was not happy with the food at the facility and did not like the menu. She stated the resident liked cottage cheese and fruit and was not aware Resident 60 was tired of cottage cheese and bananas. DNS stated she purchased special food for residents to meet their preferences but did not purchase special food for Resident 60. She stated there was no need to bring in food for Resident 60 because her brother brought in food for her. In an interview on 7/20/23 at 10:21 a.m., the Regional Registered Dietitian (RRD) stated visits to a resident to ask food preferences can be dependent of the resident and needs of the resident. RRD stated for a resident who complained about food and had continuous weight loss, she expected more frequent visits to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide physician ordered snacks for one resident (Resident 60). This failure had the potential to result in increased weight loss and nutritional related medical complications for 1 resident out of 26 sampled residents. Findings: Review of the policy and procedure titled Nourishment and Snacks revised 4/1/2014, showed nourishments will be provided to offer nutritional support. The provision of nourishments requires a physician's order. Residents who may receive snacks include, but not limited to, residents who are under weight or have experienced weight loss and residents with poor intake. A Record review showed Resident 60 was a [AGE] year-old female, was admitted on [DATE] with a diagnoses including but not limited to malignant neoplasm (cancer) of the endometrium (membrane lining the uterus), type 2 diabetes (a condition that affects the way the body processes blood sugar), adult failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and depression. A record review showed in the MDS [Minimum Data Set] 3.0 Nursing Home Quarterly (NQ) Version 1.17.2 dated June 19, 2023, Resident 60 had a BIMS [Brief Interview for Mental Status; a test used to get a quick snapshot of how well a resident is functioning cognitively at the moment. A score of 13-15 suggests the resident is cognitively intact, 8-12 suggests moderately impaired, and 0-7 suggests severe impairment) score of 9. A record review for Resident 60 Review showed an untitled physician order dated 4/19/23, which read Snack twice daily two times a day for supplement. A record review for Resident 60 showed the Order Summary Report for printed on July 19, 2023, and showed the orders on the document were active orders as of 7/19/23. The document showed Snack twice daily two times a day for supplement was ordered on 4/19/23 and was started on 4/20/23. A record review for Resident 60 showed a Nutrition/Dietary Note dated 7/10/23 and written by RDN 1. The note showed Resident received snacks BID (twice a day). RDN 1 also stated, Resident 60 had variable and poor intake, with significant weight loss in 6 months (10 percent weight loss in six months is considered significant) and insidious weight loss (continuous and gradual weight loss) in 1 and 3 months, and no further weight loss was recommended. In an interview on 7/19/23 at 1:35 p.m., Regional Registered Dietitian (RRD) stated if a resident is receiving snacks, the surveyor needed to check with the kitchen to find out what type of snacks Resident 60 received. In an interview on 7/19/23 at 2:01 p.m., the Director of Nutrition Services (DNS) stated Resident 60 received fruit cups for snacks twice a day. She stated BID snacks were delivered to the residents at 10 a.m. and 2 p.m. DNS checked the snack list and Resident 60 was not on the snack list. She stated because Resident 60 was not on the snack list, she did not receive snacks. In an interview on 7/20/23 at 10:21 a.m., DNS stated it was her error that Resident 60 did receive snacks or make it to the snack list.

Based on observation, interview, and record review, the facility failed to ensure the outside garbage storage area was maintained in a sanitary condition when refuse, bones, and dark liquid waste was found on the ground surrounding the garbage receptacles. This failure put the facility at increased risk for attracting pests and potentially causing pest related disease in 95 of 95 residents. Findings: A concurrent observation and interview on 7/17/23 at 12:40 p.m. with Maintenance Assistant (MA), showed the outside garbage area included garbage, green waste, and recycling dumpsters. On the ground, just to the left of the garbage dumpster were bones and debris such as discarded plastic bottles containing fluid, latex gloves, food packaging and paper napkins. There was also a significant amount of dark liquid waste on the ground in front of the garbage and green waste dumpsters. The dark liquid came from the green waste dumpster and had paper debris sticking to it such as straw wrappers. In addition there was a significant amount of flies and ants surrounding the liquid and the green waste dumpster and there was a thick, brown and black residue on the outside surface along the ledge of the dumpster and black drip marks covering the front surface. Inside the green waste dumpster were bags of discarded food and food containers. MA confirmed the green waste dumpster was used for food waste. MA also stated the area was not clean and could cause pest or rodent problems. MA also stated the facility did not keep maintenance logs for the cleaning of the external garbage area to show when the area was cleaned last. During a review of Pest Elimination Service Report dated 7/6/23, the service report recommended removing clutter, debris and vegetation away from building to deter pest activity. During a review of the facility's policy and procedure titled, Waste Management, dated 4/21/22, indicated the facility is to maintain safe, secure and clean holding area for waste. The policy further indicated the facility is to clean area once daily and whenever spills occur.

Based on observation, interview, and document review, the facility failed to provide palatable pureed bread for 11 residents on a pureed textured diet and palatable bread rolls for at least 10 residents on a regular textured diet. Serving food that was not palatable had the potential for 21 of 95 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Findings: During a concurrent observation and interview on 7/18/23 at 11:30 a.m. with [NAME] 2 in the kitchen, tray line (process where food is plated according to order and placed on trays to serve) was observed. [NAME] 2 placed a scoop of a pureed white substance on the plates with diet orders for a pureed diet. [NAME] 2 stated, the white pureed substance being placed on puree trays was pureed bread. In addition, a large pan held bread rolls and [NAME] 2 placed bread rolls from the pans on plates for residents with a regular texture diet. More than 10 of the bread rolls in the pan were flat compared to the rest of the rolls which were more spherical shaped. During a concurrent observation and interview on 7/18/23 at 12:55 p.m., with Regional Registered Dietician (RRD), in small dining room, regular and puree diet test trays were sampled. The pureed bread was white in color and was very bland. The flat wheat roll served on the regular diet tray was very bland, had very little flavor and the texture was dense compared to the spherical wheat roll which tasted more like yeast (agent used to make bread rise, or become expanded) bread and the texture was more light and airy. RRD stated the flat wheat roll was denser and bland. RRD stated she was thinking the flat rolls didn't rise the same at the spherical-shaped rolls. During an interview on 7/18/23 at 1:00 p.m. with [NAME] 2, [NAME] 2 stated she prepared the pureed bread and used breadcrumbs and milk instead of pureeing the bread rolls. During an interview on 7/19/23 at 10:36 a.m. with Regional Registered Dietician (RRD), RRD stated bread should be used for puree bread instead of breadcrumbs. RRD stated the recipe should be followed and it would be better to use bread versus breadcrumbs for palatability. RRD also stated she didn't know why some of the wheat rolls were flat and dense yesterday because they came from boxes that were labeled the same. During a review of Recipe: Pureed Breads .and other Bread Products, (undated), the Pureed Bread Recipe indicated complete regular recipe and measure out the total number of portions needed for puree diets. The recipe instructed puree at low speed and gradually add milk according to serving size. During a review of Summer Menus, dated Week 3 Tuesday . 7/18/23, the menu indicated one-half or one wheat roll for regular texture, pureed, carbohydrate controlled, and renal diets.

Based on observation, interview, and record review, the facility failed to ensure Freezer #3 was maintained in good repair when the rubber gasket (a rubber piece that surrounds the inside perimeter of the freezer door to help keep the cold air in) around the interior perimeter of the door was torn and peeled away from the door. This failure had the potential for the freezer to not maintain appropriate temperatures that put the facility at risk for decreasing the quality of food stored in the freezer and/or affecting the safe storage of food leading to food borne illness for 95 residents who received food from the kitchen. Findings: During an observation on 7/17/23 at 10:05 a.m. during the initial kitchen tour, the rubber gaskets around the interior perimeter of both doors to Freezer #3 were torn and portions of the gasket were peeled away from the righthand side door. Review of the document titled Dietary Quality Control Review dated 5/31/23, showed the document was completed by Regional Registered Dietician (RRD) and indicated a torn gasket on Freezer #3. The corresponding correction indicated was to replace torn gasket. During a review of Dietary Quality Control Review dated 6/29/23, the Dietary Quality Control Review completed by RRD indicated a torn gasket on Freezer #3 and identified correction was to replace gasket. During a concurrent observation and interview in the kitchen on 7/17/23 at 11:25 a.m. with Director of Nutritional Services (DNS) , DNS stated the gasket for Freezer #3 was torn and needed to be replaced. She stated she was responsible for checking and maintaining it. DNS stated she did not realize RRD identified the ripped gasket for Freezer #3 in RRD's audit. According to the 2022 Federal Food Code, equipment components such as doors and seals are to be kept intact and tight.

Based on observation, interview and record review, the facility failed to ensure staff were competent in appropriately testing and recording the surface sanitizer. This failure put 95 residents who received food from the kitchen at risk for illness from potentially ineffective sanitizing solution not being identified. Findings: During a concurrent observation, interview, and document review on 7/18/23 at 9:21 a.m. with DA 1 in the kitchen, stated she was responsible for filling the red buckets with sanitizer solution and recording the solution strength on the log. DA 1 filled a red bucket with a quaternary ammonia sanitizer solution from a hose located above the 2-compartment sink. She stated the solution was very hot. The temperature of the solution was measured with the surveyor's calibrated thermometer and it read 165 degrees Fahrenheit (F). DA 1 inserted a quaternary ammonia test strip into the red bucket that held a sanitizer solution. When she dipped the test strip into the solution, she immediately withdrew it. Then DA 1 held the strip to the color chart located inside the test strip container. DA 1 removed the strip and held it to the color chart on the strip container and stated it read 300 parts per million (ppm - a way of expressing very dilute concentrations of a substance in water). She also stated she could not adjust the temperature of the solution that came out of the hose bacause the faucet was stuck on hot. The instruction on the quaternary ammonia test strip showed to dip paper for 10 seconds. Compare color at once . Temperature between 65 and 85 Degrees F. During a concurrent observation and interview on 7/20/23 at 10:01 a.m. with DA 1 and RRD in the kitchen, RRD stated a plumber was called in to adjust the hot water because the maintenance staff at the facility was not able to fix it. She stated the water/sanitizer temperature was fixed. DA 1 took the temperature of the red sanitizer bucket using a yellow digital thermometer. DA 1 stated she always used a digital thermometer when she checked the temperature of the solution. DA 1 emptied the bucket and ran new water/sanitizer solution into the bucket. DA 1 stated, water temperature was 72.5 and the sanitizer test strip measured 300 ppm. During a concurrent interview and record review on 7/20/23 at 10:06 a.m. with Director of Nutritional Services (DNS), the Red Bucket Sanitizer Log, dated June and July 2023 was reviewed. The Red Bucket Sanitizer Log indicated 200 ppm/70 record every day for breakfast, lunch, and dinner testing 6/1/23 through 7/18/23. DNS agreed the logs were not accurate and stated staff would not get the same temperature or test strip results every single day, especially if a digital thermometer was used to check the temperature of the solution. DNS stated she is ultimately responsible for reviewing logs and ensuring accuracy. During a review of the facility's policy and procedure titled Dietary Department - General dated 6/1/14, indicated, the Dietary Manager and/or Dietician are responsible for planning and providing dietary staff with in-service education. The policy also indicated, the Dietary Manager is also responsible for the day-to-day education of dietary staff with regard to topics such as sanitation, food preparation, etc.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. A resident food refrigerator was dirty, food was not labeled and dated, and the refrigerator temperatures were not monitored appropriately to keep food safe. 2. Staff did not follow appropriate hand hygiene procedures. 3. Stored equipment and utensils were dirty and ready for use. 4. The inside surface of the ice machine bin door was dirty. 5. Dry food storage bins were dirty and cracked. 6. Food storage areas were dirty. 7. Eggs and chicken were not stored appropriately. 8. A reach-in freezer door was in poor condition. 9. Plastic bags used to store food were not durable to protect food from contamination and adulteration (the action of making food poorer quality or unsafe by the addition of another substance). These failures put the facility at increased risk for food contamination and food borne illness for 95 residents who received food from the kitchen. Findings: 1. An observation and document review on 7/17/23 at 12:00 p.m. showed a counter-top refrigerator holding food, located in the Station 1 & 2 medication room. The resident food refrigerator contained an opened and partially used, unlabeled, and undated container of Fortified Sweet Blend with honey and sugar bits. In addition, there was dried brown residue inside on the bottom surface of the refrigerator. Dark pink residue was adhered to the right side of the refrigerator and on the bottom wire shelf. Also, dried tan particles were on the surface of the shelving in the door of the refrigerator. A temperature log posted on the outside door of the refrigerator titled Medication Refrigerator Daily Temperature dated July 2023 showed a column for a.m. shift refrigerator temperatures and a column for NOC (night) shift refrigerator temperatures. From July 1 to July 17, 2023, seven temperatures were documented at 42 degrees Fahrenheit (F). The directions on the log showed Refrigerator temperature to be monitored and documented on AM shift and NOC shift to maintain a desired refrigerator temperature of 36 degrees F - 46 degrees F. In addition, the document instructions said the refrigerator should be cleaned weekly. If the temperature was outside the stated parameters, what action was taken and comment above. There was a comment column with no comments added. There was also a paper taped to the refrigerator that read Attention: any food container that are not labeled will be discarded. During a concurrent interview and record review on 7/17/23 at 12:06 p.m. with Licensed Vocational Nurse (LVN 2), the Medication Refrigerator Daily Temperature Record dated July 2023, was reviewed. LVN 2 stated she was responsible for documenting resident food refrigerator temperatures for the refrigerator located in Nursing Station 1 & 2. She stated the resident refrigerator temperature should be 38-42?. LVN 2 also stated she called maintenance if the temperature was above the acceptable range. During a concurrent observation and interview on 7/17/23 at 12:09 p.m. with Director of Nursing (DON) in the Station 1 & 2 medication room, the resident refrigerator and temperature log were reviewed. DON stated the refrigerator was not clean. She said the refrigerator cleaning was to be done weekly and should be done by whomever was available. DON also stated staff were trained by Director of Staff Development (DSD) and the acceptable temperature range for the refrigerator was 36-46?. DON also stated she did not know which resident the opened container of Fortified Sweet Blend belonged to because it did not have the resident's name on a label. She also said the food must have a label with date showing when it was opened. Review of Medication Refrigerator Daily Temperature Record dated May 2023 and June 2023, and provided as the logs to document the resident food refrigerator in Nursing Station 1 and 2, showed 42 degrees F documented 19 times and 43 degrees F documented one time in May, and 20 temperatures ranging from 42 degrees F to 44.2 degrees F in June. There were no comments added on the documents for May and June to show the temperatures of the refrigerator were out of range or any action was taken. During an interview on 7/17/23 at 12:15 p.m. with DSD, DSD stated she did the training and inservices; however, she did not do training related to the resident refrigerator. During an interview on 7/17/23 at 1:12 p.m. with DSD, DSD stated there was no documentation of training for the past couple of years for resident refrigerator temperature monitoring. During an interview on 7/20/23 at 10:35 a.m. with Regional Registered Dietitian (RRD), RRD stated she checked the resident refrigerator located in Nursing Station 1 and 2, for cleanliness and that the temperature logs were completed. RRD stated the resident refrigerator temperature should be 41? or below. RRD also stated dietary did not provide staff training on resident refrigerator and she did not know if staff were using medication temperature logs instead of kitchen temperature logs. Additionally, RRD stated she notified DON of any issues found and would report out of range temperatures to DNS or maintenance. RRD stated she did not remember notifying anyone of out-of-range temperatures. During a review of the facility's policy and procedure titled, Refrigerator/Freezer Temperature Records dated 11/1/14, indicated, The refrigerator temperature must be 41? or below. Temperatures above these areas are to be reported to the Dietary Manager immediately. The policy also indicated, corrective action should be taken to correct the temperature, or the items should be moved to another storage area to maintain acceptable temperature. Review of the policy and procedure titled Food Brought in by Visitors revised June 2018, showed if perishable food is refrigerated, it will be labeled and dated. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. 2. An observation and concurrent interview with [NAME] 1 on 7/18/23 at 10:49 a.m., showed [NAME] 1 put on gloves without washing her hands first. She then handled the recipe binder and a pan of melted butter. Then she went to the dirty side of the dish machine and scrubbed a food processor. Then [NAME] 1 placed the food processor inside the dish machine. [NAME] 1 removed her gloves and put on a new pair of gloves and removed the items from the dish machine when the cycle ended. She removed the food processor from the dish machine and placed it on a preparation table. [NAME] 1 did not wash her hands in this entire sequence of events. [NAME] 2 used the food processor to puree rice. [NAME] 1 stated she only changed gloves when going from the dirty to the clean side of the dish machine and handwashing was only needed if she handled food. She also stated sometimes she dipped her hands into the sanitizer bucket for a few seconds. In an interview on 7/18/23 at 10:57 a.m., DNS stated the proper sequence for hand hygiene was to remove gloves after washing dishes, wash hands, then put on clean gloves before touching clean items. Review of the policy and procedure titled Dietary Department - Infection Control for Dietary Employees dated November 9, 2016, showed proper handwashing by personnel will be done after handling soiled equipment or utensils, and before donning gloves for working with food. 3. A concurrent observation and interview during the initial kitchen tour on 7/17/23 at 10:52 a.m., with Director of Nutritional Services (DNS), seven of seven randomly selected pans from those stacked and stored on a clean storage rack opposite Freezer #3 had residue on the inside surface. Six of the pans had tan and reddish-brown residue inside surface that was rough to the touch and scraped off. One pan had black residue in the bottom inside surface that scraped off. DNS stated the pans were dirty and should have been washed again. During a concurrent observation and interview in the kitchen on 7/17/23 at 11:18 a.m. with DNS and [NAME] 1, a knife stored in a knife holder on the wall had beige-colored residue on the blade and on the handle where the blade was inserted. In addition, two pans hanging from a pot rack above the two-compartment sink had dark brown-black residue build-up around the top interior surface and rim of the pans. A pot, hanging on the rack, had dark brown-black residue on the exterior of the pan that resembled dried food and could be scraped off. [NAME] 1 looked at the residue on the pot and stated she washed her own pots and sometimes she was in a hurry to get all of the residue off. DNS stated the knife and pot were dirty and need to be rewashed and that anything that came out of the dish machine dirty, had to be rewashed before storing. DNS also stated the pans with the black residue build-up had to be replaced. During a concurrent observation and interview during the initial kitchen tour on 7/17/23 at 11:25 a.m., with DNS, food preparation and food serving tools were located in drawers adjacent to Freezer number 3. Inside the drawers were four food ladles (two black, one turquoise and one orange-handled) with dried orange residue that resembled dried food on the handles. DNS stated the ladles should be rewashed. DNS stated the orange-handled server needed replacement because the orange coating was melted. Additionally, a cheese grater had hard, white residue on the top of the handle and on the interior surface. DNS stated the residue was cheese and the grater was dirty and needed to be rewashed. Another item stored in the drawers was a small pan, with a non-stick surface that was significantly scratched and peeling. DNS confirmed the pan was scratched and stated it could cause harm. An observation and interview during the initial tour of the kitchen on 7/17/23 at 11:53 a.m. showed the blade of an industrial can opener mounted to a preparation table had cream-colored debris on the surface. In addition, the can opener base that held the can opener had brownish residue on the surface. DNS stated the can opener was dirty and should be cleaned after each use. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. During a review of the facility's policy and procedure titled, Can Opener Use and Cleaning, dated 10/1/14, indicated, The can opener will be sanitized between uses. The document also showed sanitation instructions which included washing the can opener, including the blade with detergent and a brush, then rinse and sanitize or run through the dish machine. The instructions also showed to scrub the base attached to the table, using detergent and a brush. Then rinse and sanitize the base plate. 4. An observation in the kitchen on 7/17/23 at 11:14 a.m., showed an ice machine filled with ice and with various residues on the inside surface of the bin (the ice storage area of an ice machine) door. There were three smudges of pink residue, a reddish-brown residue the size of a pea, and two light pink globs of residue which easily wiped off with a napkin, In an interview on 7/18/23 at 9:55 a.m., DNS stated kitchen staff cleaned the outside of the ice machine and the inside of the bin door. She stated if it was dirty, staff should clean it. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. 5. An observation on 7/17/23 at 11:25 a.m. showed four plastic food storage bins located in the dry food storeroom. The bins were filled with food and labeled thickener, flour, sugar and brown sugar respectively. Thickener: The interior of the bin had yellow-orange residue on the surface of the container approximately one (1) inch above the thickener, as well as beige residue along the inside lip of the bin There was also orange-brown debris, the size of a pea in the thickener (which was white). Flour: Yellowish residue was on the interior wall of the bin. There was orange-brown matter along the rim of the bin. Sugar: There was orange-brown residue on the inside bin surface as well as brownish residue along the rim of the front of the bin. Brown Sugar: There was crusty reddish-brown residue on the interior surface of the bin. Also, the bin was cracked and had pieces broken off, so the lid did not fit tightly. In a concurrent interview with DNS on 7/17/23 at 11:25 a.m., DNS stated the bins were dirty and were supposed to be cleaned as needed. DNS also stated the cracked brown sugar bin needed to be disposed of. During an interview on 7/18/23 at 11:09 a.m. with DNS, DNS stated there was no schedule for cleaning bins in the storage room. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. During a review of the facility's policy and procedure titled, Food Storage, dated 7/25/19, indicated, Any opened products should be placed in storage containers with tight fitting lids. 6. During a concurrent observation on 7/17/23 at 10:10 a.m. in the dry storage room, there was dark brown residue build-up and dark, fuzzy matter along the baseboards behind the food storage racks. There was also dark brown matter accumulated a around a leg of the rack, where it met the floor. As the observation of the dry storeroom continued on 7/17/23 at 10:42 a.m., a set of cabinets attached to the wall that held single use food service items had doors with dark residue surrounding the cabinet handles. In addition, there was peeling paint and chipped wood on the cabinet doors. Another free-standing cabinet that held staff personal items, had doors with black residue on the outside surface, especially around the handles. At the base of the outside surface of the cabinet was dark brown residue, as well as residue build-up on the floor next to the cabinet base. During an interview and observation inside the dry food storeroom on 7/17/23 at 11:25 a.m., DNS stated the floors were dirty behind the racks and said a deep cleaning was not scheduled yet. She stated staff mopped the floor every day but did not pull the racks out. She also stated the floorboards needed to be cleaned. She also stated the cabinets attached to the wall were in disrepair and confirmed there was peeling paint and chipped wood. She also confirmed the staff storage cabinet was dirty and had to be cleaned. During a review of the facility's policy and procedure titled, Food Storage, dated 7/25/19, indicated, The walls, ceiling, and floor should be maintained in good repair and regularly cleaned. During a review of the facility's policy and procedure titled, Floor Safety, dated 11/1/14, indicated, Floors should be kept clean . 7. During a concurrent observation and interview during the initial kitchen tour on 7/17/23 at 11:25 a.m. with DNS, a box of frozen chicken was opened so the chicken was not covered and open to the air, undated, and ice crystals were formed on pieces of chicken and in the plastic bag. DNS stated the bag of chicken should have been resealed and the ice buildup was not acceptable. During an observation on 7/18/23 at 9:33 a.m. in the kitchen, the refrigerator near tray line contained a carton of raw, shell eggs. Inside the carton, a cracked raw egg was on top of other eggs. Raw egg liquid from the cracked egg came into contact with the eggs it was resting on. The cracked egg was shown to [NAME] 2 who acknowledged there was a cracked egg. During a concurrent observation and interview on 7/18/23 at 1:41 p.m. with DNS in the kitchen, the cracked egg on top of the other eggs remained in the carton in the refrigerator. DNS stated the expectation was for cracked eggs to be thrown away when they were identified. During a review of the facility's policy and procedure titled, Food Storage, dated 7/25/19, indicated frozen meats and poultry are to be, . stored in airtight container or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items. The policy also indicated, Eggs should be checked for cracks and any damaged ones should be disposed of. 8. On 7/17/23 at 10 a.m., an observation in the kitchen showed a two doored reach-in freezer (Freezer number 3) had a foam covering the entire inside surface of one door. The foam had indentations, scratches, pits, as well as black residue on some areas on the perimeter of the foam close to the rubber gasket which framed the foam. When pressed, the foam was soft and easily indented. In an interview on 7/17/23 at 11:25 a.m., DNS stated the foam had to be replaced. According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning are to be constructed of a corrosion-resistant, nonabsorbent, and smooth material. In addition, nonfood-contact surfaces of equipment are to be free of crevices and designed and constructed to allow easy cleaning to facilitate maintenance. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 9. An observation of the kitchen dry food storeroom on 7/17/23 at 10:26 a.m., showed a plastic bin lined with a clear plastic bag holding a white, powder substance. The container was labeled non-dairy creamer. The plastic bag holding the non-dairy creamer had multiple holes and rips. In an interview on 7/17/23 at 11:25 a.m., DNS stated she received the plastic bags used to store the non-dairy creamer from housekeeping. She confirmed there were holes in the plastic bag that held the non-dairy creamer. According to the 2022 Federal Food Code, food packages are to be in good condition and protect the integrity of the contents so that food is not exposed to adulteration or potential contaminants. In addition, materials used in the construction of food-contact surfaces are to be durable with a smooth surface.

Based on observation, interview and record review, the facility failed to ensure staff followed the facility policy for food brought into the facility for residents by family and/or visitors and stored for residents up to 48 hours. This failure had the potential for a decreased consumption of food, as well as create an environment that was not home-like for 95 residents out of a facility census of 95. Findings: In an interview on 7/17/23 at 12:06 p.m., Licensed Vocational Nurse 2 (LVN 2) stated when food was brought in from a family or visitor, the facility could store the food up to 24 hours then discard the food. During an interview on 7/17/23 at 12:09 p.m. with Director of Nursing (DON), DON stated food brought from outside the facility for residents must be consumed or discarded the day it is brought in. During an interview on 7/17/23 at 12:15 p.m. with the Director of Staff Development (DSD), DSD stated she does the training and inservices; however, she did not do training related to the resident refrigerator. During a concurrent interview and document review on 7/19/23 at 10:20 a.m. with DON, the facility's policy and procedure (P&P) titled Food Brought in by Visitors, dated June 2018 was reviewed. The policy indicated, DSD is to make staff aware of policy addressing food brought in by family or visitors upon orientation. The policy also indicated food brought into the facility for residents that required refrigeration will be labeled, dated, and discarded after 48 hours. After reviewing the policy, DON confirmed the policy stated food brought for residents had to be consumed within 48 hours, and staff should follow policy.

Based on interview and record review the facility failed to a water management program to help reduce the risk for legionella and prevent spread of water borne pathogen growth. This failure had the potential to cause spread of water borne pathogen growth in the facility. Findings: During an interview on 7/19/23 at 11:06 a.m., with Administrator (Admin), Admin stated, facility had no water treatment program at this time. Admin could not provide documentation for facility's water treatment program to prevent legionalle and spread of water pathogen. Admin stated, she understood that water treatment program was required to be completed anuually and as needed to prevent spread of water pathogen. During a review of the facility's policy and procedure, titled, Water Management Program revised June 201, the policy and procedure indicated, The facility will develop and maintain a water management program to reduce Legionella and other waterborne pathogen growth and potential spread in facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of 25 (Resident 5) sampled residents, the facility failed to inform and provide information to the residents and/or the resident representatives, the option to formulate an advance directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make a decision for themselves because of illness or incapacity). This failure had the potential to result in delay of the treatment directions to healthcare providers regarding Resident 5's medical care. Findings: Review of the Resident Face Sheet, printed 10/8/19, indicated Resident 5 was readmitted to the facility on [DATE]. During a review of the medical record for Resident 5, the Physician Orders for Life-Sustaining Treatment (POLST) form, signed 11/4/18, indicated Section D - Information and Signatures regarding Advance Directives was left unanswered. Review of Resident 5's significant change in status Minimum Data Set (MDS - an assessment tool used to direct care), dated 6/26/19, indicated the advance directive section was not completed. Review of a document titled Social Services Assessment, dated 11/7/18, indicated Resident 5 did not have an advance directive. During a concurrent interview and record review with the Social Services Director (SSD) on 10/08/19 at 11:55 a.m., she showed that the advance directive question had been marked no on the Social Services Assessment document dated 11/7/18. SSD stated although she marked Resident 5 did not have an advance directive, she did not document that she had informed Resident 5 and his resident representative (RR) of the pros and cons of an advance directive. SSD was unable to show documentation that Resident 5 and his RR were offered an opportunity to develop one. SSD was not able to show documentation in the Interdisciplinary Team notes that the advance directive had been discussed with Resident 5 and his RR. Review of facility's policy and procedure titled Advanced Healthcare Directives, revised 2/2017, indicated, .I. Upon admission, admission Staff or designee will inform the resident of his/her right to execute an Advance Healthcare Directive. X. Inquiries concerning Advance Directives are referred to the Director of Social Services/Designee

Based on observation, interview, and record review, for one of 25 sampled residents (Resident 73), the facility failed to provide care and services for feeding tubes. Certified Nursing Assistant (CNA) 2 lowered Resident 73's head of the bed to the flat position to provide personal hygiene care while Resident 73's enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) was being administered through the G-Tube (Gastrostomy Tube - a tube inserted through the belly that brings nutrition directly to the stomach) via a pump. For Resident 73, this failure had the potential to result in aspiration (inhalation) of the feeding formula and lead to aspiration pneumonia (a lung infection that develops after aspirating food, liquid, or vomit into the lungs). Findings: Review of Resident 73's Minimum Data Set (MDS - an assessment tool used to guide care) indicated Resident 73 was severely impaired of cognitive skills, required one to two-person assistance for dressing and personal hygiene, and had a feeding tube for nutrition. Review of Resident 73's physician orders for October 2019 indicated an order for Resident 73 to receive .Jevity 1.5 (enteral feeding formula) at 55 milliliters (mLs) per hour via pump for 20 hours via G-Tube on at 2 p.m. and off at 10 a.m. or continue enteral feeding infusion until total volume is infused to provide 1100 mLs The physician's order also indicated instructions to Elevate head of bed 30-45 degrees while tube feeding is on. During an observation on 10/7/19, at 8:44 a.m., Certified Nursing Assistant (CNA) 2 provided hygiene care to Resident 73 with the head of bed in the flat position. Resident 73's enteral feeding pump was on and administering the enteral feeding formula during the care. Resident 73 began to cough and CNA 2 said Oh you got a cough. CNA 2 completed Resident 73's hygiene care and then raised Resident 73's head of the head of the bed. During an interview with CNA 2 on 10/7/19, at 8:50 a.m., CNA 2 stated they did not inform the licensed nurse that hygiene care was to be provided to Resident 73. During an interview with Licensed Vocational Nurse (LVN) 2 on 10/7/19, at 9:26 a.m., LVN 2 stated the tube feed pump needed to be turned off when Resident 73's head of bed was flat during hygiene care. LVN 2 stated they was not aware that CNA 2 went to clean Resident 73 and that Resident 73 was coughing. LVN 2 confirmed the pump was still running and would be shut off at 10 a.m. A review of the facility's policy and procedure titled, Enteral Feeding - Closed with a revised date of 1/1/12, indicated .5. The head of bed should be elevated 30 degrees during feedings

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when there were multiple plastic wares stored wet inside the kitchen cupboard. These deficient practices had the potential to result in foodborne illnesses. Findings: During the initial tour observation of the kitchen and concurrent interview with the Dietary Aide 1 (DA 1) on 10/7/19 at 8:04 a.m., multiple stacked pink-colored plastic cups and mini trays, and blue-colored water pitcher lids were stored wet inside the cupboard. DA 1 stated dishes needed to be fully air-dried before they were stored in the cupboard. In an interview with the Dietary Services Supervisor (DSS) on 10/8/19 at 11:16 a.m., DSS stated dishes should be racked loosely and air-dried completely for safer storage to prevent microorganism growth. Review of the undated facility policy and procedure titled, Dish Washing indicated that .Dishes are to be racked loosely without overlapping .Dishes are to be air dried in racks before stacking and storing

Based on observation, interview, and record review, the facility failed to ensure on (Resident 4) of 21 sampled residents received assistance with activities of daily living (ADL - e.g. personal hygiene) when Resident 4 (a female) did not receive assistance personal grooming and had a full beard. This failure resulted in Resident 4 feeling bad about herself. Findings: Review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 12/27/17, indicated Resident 4 mental status was severely impaired and required the assistance of one staff person with ADLs. In an observation on 11/27/18, at 11:03 a.m., Resident 4 had a full beard. During an interview on 11/27/18, at 11:03 a.m., Certified Nursing Assistant (CNA) 1 stated Resident 4 refused shaving. In an observation on 11/28/18, at 9:30 a.m., Resident 4 was clean shaven and smiling. Resident 4 stated that now she felt pretty. In an observation on 11/28/18, at 10:30 a.m., Resident 4 was still smiling about being clean shaven and was co-operating with facility staff.

Based on observation, interview and record review, for two of 21 sampled residents, the facility failed to implement their Pain Management policy and procedure when Residents 6 and 243 experienced pain and Licensed Vocational Nurse (LVN) 1 did not assess the Residents for pain using the zero to 10 pain scale (zero being no pain and 10 being the worst pain). This failure had the potential to result in Resident 6 and Resident 243's pain to be incompletely relieved or managed. Findings: 1. Review of Resident 6's Facesheet, printed 11/28/18, indicated Resident 6 was admitted to the facility with diagnoses that included rheumatoid arthritis (a chronic inflammatory disorder in which the body's immune system attacks its own tissue, including joints, causing pain and swelling). Review of Resident 6's Minimum Data Set (MDS - a resident assessment too used to guide care), dated 12/1/17, indicated Resident 6 was able to identify the correct day, month, year, and could recall words presented to her. Resident 6 had clear speech and could express ideas and wants and had clear comprehension of verbal content. Review of Resident 6's Pain Re-Assessment, dated 11/25/18, indicated Resident 6 was at risk for pain due to a diagnosis of Rheumatoid Arthritis. Review of Resident 6's Care Plan for Pain, dated 12/1/18, indicated Resident 6 was at risk for pain due to kidney disease and arthritis. Interventions included pain medication and Hot packs as needed to bilateral knees for pain. During an observation and concurrent interview on 11/28/18, at 9:05 a.m., Licensed Vocational (LVN) 1 asked Resident 6 if she was in pain. Resident 6 stated she was very stiff. LVN 1 told Resident 1 she would go and get Resident 6's pain medication. LVN 1 did not ask Resident 6 to rate her pain on a scale of 0 to 10, where the stiffness was, or what measures either relieved the discomfort or made it worse. In an interview on 11/28/18, at 9:55 a.m., LVN 1 stated she did not know why Resident 6 was stiff. LVN 1 stated this would have been helpful information to obtain as this would allow staff to reposition her and try to find ways to make Resident 6 more comfortable. 2. Review of Resident 243's Facesheet, printed 11/28/18, indicated the Resident 243 was admitted to the facility with diagnoses that included muscle weakness and peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of Resident 243's Pain Re-Assessment, dated 11/28/18, indicated Resident 243 had back pain which was rated between 5 and 7 on the pain scale of 0 to 10. Non-medication interventions being used included Relaxation and repositioning. Review of Resident 243's Care Plan Pain, dated 11/15/18, indicated Resident 243 was at risk for pain due to neuropathy, back pain and kidney failure. Interventions included medication administration as well as repositioning, distraction, quiet environment and dimmed lights. Review of Resident 243's Minimum Data Set (MDS - a resident assessment too used to guide care), dated 11/21/18, indicated Resident 243 had clear speech, was able to express his ideas and wants and understood what others said to him. In an observation and concurrent interview on 11/28/18, at 8:40 a.m., LVN 1 asked Resident 243 if he had pain. Resident 243 told LVN 1 Yes, he had pain. LVN 1 then turned to retrieve the pain medication from the medication cart. LVN 1 stated she did not know where Resident 243's pain was located, the intensity (on a scale of 0-10), or what made the pain worse or better. In an interview on 11/29/18, at 12:30 p.m., the Director of Nursing (DON) stated licensed nursing staff were to ask if the resident has pain, where the pain is located, where the pain is on the pain scale, what brings the pain on and what makes the pain better. The DON stated these questions needed to be asked in order to address the pain correctly and identify any possible triggers. Review of the facility's policy and procedure titled Pain Management dated November 2016, indicated .Pain Management .D. The Licensed Nurse will assess the resident for pain and document results on the (Medication Administration Record) each shift using the 0-10 pain scale .F. Nursing Staff will implement timely interventions to reduce an increase in severity of pain .J. Nursing Staff will also utilize non-pharmacological interventions to address possible issues contributing to pain

Based on observation, interview and record review, for one of 21 sampled residents (Resident 69), the facility failed to implement their Dressings - Application to ensure cleanliness policy and procedure when Licensed Vocational Nurse (LVN) 2 did not re-clean Resident 69's sacral (lower back) pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) after Resident 69 rolled onto the open wound during a dressing change. This failure had the potential to result in infection. Findings: Review of Resident 69's Facesheet, printed 11/28/18, indicated Resident 69 was admitted to the facility with diagnoses that included muscle weakness. Review of Resident 69's Physician's Telephone Orders, dated 10/31/18, indicated Resident 69 had a sacral pressure injury that required cleaning and dressing changes, daily and as needed, by the facility's licensed nurses. Review of Resident 69's Care Plan, Pressure Injury, dated 9/16/18, indicated Resident 69's pressure injury was to be free of signs and symptoms of infection. In an observation on 11/29/18, at 10:04 a.m., Resident 69 was assisted into his bed and laid on his left side so LVN 2 could clean his sacral pressure injury and change the dressing. Resident 69's buttocks were on a blue pad (chux - blue absorbent pad commonly used for resident's who may have occasional leakage of bowel or bladder). LVN 2 removed Resident 69's old sacral dressing and cleaned the sacral pressure injury with the normal saline. Resident 69 stated he was uncomfortable being on his side and rolled back onto his back and onto the chux. LVN 2 then assisted Resident 69 back onto his left side. LVN 2 applied the new clean dressing and medication to Resident 69's sacral injury. LVN 2 did not re-clean Resident 69's sacral pressure injury with normal saline after the contact with the incontinent pad. In a concurrent interview, LVN 2 stated she should have re-cleaned Resident 69's sacral (injury) wound before applying the medication and dressing. In an interview at 12:40 p.m., the facility's Director of Nursing (DON) stated the sacral dressing change is a Clean procedure. If the resident rolled back over onto the incontinent pad which had been there for an unknown number of hours, staff should have re-cleaned the wound to diminish the chance of infection. Review of the facility's policy and procedure titled Dressings - Application, dated 1/1/12, indicated the purpose was to .ensure cleanliness and prevent infection by protecting the skin's surface and to promote resident comfort and wound healing